Inspection on 17/11/06 for 290 Dyke Road

This inspection was carried out on 17th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

290 Dyke Road 11/09/08

290 Dyke Road 22/02/06

290 Dyke Road 13/07/05

290 Dyke Road 15/02/05

290 Dyke Road 27/07/04

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

CARE HOME ADULTS 18-65 290 Dyke Road Hove East Sussex BN1 5BA Lead Inspector Niki Palmer Unannounced Inspection 17th November 2006 11:00 290 Dyke Road DS0000060764.V314067.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 290 Dyke Road DS0000060764.V314067.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. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 290 Dyke Road Address Hove East Sussex BN1 5BA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 552069 www.caremanagementgroup.com Care Management Group Limited Louise Davie Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of service users to be accommodated is five (5). That service users should be younger adults aged between eighteen (18) and sixty-five (65) years on admission. That service users to be accommodated have a learning disability, or a physical disability. 22nd February 2006 Date of last inspection Brief Description of the Service: 290 Dyke Road is a care home, which provides personal care and accommodation for up to five residents with profound physical and learning disabilities. The home is owned and run by Care Management Group (CMG) who are a large organisation that provides care for people with learning disabilities. The home is a converted bungalow with a wheelchair accessible garden to the rear of the property. All bedrooms are for single occupancy. There are suitable bathing facilities at the home to meet the assessed needs of residents. The home is located on a main road on the outskirts of Brighton, with nearby access to some local amenities and public transport. There is some parking available at the home, however free parking is permitted on the street. Residents are provided with an opportunity to attend a day centre provided through the use of the organisations development centre. The home provides personal care and support to residents who are funded by Social Services. The home’s fees as of 3rd October 2006 range between £1150 - £2000 per person per week. Additional costs are charged for chiropody (£10). Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home’s most recent inspection report is available on request at the home. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 290 Dyke Road will be referred to as ‘residents’. This unannounced inspection took place on Friday 17th November 2006 and lasted approximately five hours. Five residents were accommodated on the day of the inspection, all of which were male and aged between 21 and 28 years of age. Two residents were at home during the course of the inspection. In order to gather evidence on how the home is performing, individual discussions took place with two members of care staff on duty, a Speech and Language Therapist and the Manager of a nearby day service who was attending an annual review at the home for one of the residents. The latter part of the inspection was undertaken with the Registered Manager. Two care records were examined in some detail for the purpose of monitoring care. Other records and documentation inspected included: the home’s preadmission assessment procedures, medication practices, the provision of activities, complaints procedure and the systems in place to safeguard residents from harm, staffing levels and the provision of relevant training. In addition the home’s systems for monitoring their own effectiveness and managing residents’ monies were inspected. All communal areas and most individual rooms were seen. A detailed pre-inspection questionnaire was received prior to the visit to the home. This provided the Inspector with information relating to the premises, maintenance and associated records, details of the homes policies and procedures and staffing details. What the service does well: 290 Dyke Road is a well managed service, which is staffed by a consistent and well trained staff team. A good level of information is provided prior to admission in order to support prospective residents in their decision of where to live. The compatibility of residents currently living at the home is good. All residents are provided with a variety of opportunities to engage in occupation and activities both within and outside of the home. Maintaining contact and friendships with others is promoted. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 6 Care staff receive regular training in order to better support them to meet residents’ needs. There is good evidence of multidisciplinary working happening on a regular basis. The home presents as a comfortable and homely place to live, with all bedrooms being individually personalised. The home has good systems in place to ensure that any concerns or complaints raised either by residents or others will be quickly resolved. Feedback from others is sought on a regular basis with a high proportion of the comments being positive. What has improved since the last inspection? What they could do better: Albeit that care staff have a good understanding of individual needs, care planning procedures and specific individual guidelines need to be more detailed, particularly in relation to the management of epilepsy and nutritional care needs. The Manager needs to ensure that all staff adhere to the home’s procedures for handling residents’ finances. