Inspection on 23/07/07 for 3 Brae Walk

This inspection was carried out on 23rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

3 Brae Walk 18/08/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 3 Brae Walk 3 Brae Walk The Wheatridge Gloucester Gloucestershire GL4 5FA Lead Inspector Mr Richard Leech Key Unannounced Inspection 23rd & 27th July 2007 10:00 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 Brae Walk DS0000066771.V342819.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. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Brae Walk Address 3 Brae Walk The Wheatridge Gloucester Gloucestershire GL4 5FA 01452 530119 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.brandontrust.org The Brandon Trust Mr Michael-Paul James Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (2), Physical disability (2) of places 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2006 Brief Description of the Service: 3 Brae Walk is a detached two-storey house in a residential area about two miles from Gloucester city centre. There are two bedrooms on the ground floor for people with mobility difficulties. There are further four bedrooms on the first floor. The home has a lounge, a kitchen-diner and a landscaped garden. Some of the bedrooms have en-suite facilities. There are bathrooms on the ground and first floors which are fitted with aids and adaptations. The home is run by the Brandon Trust, which also runs other care homes in Gloucestershire and the South-West. Accurate information about fees was not obtained during this inspection. Prospective service users are offered the opportunity to visit the home and have access to the Statement of Purpose and Service Users Guide. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Monday morning, lasting until early afternoon. A second visit was made on the following Friday from about 10:00 to early afternoon. All of the people living in the home were met with, along with most of the staff team. The manager was not working in the home at the times when the visits took place. Prior to the inspection the manager completed an Annual Quality Assurance Assessment (AQAA). Surveys were also distributed to people involved with service users’ care, resulting in a good response rate. Respondents included staff, healthcare professionals and family members. During the visits to the home all of the communal areas were checked, along with some people’s bedrooms. Various records were looked at including examples of care plans, risk assessments, medication charts, training summaries and policies & procedures. At the time of the both visits the home was without running water due to a prolonged water supply emergency affecting most of the county of Gloucestershire. Just before the visits the home had also been affected by some power cuts. What the service does well: Good systems are in place for assessing the needs of people who may move into the home. This helps to ensure that the service would be able to meet these needs. There are also good systems for care planning and for assessing and managing risk. Care is very individualised and people are offered choices and helped to be in control of their lives as far as possible. Their rights are respected and they are included in the running of the home. Service users are listened to and staff are skilled at communicating with the people that they support. Measures are in place which help to keep the people living in the home safe from harm and abuse. The people living in the home are supported to take part in a range of activities which reflect their needs and interests, both indoors and in the community. They are also supported to stay in contact with family and friends. People are offered an imaginative menu. Individual needs around eating and drinking are appropriately met. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 6 The team supports people well with their personal care needs. Healthcare needs are also appropriately met and the team has good links with healthcare professionals in the community. The handling of medication is generally good. The team is commended for the excellent care provided for somebody at the end of their life. Feedback from professionals and family members about the care was very positive indeed. The physical environment meets people’s needs, although some planning will need to take place as issues around ageing and mobility become more significant. Staff keep the home fresh and clean. Health and safety is well managed. Staff are caring, dedicated and skilled. There is a strong commitment to providing the team with appropriate training. The service is well run. Systems are in place for checking and improving the quality of care. Excellent feedback was obtained from people with an interest in the service including healthcare professionals and relatives. There was consensus that the standard of care was good. What has improved since the last inspection? In the AQAA it was reported that the Statement of Purpose and Service Users Guide had been updated. Improvements have been made to people’s activity schedules, helping them to lead fuller lives. The systems for handling people’s money have been made more robust. Some improvements have been made to the physical environment, including building a wet room facility on the first floor. A new vegetable plot has also been created in the garden. Further progress has been made with updating care plans and making them more accessible and person-centred. Work on health action planning has been taken forward. Staff have been supported to access more specialist training about the conditions and needs of the people living the home. The home is now connected to the Internet and email, improving communication and access to information. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 7 The service has responded positively to requirements and recommendations made in the previous inspections. 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. 3 Brae Walk DS0000066771.V342819.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 3 Brae Walk DS0000066771.V342819.