Inspection on 03/05/06 for 3-5 St Matthews Road

This inspection was carried out on 3rd May 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3-5 St Matthews Road 04/03/08

3-5 St Matthews Road 05/10/05

3-5 St Matthews Road 20/04/05

3-5 St Matthews Road 07/09/04

3-5 St Matthews Road 05/04/04

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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 3-5 St Matthews Road St Leonards on Sea East Sussex TN38 0TN Lead Inspector Caroline Johnson Key Unannounced Inspection 3rd May 2006 09:30 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 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 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 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. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 3-5 St Matthews Road Address St Leonards on Sea East Sussex TN38 0TN 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) 01424 445924 Sussex Autistic Community Trust (Care Services) Limited Mr Stewart John Cowley Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only service users with an autistic spectrum disorder may be admitted. That the maximum number of service users to be accommodated is 9 (nine). That service users are aged between 18 (eighteen) and 65 (sixty-five) years on admission. 5th October 2005 Date of last inspection Brief Description of the Service: 3-5 St Matthews Road is registered to accommodate nine adults with an autistic spectrum disorder. The home is one of four homes in East Sussex run by the Sussex Autistic Community Trust. The registered premises consist of two semi-detached houses arranged into three separate units. House no.3 has one unit accommodating five residents whilst house No.5 has two units, one for one resident and the second for three residents. Each unit is staffed separately, whilst a manager oversees the whole service. The home is situated a short walk from the Silverhill area of St Leonards on Sea, where there are local amenities and shops. Bus services run close to the home. The home makes CSCI reports available to prospective residents and their relatives/representatives upon request. The gross weekly fee inclusive of income support is £1,405 to £1,833 as at 10 May 2006. At the time of inspection residents were paying their full disability living allowance in respect of mobility but the arrangements for this are to be changed. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection there were two site visits. The first site visit was unannounced on 3 May 2006 and that inspection lasted from 9.40am to 2.40pm. A member of care staff facilitated the inspection. During the inspection there was an opportunity to speak with two residents, a permanent care worker, a relief worker, and an NVQ Assessor. Three care plans were examined in detail. A wide range of record keeping was also examined including records of house meeting minutes, medication, menus and health and safety documentation. There was also an opportunity to see the communal areas in both homes and one of the resident’s bedrooms. The second site visit was on 10 May 2006 and that was announced. The inspection lasted from 09.30am until 6.00pm. The manager facilitated that inspection. During the day there were opportunities to examine a wide range of record keeping in relation to care plans, staffing rotas, quality assurance, complaints, residents’ finances and health and safety. Prior to the first site visit the inspector had visited the home to see the redecoration of the flat in house three and to meet with the resident occupying the flat. In addition an appointment was made the head office on 9 May to look at staff recruitment records. Three relatives were contacted as part of the inspection process but only one chose to share their comments. The comments received were very positive. They were very supportive of the home saying that there had been `a big improvement’ in their relative’s `mental health since he moved to the home’. There relative attends a good range of activities and they would like the number of activities increase further. They have raised this at reviews and the home is seeking additional funding to try to achieve this. They also stated that St Matthews is homely, the diet is good and that staff make arrangements for their relative to attend a wide range of health care appointments. What the service does well: The Trust offers a very comprehensive staff training programme and staff have regular opportunities to attend a variety of courses relevant to the client group that they care for. Four staff have completed a National Vocational Qualification (NVQ) at level three and another three staff are studying for a NVQ, two at level three and one at level four. Staff spoken with stated that the manager is `very supportive’ and that they would be able to discuss any problems that they might have in the workplace with him. There is a wide range of activities offered to residents. Each of the residents has a timetable of the activities that they participate in and the home keeps the timetables under regular review to ensure that the residents are continuing to enjoy their 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 6 activities. A resident spoken with stated that he was looking forward to his session at the gym on the day of inspection. What has improved since the last inspection? 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. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 7 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 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 8 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): 2. Quality in this outcome area is good. The home has a good record of assessing the needs of the residents and keeping assessments up to date. This ensures that all staff are clear about each of the residents abilities and needs. EVIDENCE: As required at the last inspection of the home arrangements were made for a social care assessment to be carried out to determine the needs of one of the residents. As the resident has complex needs a plan has been put in place to gradually work towards meeting his needs. There have been no new admissions to the home since the last inspection. A new format is being introduced for care planning and as part of this process the needs of all the residents will be reassessed. In relation to the plans seen it was noted that religious and cultural needs had not been assessed. The manager agreed that this was an area that needs to be assessment in relation to all residents. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 9 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): 6,7,8,9 Quality in this outcome area is adequate. It is acknowledged that the task of introducing a new format for care planning is not easy and that the transition period can be difficult. Further work is required to improve the quality of the record keeping in relation to daily records but with the future planned staff training, the new care plan system used to its full potential could be excellent. If there are no changes to a training plan after a year the home needs to consider whether it is appropriate to continue with the plan. EVIDENCE: The home is the process of introducing a new format for care plans. Three care plans were examined in detail during the first site visit. One had been completed under the new format and two were half completed. Information provided in the completed care plan included a detailed assessment of abilities and needs and an assessment of how autism affects the individual. There were detailed management guidelines and individual goals and training activities. Risk assessments were completed but had not been dated or signed. (These had been dated and signed by the second visit). In general the home does not use physical restraint. However in some cases where there are 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 10 specific guidelines in place where this is permitted. In relation to the care plan seen the guidance was conflicting and the manager acknowledged that it should be clarified. In relation to the second care plan, the home had just started the process of changing the format. Risk assessments had been reviewed on 24/1/05 and training plans had been reviewed on 9/5/06 and all were ongoing with no changes made. The third care plan was being worked on and information to be included was in three different locations. Details of the strategies to be used for managing this resident’s needs were found located alongside the daily records but were behind details of dates that were important to the individual. A behaviour chart was being kept and although the chart said 2006 it did not include the month. On the record chart seen for the month of May (confirmed by staff) there were entries to indicate that the resident had been verbally abusive on two occasions. On checking the daily records for details of the incidents there was no record that the resident had been abusive. On the second site visit the manager confirmed that incident forms had been completed for each occasion but he acknowledged that an entry should have been made on the daily record to see the incident report. There were risk assessments in place for the third individual. However it was noted that the individual had started to attend activities in the evenings. Some of the risks identified had been risk assessed such as challenging behaviour whilst in the car but there were other risks that had been identified but no written risk assessment had been drawn up. Examples include the timing of the activity, the need for experienced staff, the numbers of staff to be involved in each activity. Some of the daily records were detailed giving a good account of each individual’s day. Some were less detailed. The manager acknowledged that this is an area that he wants to see improve and training is being arranged to ensure that everyone is clear about what information needs to be recorded. It was noted that religious and cultural needs had not been assessed in any of the care plans. The manager agreed that this was an area that needs to be assessment in relation to all residents. Between the first and second site visit a lot of work had been carried out to speed up the updating of care plans but also to ensure that whilst care plans are in the transition period all relevant information is still available to staff. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 11 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): 12,13,15,16,17 Quality in this outcome area is good for almost all the residents and in relation to one of the residents very good progress has been made since the last inspection to introduce new activities. Record keeping in relation to meals served in the home needs to improve so that a judgement can be made about each individual’s diet. In relation to house meetings, records need to show more clearly the suggestions made by residents in relation to menus and how decisions are reached. EVIDENCE: In relation to three of the residents it was noted that two of the three had very full and varied timetables of activities. The majority of residents attend activities at one of the home’s day centres and also make use of community facilities via the day centre. Activities include woodwork, library, gym, swimming, bowling, college placements, work placements, art and gardening. At St Matthews residents enjoy watching videos, have aromatherapy sessions and enjoy pub trips. One of the residents spoken with had a very large selection of videos and this is his favourite pastime in the evenings. He stated 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 12 that he especially enjoyed his work placement and gardening and his regular trips to see his family. In respect of the third resident there was a detailed timetable in place but this was the plan that the home were working towards. This resident has recently starting attending the day centre one evening a week and the plan is to increase the frequency of these sessions. Very good progress is being made and the resident is now asking to stay longer and wanting to try new activities. They also have aromatherapy once a month and regular candle sessions through the week. This resident was spoken with during a visit to the home a few weeks prior to the inspection and they advised that they were enjoying the sessions at the day centre. On the first site visit the residents were attending their day centres and on the second visit the day centres were closed for staff training so the residents had all gone out on day trips. The daily routines are clear and there are rotas in place detailing each of the residents cleaning responsibilities. Some of the residents require support to complete these tasks and this is included in their individual programmes. During the inspection one of the residents went out independently to buy vegetables for the evening meal. Staff spoken with over the course of the inspection advised that they are in regular contact with the relatives of the residents. One of the relatives spoken with stated that they were happy with the range of activities provided