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 7 Following the last inspection an assessment of the premises was undertaken in March 2006 by an Occupational Therapist. Despite recommendations being made at this time, these areas have yet to be addressed. Cracked kitchen cupboard doors and torn linoleum flooring need to be replaced. It is strongly recommended that consideration be given to having the kitchen refurbished and being made more user friendly and accessible for wheelchair users. 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. 290 Dyke Road DS0000060764.V314067.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 290 Dyke Road DS0000060764.V314067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and others are provided with sufficient information prior to admission in order to support their decision of where to live. Good systems are in place to ensure that only residents whose needs can be met are admitted to the home. EVIDENCE: The home has a detailed Statement of Purpose and Service Users’ Guide in place, which were forwarded to the Commission for Social Care Inspection (CSCI) following the last inspection. The Statement of Purpose provides the reader with an introduction to CMG including the home’s aims and objectives, details of the Registered Provider and Manager, organisational and staffing structure and colour photographs of the accommodation provided. The Service Users’ Guide offers a good level of information regarding the services and facilities provided, residents’ charter, contact details of the CSCI and the arrangements in place for health and social care support. Both documents are presented in an easy to read and understand format, which incorporate the use of colour pictures and symbols. CMG employs a team of centrally based assessment referral officers, who are responsible for considering and assessing all initial referrals for each of the care homes across the South East region alongside the Registered Manager. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 10 Most of the residents accommodated have lived together for a number of years in other establishments prior to moving in to 290 Dyke Road. The compatibility of residents is at this time good. There have been no new admissions to the home since the last inspection. Contracts are negotiated between CMG’s head office and the purchasing authorities. It was required at the last inspection for the home to ensure that copies of all residents’ contracts/terms and conditions are available for inspection. The Manager confirmed that two have yet to be signed. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are mostly supported by the home’s care planning procedures. Staff have a good understanding of residents’ needs. EVIDENCE: Two individual care plans called “All about me’ were inspected. Both were found to be reasonably detailed and person-centred to individual needs. Since the last inspection all residents have a completed Health Booklet in place, which have been produced by CMG. Care staff spoken with were clearly able to demonstrate their knowledge of the assessed care needs of residents. Both plans of care contained detailed personal information in relation to how residents’ needs are to be met in accordance with personal preferences. Daily records are kept separately from care plans, however these were noted to be exceptionally brief. The home is required to maintain detailed and accurate daily records within individual care plans and ensure that all care plans are updated in respect of the management of epilepsy and nutritional care needs. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 12 All of the residents living at the home have profound physical and learning disabilities and are therefore reliant on care staff, their relatives and other health and social care professionals to act in their best interests and make decisions on their behalf about many aspects of their lives. Albeit that residents’ verbal communication is limited, staff working in the home were observed to interpret individuals’ subtle level of communication and include residents in the daily routines of the home wherever possible. A number of core risk assessments for activities of daily living are in place within individual plans of care e.g. epilepsy, eating and drinking, swimming and moving and handling. Whilst on the whole these were noted to be reasonably detailed and there was evidence that they had been recently reviewed, a number of them failed to clearly identify what the actual level of risk is in certain areas. The Manager commented that she would benefit from undertaking further training in assessing risks. A requirement has been made in respect of this. As per the last inspection report, risk assessments have been undertaken in respect of door locks on individual bedroom doors and the activities that residents take part in when being supported to prepare food in the kitchen. 290 Dyke Road DS0000060764.V314067.