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A good framework is in place for handling admissions, helping to ensure that the home can meet the needs of people who move in. EVIDENCE: There had been no new admissions since the previous visit. In the last inspection a referral form was viewed along with an admissions flowchart. The manager had also described his understanding of the admissions procedure. In the AQAA the manager provided an update, stating that prospective service users were: • • • • Offered a copy of the Statement of Purpose and Service Users Guide Invited to visit the home Offered lunch and/or an evening meal Supported to have an overnight stay The manager also stated that there was a three-month trial period and that the package of care was tailored to meet individual needs. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 10 At the time of the inspection it was reported that one person had visited the home with their social worker and a relative with a view to possibly moving in. It was noted that the Trust’s policy about admissions dated from 2000. This therefore pre-dates the National Minimum Standards. Although it provides a reasonable framework, this should be reviewed and updated, including taking into account the relevant National Minimum Standards. 3 Brae Walk DS0000066771.V342819.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs and goals are reflected in their individual plans, helping to ensure that care is person-centred. A system is in place for assessing and managing risks, promoting people’s safety in day-to-day life and when they participate in activities. People using the service are enabled to make meaningful choices, helping them to feel in control of their lives. EVIDENCE: Care plans for two of the people living in the home were checked. These provided clear guidance about how their individual needs were to be met, covering areas such as communication, personal care, eating & drinking, mobility and activities. Care plans included an emphasis on promoting independence and reflected people’s identified preferences and choices. There 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 12 was documentary evidence of regular review. Examples of monthly keyworker summaries were also seen, providing a good overview of key areas and noting issues around choice. There was evidence of the people living in the home being invited to contribute as far as possible. Observation along with discussion with staff provided evidence of care plans being followed, such as around eating & drinking. The manager attended a person-centred facilitator’s meeting in May 2007 and had brought back some literature about facilitating person-centred planning. During the visits staff were seen offering people choices around such areas as activities and food & drink. Daily records provided further evidence of people being offered choices in daily life. Care plans also referred to limitations where relevant, including a rationale and with evidence of regular review. CSCI had been informed of an issue around restrictions earlier in the year, and the team had liaised with external professionals for advice. Risk assessments for two people were checked. These covered significant areas of risk and provided guidance for staff. There was written evidence of periodic reviews and updates as appropriate. In due course they may benefit from being typed up in order to improve legibility and to facilitate update. Missing person’s proformas had been completed for the people living in the home, including photographs. 3 Brae Walk DS0000066771.V342819.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 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to take part in a range of activities in the home and community which reflect their needs and interests, promoting their physical and mental wellbeing. This includes maintaining contact with family and friends. The rights of the people living in the home are respected, helping them to feel valued and included. A varied and balanced menu is offered which takes into account people’s needs and preferences, promoting their health and quality of life. EVIDENCE: Care plans made reference to people’s activities, and noted their right to choose and to refuse these. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 14 At the time of the visits normal activity programmes had been suspended due to the flooding and water supply difficulties affecting most of the county. Staff were seen providing in-house opportunities for people on an individual basis, as well as taking people out for trips to shops and local attractions. The mood was cheerful and positive and the people living in the home appeared to be engaged and stimulated. Daily records and monthly keyworker summaries for two people were looked at. These provided evidence of people being supported to take part in activities appropriate to their individual needs. This included attending day centres, shopping, having meals and drinks out, visiting attractions such as a zoo, having reflexology and taking part in hydrotherapy. Some correspondence on file for one person from a healthcare professional stated, “…[service user] has a good programme of activities during the week…” Staff described the holidays that people had taken to date in 2007. This had included a very successful stay at a farm, where one person had enjoyed watching the activities taking place there as well as exploring the local area. On the AQAA it was noted that people living in the home were now accessing local sensory facilities and that some people were also using public transport around Gloucester. Plans for the next 12 months included mapping facilities in the local area in more detail with a view to expanding the opportunities available to people and to encourage staff to continue to be creative and imaginative about offering people new activities. The team was also looking at alternative music sessions, those previously on offer having ceased due to circumstances beyond their control. It was reported that new vehicle was about to be delivered which would accommodate more wheelchair users at a time. Care plans noted important family relationships and how these were promoted. Discussion with staff as well as notes such as keyworker summaries provided much evidence of family contact being maintained as far as possible. The visitors’ book also provided evidence of visits by family members. Very positive feedback was obtained from relatives completing CSCI survey forms. People’s rights were referred to on care plans, such as the right to privacy. Discussion with staff along with daily records provided evidence of staff respecting people’s rights. People were seen choosing where they spent time in the home. People were also seen being involved in the daily running of the home such as by taking part in household tasks. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 15 Menus were seen in the kitchen. These were varied and imaginative. During the visits some mealtimes were observed. People were seen to be having appropriate support and appeared to be enjoying their food. The atmosphere was relaxed and convivial. As noted, care plans made reference to individual needs around eating and drinking. Observation and discussion with staff provided evidence of these being carried out. Some of the people living in the home were asked if they liked the food and indicated that they did. They were seen to be offered choices, such as about sandwich fillings and drinks. Staff were seen describing what they were doing/about to do in a respectful manner, such as when putting on a protective apron. On the AQAA it was noted that photos of food/meals would be taken again in order to renew the total communication aspect of menu planning for the people living in the home. 3 Brae Walk DS0000066771.V342819.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, 20 & 21 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs are met, helping them to stay well. There is scope to improve some aspects of policy and practice around the handling of medication in order to provide a more robust framework. Issues around illness and death are handled with great skill, compassion and sensitivity, ensuring that excellent care is provided when people are at the end of life. EVIDENCE: Care plans described how people’s personal care needs were to be met. At the time of the visits staff were having to meet these in different ways due to water supply issues. However, the people living in the home were seen to be clean and were dressed smartly and individually. One survey form from a relative noted that the people living in the home were always well dressed in their experience. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 17 Protocols about the management of seizures were seen. These provided clear guidance and had been reviewed in June 2007. Staff were seen to be attentive to individuals’ comfort, for example, closing a curtain when they noticed that the sun had come out and may be making one person feel hot. Staff were also observed being discreet and sensitive when offering routine personal care support during the day. Healthcare notes, health action plans and keyworkers’ monthly summaries all provided evidence of people accessing routine and specialist healthcare services according to their needs. There was documentary evidence of people being offered annual health checks. Positive comments from healthcare professionals were seen on letters. There was also feedback from healthcare professionals completing CSCI surveys about the home. Comments included that the team was ‘excellent’ and that healthcare needs were met ‘in a sensitive way’. There was also a comment that ‘recommendations are always acted on’. Surveys noted good communication with external professionals and best interests meetings being arranged when appropriate. Particularly positive feedback from a wide range of sources was obtained about the terminal care provided for one person. A typical summary was, “…staff were responsive, empathic and committed to providing the best care they could and to maintain dignity and quality of life”. Other comments included that care had been ‘first rate’ and ‘the best care possible’. Tremendously positive feedback had also been written in the visitors’ book by family members of the person who had passed away. Examples of medication administration records were checked and appeared to be satisfactory. Storage appeared to also be in order besides one preparation being found with an expiry date of September 2006. Staff said that it was no longer used but nonetheless this needed to be disposed of. The Trust’s medication policy was seen to date from 2000, before the National Minimum Standards. This should be reviewed and updated to take into account the Standards as well as other relevant national guidance issued since then. The AQAA noted plans for future improvements around health and personal care including: • • • More person-centred planning in this area, for example to help empower people to make healthcare choices. Accessing further training to raise staff awareness around issues of ageing for people with learning disabilities. Training in the Mental Capacity Act 2005. It was also reported that staff had received training about key areas such as diabetes, epilepsy, dementia care, intensive interaction and mental health. 3 Brae Walk DS0000066771.V342819.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 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to respond to expressions of unhappiness and dissatisfaction, helping people to feel listened to and valued. Appropriate measures are taken to help protect the people living in the home from harm and abuse. EVIDENCE: The complaints procedure was checked. Text and picture versions were available. These provided a framework for the handling of complaints and included details of CSCI. Care plans included reference to how people communicated, including expressing discontent. Staff were seen throughout the inspection gauging people’s moods and feelings and responding appropriately. The Trust has policies covering safeguarding adults and whistle blowing, although the latter dated from 2000 and should be reviewed. The home has a copy of the local adult protection procedures. There is a traffic light system for responding to challenging behaviour where necessary. Examples viewed were seen to be clear and comprehensive. Staff talked through how they responded to incidents of challenging behaviour. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 19 Training records indicated that staff had accessed training about the protection of vulnerable adults. Discussion with staff provided evidence of a culture where people felt empowered to challenge practices and confident about raising concerns if necessary. Financial records for two of the people using the service were sampled. All spending was accompanied by a numbered receipt and records seen appeared to be in order. Regular balance checks were being done. In some cases entries had just one signature. Ideally a second person should check and sign each entry. Discussion with staff along with the response to the previous report provided evidence that issues around the funding of staff refreshment costs when accompanying service users on trips had been clarified. According to the AQAA staff were to receive further training about the handling of service users’ finances to improve their understanding of this area. The manager was due to attend training called ‘Money Matters’ in July 2007. 3 Brae Walk DS0000066771.V342819.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 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A clean and comfortable environment fitted with aids and adaptations is provided, making the home appropriate to people’s needs. Planning for the future will need to begin in view of the likelihood of increasing mobility issues. EVIDENCE: All of the communal areas and some bedrooms were checked. The home was reasonably decorated throughout. The atmosphere was homely. Aids and adaptations were provided as necessary and furniture appeared to be of good quality. New curtains had been fitted in the lounge. Staff reported that the lounge carpet had been cleaned, although it was agreed that it was beginning to need cleaning again. The walls in the room would also benefit from being repainted. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 21 A new wet room was in operation on the first floor. There was also an adapted bathroom on the ground floor. A requirement about the décor in one person’s bedroom had been met. The garden was seen to be well maintained. However, the patio was uneven, with some slabs being loose. Staff said that this had been reported and that quotes were being obtained for this to be addressed. This should be taken forward. A new vegetable patch has been created. Staff reported that several of the people living in the home enjoyed looking at this and/or helping to maintain it. A cleaning schedule was seen in the kitchen. The home was clean and fresh throughout, despite the water supply difficulties at the time. Staff were temporarily using other local laundry facilities. It was reported that the home had been awarded four stars (a very good rating) on the Environmental Health Department’s scoring system. Whilst the physical environment was meeting people’s needs at the time, some staff expressed concern about the future given the age of the people living in the home. There was a feeling that it was only matter of time before some people would have difficulty going up and down the stairs to the point where it would be unsafe or impossible. The nature of the home would mean that fitting a shaft or stair lift would almost certainly not be feasible. Some healthcare professionals also raised this point. Issues around ageing and mobility in respect of the physical environment will need to be considered and planned for. According to the AQAA the home was due for repainting within the next 12 months. The Housing Association was also being asked to fit bedroom door locks for three of the people living in the home. It was also reported that the vegetable plot would be expanded and a sensory herb garden would be created. 3 Brae Walk DS0000066771.V342819.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 & 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are competent and skilled and have access to professional development opportunities, promoting the quality of care provided. Whilst practice in recruitment and selection appears sound, updating the underpinning policy would make the framework more robust. Good arrangements are in place for staff training, enhancing the standard of care. EVIDENCE: According to the AQAA over 50 of the staff team had attained NVQ level 2 or higher in health and social care, with further plans for people to access NVQ courses. Staff turnover in the home was reported to be low. Throughout the inspection staff were seen to be very focussed on service users’ needs. They were highly attentive and provided individualised support in a sensitive, skilled and warm 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 23 manner. When supporting people they were seen to describe what they were doing/about to do in order to keep the person informed. As noted, the home was experiencing difficulties with water supply. It was evident that the team was pulling together and responding to the situation in a calm and professional way. Survey forms returned to CSCI were tremendously positive about the staff team. Comments included, “staff are very skilled and client orientated” and “staff keep the clients very happy”. Some of the people living in the home were asked if they liked living there and replied that they did. It was reported that there had been no new permanent staff since the last inspection. Staffing files were therefore not checked on this occasion. The AQAA described procedures around recruitment and selection, the manager expressing confidence that systems were ‘robust’. Staff surveys returned to CSCI provided evidence of correct recruitment procedures being followed in the past. The standard was assessed as met when previously inspected in August 2006. The Trust’s recruitment and selection policy was dated April 2004. This predates PoVA and associated changes to the Care Homes Regulations (although other more up to date policies and procedures did refer to staff being checked against the PoVA list). It should therefore be reviewed and updated. A copy of the Trust’s learning and development programme for 2007/2008 was seen in the home. A wide range of courses was offered. A training summary was seen. This provided evidence of staff having access to a range of mandatory and specialist training relevant to the needs of the people living in the home. As noted, this included areas such as autism, diabetes, dementia and epilepsy. According to the schedule all staff were due to have training about continence in October 2007. At the time of the inspection a person had just finished a secondment from another home to act as deputy manager. According to the AQAA a position of senior social care worker was to be readvertised and filled. Staff in the home reported that there were regular bank staff who could be called upon to cover shifts when necessary. Staff surveys were very positive about the service and the care provided. Some people felt that communication within the team could be further improved and that there was some duplication of paperwork. People commented on how well the team worked together. 