for her son. Weekly house meetings are held and a record is kept of the outcome. Records include details of issues raised by individual residents, of complaints, of menus discussed, of holidays and appointments. There is an eight-week rotating menu in place. Menus do not show lunches, as residents tend to make their own packed lunches. There are no records kept of the choices they make. Records show that residents have a dessert one evening a week. Staff spoken with stated that although there is no dessert on the menu generally residents help themselves to fruit and yoghurts and can help themselves to snacks as and when they choose. Menus for the Sunday main meal are decided at the weekly house meetings. However records seen do not say what meal has been chosen, records seen stated `menus discussed, no problems’. The menus include a variety of meat, fish and vegetarian foods. One of the residents is a vegetarian and occasionally the menus make reference to a vegetarian alternative but not always. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 13 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): 18,19,20,21 Quality in this outcome area is good. There are good procedures in place to ensure residents’ healthcare needs are met and professional advice is sought when necessary. In the interest of security, the home needs to review the procedures for the storage of the key to the medication cupboard so that whoever is the designated key holder is accountable for the whereabouts of the key at all times. EVIDENCE: Staff spoken with over the course of the inspection confirmed that they support residents to attend healthcare appointments as required. A relative spoken with also echoed that the home is good at ensuring that healthcare appointments are made. When residents require specialist advise and support the home ensures that this is put in place. At the time of inspection the home had arranged for a psychologist to assist them in putting in place risk assessments and guidelines for one of the residents who has chosen to participate in some new activities and to consider some ethical dilemmas associated. Medication was examined in one house only. Record keeping for medication administered to residents was in order. Staff confirmed that they had received training on medication recently. It was noted that there were two tablets in a pot in the cupboard but it was not clear when they had been dispensed or 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 14 whom they were for. There are clear arrangements in place for the signing of keys at handover however the person with responsibility for the keys does not always hold the key on their person throughout the shift. The Trust has recently revised their policy on medication but the storage of the medication keys is not included in the policy. There is no written assessment of residents’ individual ability to understand the subject of dying and death. It was acknowledged that this is a long-term piece of work. The manager agreed to discuss this with other managers from within the Trust and that they could devise a questionnaire to send to relatives to seek their views and following this to assess what contribution, if any, residents would be able to make in an assessment of their individual wishes. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 15 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): 22,23 Quality in this outcome area is good. The home takes the views of residents and external complainants seriously and they do what they can to resolve issues quickly. Some of the complaints have been ongoing but with clearer record keeping some could be closed down as the original complaints have been addressed. There are good procedures in place in relation to adult protection. The individual arrangements for the management of disability living allowances need further clarification so that everyone is clear about how they are to be managed. EVIDENCE: There were eleven complaints recorded since the last inspection. Records show that the home responds quickly to take action when issues are raised. A small number of the complaints are complex. The home has dealt with the original complaints but as part of the process further issues have arisen. As a result the complaint record is ongoing. All staff spoken with over the course of the inspection stated that they had received training in adult protection and prevention of abuse. One incident of an adult protection nature was reported to the Commission and was investigated by Social Services under adult protection guidelines. The outcome was that the home had taken appropriate action. Two of the residents’ finances were examined in detail. Residents have their own bank accounts and all entitlements are paid directly into their accounts. A direct debit has been set up to pay the Trust their individual contributions for rent and transport. At the time of inspection the majority of residents were paying their full disability living allowance entitlement to the Trust. However, the arrangements for the management of these allowances are to be changed. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 16 The home also has a mobility budget so that if residents use buses or taxis the Trust pays for this. As recommended at the last inspection the arrangements for the storage of some documents held in relation to residents’ finances had been changed. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 17 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): 24,27,28,30 Quality in this outcome area is good. The home is well maintained and redecoration is ongoing. Good progress has been made since the last inspection in recording an evaluation after fire drills. Always including the length of each drill will assist in evaluating how frequently drills need to be held. EVIDENCE: All communal areas of both houses were seen and a small number of bedrooms. There is a programme in place to show the projected timescales for work to be undertaken. Since the last inspection the top floor flat in house three has been redecorated. This was seen in a site visit a few weeks prior to the first inspection date. Work carried out was to a good standard. The doors for the kitchen cupboards have been ordered. The resident who lives in the flat stated that he was very pleased with the changes made to the flat. He had chosen the colour scheme for the flat and was very happy with the result. The manager advised that the main priority now is the ground floor flat. It is anticipated that this areas will be redecorated in the next six