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with opportunities for personal development and to be involved in the local community. The provision of food is good. EVIDENCE: CMG owns a development centre, which is accessed by four of the residents on a daily basis Monday to Friday. This provides opportunities for residents to engage in informative and creative activities should they wish, including sensory stimulation, art, postural movement, Speech and Language Therapy, physiotherapy, music, and IT. One person attends a day centre where he is supported on a one-to-one basis. Staff confirmed that weekends are more relaxed and residents are often supported out into the local community – cinema, pub, a walk along the seafront, bowling and shopping, however this is dependent on the availability of transport as the organisation has four vehicles which are shared between five homes in the Brighton area, a school and the development centre. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 14 Visitors are welcomed at the home. Residents may see visitors in their own rooms if they wish. All visitors are requested to sign in to the home on arrival in a book located at the main entrance of the building. All food preparation is undertaken within the home by care staff who have obtained a certificate in food hygiene. Residents are encouraged to take turns on a weekly basis to choose and plan the menu for the week. As required at the previous inspection, a list of residents’ likes, dislikes and allergies are displayed in the kitchen area as a guide for staff when preparing and cooking food. Residents are encouraged to participate in the preparation of meals, however due to the poor layout and inaccessibility to wheelchair users, this activity is limited. The kitchen is small and only one resident is able to assist a staff member at any given time. The Registered Manager has liaised with CMG in respect of updating the kitchen, however a final decision has yet to be agreed. It is strongly recommended that consideration be given to having the kitchen refurbished and being made more user-friendly and accessible for wheelchair users. Due to the complex physical care needs of the residents accommodated, all are reliant on staff support at mealtimes. One person has a specialist-feeding programme in place for his nutrition to be administered via a PEG tube. Only care staff who have received the appropriate training are permitted to support this person as per his feeding regime. The Speech and Language Therapist confirmed that she is responsible for devising and reviewing all eating and drinking guidelines and for providing training to staff. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are mostly met by the home. Residents are protected by the home’s safe medication administration procedures. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all appointments as necessary. Six monthly routine check ups are arranged at the home, whilst specialist referrals are made on an individual basis. CMG employs a full-time Physiotherapist and part-time Speech and Language Therapist who both work into the home on a regular basis due to the complex physical healthcare needs of residents. All personal care is carried out in the privacy of one of the communal bathrooms or in residents’ own bedrooms. Baths/showers are carried out at flexible times according to the preferences of each individual. All of the residents have individualised programmes of care for postural management, which are overseen by the Physiotherapist. It was noted in one persons care plan that their position must be moved during the night, however 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 16 discussions with staff and the examination of records identified that these guidelines are not being followed. Staff explained that there is only one waking night person on duty and all residents require 2-1 support. The home is required to seek advice from a Physiotherapist in relation to this and take the appropriate action. All of the residents living at the home have epilepsy and whilst it was pleasing to note that all staff have received training in this area including the administration of emergency medication, epilepsy management guidelines are unclear. Albeit that care staff spoken with were able to describe the action that they would take in the event of a person having a seizure, the home is required to revise all individual epilepsy management guidelines. These must include a brief history of the person’s seizures, a description of what form the seizure takes and instructions for staff to follow in the event of a seizure occurring. Clear and accurate records of seizures must be kept within individual care plans. Food charts and fluid balance records are routinely kept for all residents in their daily records, however there is no indication within individual plans of care as to the reasons why these are being recorded. The home is required to ensure that residents’ nutritional care needs are incorporated within individual plans of care. A sample of the home’s medication procedures and records were seen. The home uses a pre-packed blister pack, which is delivered by the local pharmacy on a monthly basis. All members of staff have received the relevant training and have been assessed as competent in the administration of medicines. As a measure of good practice, the home has written detailed information for staff to follow, which indicate the reasons why each of the medicines are prescribed and what their possible side-effects are. There are also clear actions for staff to follow in order to administer medicines to individuals as per their individual needs and preferences, as none of the residents are able to self-medicate. Monthly audits are carried out, records of which are kept. All medicines were found to be appropriately stored with clear and accurate records maintained. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately and that residents are protected from potential harm, neglect and abuse. The Manager must ensure that the home’s procedures are followed at all times to safeguard residents’ personal finances. EVIDENCE: The home has a detailed complaints procedure in place, which was seen on the day of inspection. It details how a complaint can be made, how the complainant can expect it to be dealt with and includes the contact details of the CSCI. No complaints have been received by either the home or CSCI since the last inspection. The home has a detailed Adult Protection procedure in place, which has been updated to state that all allegations of abuse must be referred to Social Services. In addition, the Manager has incorporated information regarding the PoVA list within the policies and procedures, however it is recommended that this be more detailed to provide staff with clearer guidance regarding the referral process. All staff spoken with had a good understanding of the home’s whistle-blowing and Adult Protection procedures. No alerts have been raised since the last inspection. The Registered Manager is the designated appointee for four residents’ finances. The home holds residents’ personal allowances at the home, which all care staff have access. Two residents’ personal monies were spot-checked. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 18 Whilst records were mostly maintained, it was concerning to note that a member of staff had taken some money to make a purchase on behalf of a resident almost one month ago, yet had not supplied a receipt or indeed the purchased item. In addition a handwritten petty cash slip was found in the same resident’s money tin, without any date or name of the member of staff who had taken the money. Despite residents’ monies being double-checked at each time of handover of staff, these discrepancies failed to be identified. This was discussed in detail with the Registered Manager and a requirement made. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 290 Dyke Road presents as a reasonably clean, well-maintained and homely place to live, however residents will have greater opportunities to participate in activities within the home once adaptations and improvements have been made. EVIDENCE: The Inspector was shown around all areas of the home, with the exception of one bedroom on the day of inspection. The home comprises of five single bedrooms, one bathroom/showering facility, a small kitchen and a reasonably good-sized lounge. A newly built conservatory leads from the lounge to the rear garden. Residents’ bedrooms are personalised to individual preferences and contain nicely framed photographs, TV, DVD player and music stereo. All rooms have height adjustable beds and overhead tracking devices. All rooms are due to be redecorated, residents having been involved in choosing the colour of the paint. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 20 Following an Immediate Requirement issued at the last inspection a thermostatic valve was fitted to the shower in the bathroom in order to ensure that hot water does not exceed the recommended 43°C. This was checked on the day of inspection and noted to comply with the regulations. Routine daily records are kept. An Occupational Therapist (OT) undertook an assessment of the premises following the last inspection. As a result of this it has been recommended that a doorway in the hallway be widened and a mobile hoist purchased in order to enable residents to spend more time relaxing the communal areas as opposed to their bedrooms. Despite the Manager having raised these issues with her line Manager, these have yet to be addressed. The home employs a cleaner on a part-time basis. Most areas were noted to be clean and hygienic on the day of inspection, with the exception of the kitchen. As already mentioned, the kitchen area is in need of updating and refurbishing. Kitchen cupboard doors were cracked and the linoleum flooring torn. Consequently these areas are not easily cleanable. The home is required to replace all cracked cupboard doors and flooring. Each night the home is staffed by one waking night person and one sleep-in person who is called upon in the event of an emergency. At this time the only suitable sleep-in accommodation for staff is in the conservatory area. Staff commented that although this is on the whole adequate to meet their needs, they said that in wet weather they are kept awake at night by the rain pouring on to the roof. It is strongly recommended that consideration be given to the sleep-in accommodation and arrangements for staffing at night. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a consistent, well-trained and supervised staff team. Recruitment procedures are good. EVIDENCE: In addition to the Registered Manager, the home employs a total of nine Support Workers, four of which have recently completed their NVQ level 2 in care, although a further three persons are due to commence this over the next few months. Two members of staff have left since the last inspection. The home is in the process of recruiting a new member of staff, although does not at this time need to use agency staff as some members of the team are keen to work additional hours. The Manager commented that this is preferable as it provides residents with familiarity and consistency. Staffing rotas confirmed that there is always a minimum of three care staff on duty with these numbers being increased to four some weekdays and most weekends. Staff commented that the team work well together. Recent mandatory training for staff includes: fire safety, the Protection of Vulnerable Adults, first aid and food hygiene. In addition to this, some staff have undertaken values training, person centred planning, health action 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 22 planning and keyworking. All records of staff training were available for inspection. The Speech and Language Therapist commented that all staff working within the home are keen to attend refresher training as necessary. This is usually planned following staff meetings when a high number of staff are present. The recruitment files for two members of staff were examined. It was pleasing to note that application forms were sufficiently detailed, two satisfactory written references had been obtained and there was evidence of a PoVA First check and Criminal Record Bureau (CRB) check in place. The Registered Manager confirmed that she is in the process of updating the home’s induction processes in accordance with Skills for Care, which replaced TOPSS in October 2006. This will be followed up at the next inspection. Staff confirmed that they receive regular supervision sessions with senior members of staff usually on a monthly basis. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well run and organised home. Health and safety aspects are improved. EVIDENCE: The Registered Manager has been in post for almost three years, although has worked within the organisation since 2000. She is currently working towards her NVQ Level 4 in Management and proposes to obtain her Registered Manager’s Award next year. She is supported well in her role by a Deputy Manager and Senior Support Worker. All of the care staff and other professionals spoken with spoke highly of her leadership sills and abilities. Seeking feedback from residents is a challenging role for 290 Dyke Road due to individuals’ complex care needs and limited verbal communication skills. However relatives and Care Managers were sent questionnaires by the home during the summer months of this year. A number of these were seen, all of 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 24 which were very positive. In addition to this the Regional Operations Manager visits the home on a regular unannounced basis, in order to gain feedback from staff and observe the daily routines and interactions within the home. Details of these visits are forwarded to the CSCI. Since the last inspection all fire doors have been repaired to ensure that they close properly. These were checked on the day of inspection and found to be in working order. In addition all windows throughout the home have been restricted and a lock has been fitted to the laundry door. Evidence provided within the home’s returned pre-inspection questionnaire identified that regular health and safety checks are carried out including fire safety, emergency lighting, adaptations and other equipment and gas installation. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 1 3 X 2 X 3 X X 3 X 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA6 YA9 YA18 YA19 Regulation 17(1)(a) (3)(a) Requirement Timescale for action 31/01/07 31/03/07 15/12/06 4. YA6 YA19 5. YA6 YA19 6. YA23 That detailed and accurate daily records are maintained for each resident. 13(4) That the Manager undertakes 18(1)(a)(c) additional training in risk (i)(ii) assessment. 12(1)(a) That advice is sought from a 13(1)(b)(5) Physiotherapist in relation to the moving and handling of residents at night as per their postural management guidelines. The appropriate action must be taken. 12(1)(a)(b) That individual epilepsy 15(1)(2) management guidelines are clear and precise. These must include a brief history of the person’s seizures, a description of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring. Clear and accurate records of seizures must be kept within individual care plans. 12(1)(a)(b) That residents’ nutritional and 15(1)(2) fluid balance care needs are incorporated within individual plans of care. 17(2)Sch4 That improved systems are DS0000060764.V314067.R01.S.doc 15/12/06 15/12/06 15/12/06 Page 27 290 Dyke Road Version 5.2 (9)(a)(b) 7. 8. YA29 YA30 9. YA37 implemented in order to safeguard residents’ personal finances. 13(5) That the recommendations of 31/03/07 the Occupational Therapist’s report are addressed. 23(2)(b)(d) That all cracked kitchen 31/03/07 cupboard doors are replaced and new flooring be fitted in this area. 9(1)(2) That the Registered Manager 30/09/07 8(1)(a) obtains the relevant managerial qualifications in care and management. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA17 YA23 YA24 YA33 Good Practice Recommendations That consideration be given to having the kitchen refurbished and being made more user friendly and accessible for wheelchair users. That information relating to the PoVA list is more detailed to provide staff with clear guidance regarding the referral process. That consideration be given to the sleep-in accommodation and arrangements for staff. 290 Dyke Road DS0000060764.V314067.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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