3 Brae Walk DS0000066771.V342819.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 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well-run, promoting positive outcomes for the people living in the home. Systems are in place for checking and improving the quality of the service. There are a range of measures in operation which help to protect service users’ health and safety. EVIDENCE: The manager has completed the Registered Manager’s Award and the NVQ level 4 in health and social care. He plans to do the NVQ assessor’s award in due course. According to information seen in the home the manager had attended a range of relevant courses and planned to do more training in the 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 25 future. Completed or planned courses included areas such as finances, performance management, supervision & appraisal and the Mental Capacity Act. In the AQAA the manager expressed a commitment to upholding the principles of the Care Standards Act and the White Paper ‘Valuing People’. As noted throughout the report there was very positive survey feedback about the home from relatives and health & social care professionals. Through surveys and discussion staff gave positive feedback about the manager, for example, describing him as dynamic. Regulation 26 reports are being forwarded regularly to CSCI. These reports are made following an unannounced visit by a representative of the service provider and take place about once a month. The Trust has a series of core quality standards. These are subject to review and periodic audits take place against them in the Trust’s services. Monthly keyworker summaries included contributions from service users where they able to provide direct feedback. As noted elsewhere in the report the AQAA included a number of areas where improvements were planned, providing evidence of a vision for moving the service forward. The AQAA also noted that pictorial service user surveys were used from time to time as part of seeking people’s feedback. There has been a good response to requirements and recommendations made in previous reports. Minutes from recent team meetings provided evidence of wide ranging discussion about aspects of the service and how the quality of care could be improved. Fire safety records were checked and appeared to be satisfactory. Other records provided evidence of routine health and safety checks taking place. On the AQAA it was noted that portable appliances had last been tested in February 2006. Some appliances had stickers confirming this although others were dated September 2006. If some have not been tested since February 2006 then they should be retested, it being generally recommended that such tests are annual. In surveys and discussion staff reported no particular health and safety concerns other than the state of some parts of the patio (see section on ‘environment’). As described earlier in the report, staff were coping well in challenging circumstances at the time of the visits. Plenty of drinking water had been 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 26 obtained and arrangements had been made for delivery of a water bowser and portaloo. The service has a general health and safety policy dated September 2005, with further policies about specific areas such as moving and handling. Some records of in-house health and safety/environmental audits were seen. These were reported to be monthly although the most recent one appeared to have been done in May 2007. If so, these should be restarted. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 27 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 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 4 3 x 3 x x 3 x 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 28 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 2 3 Refer to Standard YA2 YA9 YA20 Good Practice Recommendations The Trust should fully review and update the admissions policy dating from 2000. Risk assessments may benefit from being typed up in order to improve legibility and to facilitate update. The Trust’s medication policy dated 2000 should be reviewed as soon as possible to take into account the National Minimum Standards as well as other relevant guidance such as from the Royal Pharmaceutical Society and Royal College of Psychiatrists. Address weaknesses in the systems for auditing/checking medication storage which resulted in an out of date preparation being retained as noted in the text. Review the whistle blowing procedure dating from 2000. Entries in service users’ financial records should be consistently double signed. Consider redecorating the lounge. Consider also replacing the lounge carpet or deep-cleaning it again. DS0000066771.V342819.R01.S.doc Version 5.2 Page 29 4 5 6 YA23 YA23 YA24 3 Brae Walk 7 8 9 YA24 YA34 YA42 Begin work to resolve the issues with loose and uneven patio slabs as soon as possible. Assess and begin to plan for the kinds of issues around ageing and mobility which are likely to present in the next few years in respect of the physical environment. Review and update the policy on recruitment and selection to take into account changes to legislation and practice. Check when PAT testing last took place and whether some or all appliances are due to be tested again. Check also when the last monthly internal health and safety audit took place and whether another is due. 3 Brae Walk DS0000066771.V342819.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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