weeks. At the same time tiling will be replaced in the kitchen in house three to redecorate the area around the new boiler. The lounge area in house three is also on the list for redecoration but this could be next year. It was noted that the carpet 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 18 at the door threshold is torn and although this had been repaired previously further work is required to prevent a possible trip hazard. There is a detailed fire risk assessment in place. Records show that alarms and emergency lights are tested in line with the home’s policy. Fire equipment is serviced at regular intervals. Fire drills are carried out regularly and a brief evaluation is recorded. The length of the drill is not currently recorded but the manager advised that this could be easily added to the format. Staff receive training in infection control. There are rotas in place clearly describing the cleaning tasks that must be completed and records to show that they have been carried out. All areas of the home seen were clean and there were no unpleasant odours. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 19 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, Quality in this outcome area is good. Staff recruitment procedures are generally good but where professional references cannot be obtained for prospective staff a risk assessment to identify the level of supervision necessary in the early stages of employment would assist in safeguarding the interests of the residents. An overall matrix for staff training would help the home to see at a glance which members of staff have received training and where training is required rather than having to continually go through each staff file. EVIDENCE: Since the last inspection six staff have left employment, some to work elsewhere in the organisation and some for alternative employment. One staff member was on long-term sick leave and one was suspended pending a disciplinary hearing. A new member of staff had been appointed and was due to commence working in the home pending satisfactory checks. In addition to this the manager confirmed that there were another 1.5 staff vacancies to be recruited. One resident has one to one funding and requests have also been made to Social Services for one to one funding for another two residents so that the home can more easily meet their complex needs. At the time of inspection the home was using relief staff to cover annual leave and sickness. As required at the last inspection the home monitors the need for waking night staff in house three. Records showed how often sleep-in staff are disturbed and for how long. Records seen showed very little disturbance. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 20 On the first day of inspection there was no senior member of staff on duty but one of the care staff facilitated the inspection. On the second day the manager advised that that had changed their procedure to ensure that there would always be a senior member of staff on duty for each shift. During the inspection there was an opportunity to speak with the NVQ Assessor. Although self-employed, she works on behalf of the Trust providing support for staff on NVQ training. At the time of inspection she was supporting one member of staff through level four and the A1 Assessors course, and two staff through level three. Four staff had already completed NVQ level three. She also confirmed that there would be opportunities for more staff to start studying in September. Staff spoken with during the inspection stated that they are trained to work in both homes so that they can help out in emergency situations. They ensure that they keep up to date with changes in care plans. There is a large file containing details of all staff training. Each section contains individual staff qualifications and certificates. A couple were examined and it was found that staff have access to a wide range of training opportunities. However, there is no overall matrix detailing how many of the staff are up to date in each area of training. An appointment was made at the head office to view staff recruitment records. Two staff files were examined. Files contained completed application forms, two written references, identification and details of previous qualifications. CRB checks had been obtained for staff. In relation to one member of staff there were two character references only. Attempts had been made to seek a professional reference but there was no record to show if they had not received a reply or if the referee had refused to give a reference. The staff member had an employment history so it was not clear why there were two character references. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 21 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): 37,38,39,40,42, Quality in this outcome area is good. Improvements have been seen in the area of quality assurance with residents and their relatives completing satisfaction questionnaires. The use of partnership days is excellent and should ensure that everyone is kept informed of relevant issues to the home and the Trust. The introduction of the newsletter is also an excellent example of how the home seeks to keep everyone informed of important issues. The risk assessment in place for one of the residents who chooses to have his water hotter than the agreed limit for safety, must be updated to reflect the agreed maximum water temperature acceptable to the resident and the home. EVIDENCE: The manager has worked for a number of years with adults with autistic spectrum disorders and learning disabilities. He is a qualified nurse. He is due to start NVQ level four in September 2006. Staff spoken with over the course of the inspection stated that he was `very supportive’ and that they would be able to discuss any problems that they might have in the workplace with him. As part of the inspection process survey cards were sent to residents giving them the opportunity to comment on the quality of the care provided in the 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 22 home. Seven responses were received and each of the seven residents had received support to complete the surveys. Two included additional comments such as in relation to a question about activities through the day `I like Sussex House’ (the day centre they attend). Another stated `I’m happy’ and `I like my staff’. Four responded `sometimes’ to a question about making decisions about what they do during the day and two responded `no’ to a question asking can you do what you want during the day. Overall most of the responses were very positive. A staff member spoken with stated that the previous day a resident had stated that they had been unable to sleep the previous night. He went to his first activity but when it came to the second activity, which was swimming, he chose not to join in and instead watched the activity from the poolside. The manager confirmed that the Trust has an annual development plan but there is no specific annual development plan for the home. The home also sent a questionnaire to residents seeking their views. The manager confirmed that he would be collating the responses and making them available to residents along with any action plan as a result of issues raised. A partnership day has been arranged to be held in the summer. All relatives and staff will be invited to attend and this is an opportunity for everyone to get together socially and to hear about plans for the coming year. The home has recently introduced a new Newsletter. It is proposed to issue new letters quarterly. As part of the inspection process three relatives were contacted for their views on the quality of the care provided in the home. One relative chose to respond. They were very supportive of the home saying that there had been a big improvement in their relative’s mental health since he moved to the home. There relative attends a good range of activities and they would like to see an even greater level of activities. They have raised this at reviews and the home is seeking additional funding to try to achieve this. They also stated that St Matthews is homely, the diet is good and that staff make arrangements for their relative to attend a wide range of health care appointments. The revision of the policy and procedure manual is still ongoing. The Trust has recently recruited a new member of staff with a specific remit to review and update the policies and procedures. Policies seen included the confidentiality policy and the whistle blowing policy. On 9 May 2006 the General manager advised that the Trust hope to have the new policy and procedures manual up and running within the next three months. The manager confirmed that since he has been in post the home has not had an inspection from the Environmental Health department. He agreed to contact the department to find out the current frequency of inspections for St Matthews. The manager confirmed that window restrictors had been fitted to 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 23 windows above ground floor in house three. It has been risk assessed that this is not necessary in house five. On the first site visit water temperatures were tested at four outlets. Three were within agreed safety limits. The water temperature at the fourth outlet was 75°C, which is well in excess of the agreed limits. An immediate requirement was made to have the water temperature adjusted. By the second site visit the home had confirmed that a mixer valve had been fitted to the outlet concerned. However, the manager advised that a risk assessment had already been in place assessing the use of the bathroom as safe for the one individual who uses it and the resident had already made a complaint that the water was too cold. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 2 2 X 2 X 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3 Regulation 12(4b) 14(2a) 13(4a,c) Requirement As part of the assessment process the religious and cultural needs of all the residents must be assessed. In relation to one of the residents, the home must carry out a written risk assessment of all perceived risks associated with the newly introduced activities. Records must be kept of the actual meals served to all residents. The procedure for the storage of the key to the medication cupboard must be reviewed and included in the homes medication policy. The home must clarify their procedures for the management of residents’ disability living allowances with residents and their representatives. The loose carpet at the threshold of the lounge in house three should be repaired. The risk assessment in place for one of the residents who chooses to have his water hotter than the agreed limit for safety, must be DS0000028056.V289831.R01.S.doc Timescale for action 30/11/06 2. YA9 15/06/06 3. 4. YA17 YA20 17(2) Sch 4 para. 13 13(2) 15/06/06 15/06/06 5. YA23 17(2) Sch 4 para. 8 30/06/06 6. 7. YA24 YA42 13(4a,c) 13(4) 15/06/06 15/06/06 3-5 St Matthews Road Version 5.1 Page 26 updated to reflect the agreed maximum water temperature acceptable to the resident and the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations In relation to care planning the home should clarify their position on the use of physical intervention and ensure that there are clear procedures in place for the tracking of evidence in relation to incidents. Each week at residents’ meetings residents choose the menu for their main meal. Records of house meeting minutes should show how the decision for the Sunday meal is reached. The home should review their recording of complaints so that they can close down all complaints that have been dealt with and if further complaints arise they should be dealt with separately. The current procedure whereby residents receive money for mobility, then pay the Trust for transport costs, and then have to ask the Trust for money for buses should be reviewed. In relation to staff recruitment, where possible professional references should be obtained. If is not possible to do so then the reason should be documented and if necessary a risk assessment carried out to determine the level of staff supervision to be provided during the induction period. The home should keep a general staff matrix so that a judgement can be made at a glance about which members of staff need to attend training on particular subjects. The manager should continue to train to NVQ level 4 or its equivalent in management. There must be an annual development plan in place that is specific to St Matthews. The revised policies and procedures should to be reviewed by the board of directors and if suitable made available to DS0000028056.V289831.R01.S.doc Version 5.1 Page 27 2. YA17 3. YA22 4. YA23 5. YA34 6. 7. 8. 9. YA35 YA37 YA39 YA40 3-5 St Matthews Road staff as soon as possible. 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 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. Extracts may not be used or reproduced without the express permission of CSCI 3-5 St Matthews Road DS0000028056.V289831.R01.S.doc Version 5.1 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. 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