Inspection on 25/10/05 for 3 Hesding Close

This inspection was carried out on 25th October 2005.

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 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 Hesding Close 17/06/08

3 Hesding Close 28/01/05

3 Hesding Close 04/08/04

3 Hesding Close 04/03/04

Similar services:

32 Beaumont Way

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

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

CARE HOME ADULTS 18-65 3 Hesding Close Hanham South Glos BS15 3LP Lead Inspector Wilfried Maxfield Announced Inspection 25th October 2005 09:30 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 3 Hesding Close Address Hanham South Glos BS15 3LP 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) 0117 9607858 0117 970 9301 Aspects and Milestones Trust Mrs Anne Elizabeth Swain Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home may accommodate up to 5 persons aged 45 years and over and 1 person aged 40 years and over with learning disabilties The Manager, Mrs Swain, to undertake NVQ training at Level 4 in Care & Management by 2005 7th June 2005 Date of last inspection Brief Description of the Service: 3 Hesding Close is a care home operated by the Aspects and Milestones Trust. The home is registered for up to six adults with learning disabilities over the age of 45. 3 Hesding Close now accommodates and supports only five service users after a former double bedroom has been changed into a single occupancy room. The home consists of a detached, extended two-storey house. It is situated in a cul de sac in an area on the Bristol/South Gloucestershire border, four miles from the centre of Bristol. Local shops are within a quarter of a mile from the home. Supermarkets, other amenities and bus stops are in Hanham, which is less than a mile from the home. The premises have one single ground floor bedroom and bathroom with a hoist and four single bedrooms and one bathroom situated on the first floor along with staff sleeping-in room/office. Communal rooms consist of a main lounge, dining room and adjoining second lounge area. There are attractive well-maintained gardens to the rear of the property equipped with a barbeque, a variety of garden furniture and a summerhouse. There is also a paved area to the side of the property that is overlooked from a lounge. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first announced inspection for 3 Hesding Close in 2005. The purpose of the visit was to monitor the progress to the requirements from the last unannounced inspection in June 2005 and review the standard of the care provided to the residents at the home. The seven requirements and three recommendations made as a result of the last inspection were discussed with the Registered Manager and their satisfactory implementation followed up. The Registered Manager was in attendance throughout this visit enabling the inspector to focus on vital aspects of the organisation and management of the home. This included the inspection of essential records including service user plans and other systems required to document the care given at Hesding Close. The manager also aided a detailed tour of the premises. In spite of the considerable communication problems experienced by some of the residents at the home the manager was able to facilitate meaningful and insightful contact between the inspector and all of the residents. Three members of staff were interviewed and a comprehensive assessment of the home’s staffing situation was undertaken. The Commission received a number of ‘Comment Cards’ from Health and Social Care Professionals, Relatives and Service Users prior to this announced visit. Where appropriate, views from these were incorporated into this report. Relevant issues identified by the home’s appointed visitor in Regulation 26 reports were also incorporated in this report. A new set of policies and procedures was available at the home. A sample was read as part of this inspection. The inspection took place over a period of 8 hours. What the service does well: This was a positive inspection; although there are a number of requirements and recommendations following this visit this should not detract from the high level of support and commitment from the staff team to providing a good service at the home. 3 Hesding Close has admitted two new residents over the last 12 months. Their admissions were managed competently and professionally. The home has developed considerable specialist understanding in providing care for the needs of residents with autistic spectrum disorder. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 6 An experienced staff team looks after the complex and sometimes challenging needs of the service users. All staff interviewed commented on the positive atmosphere within the team and the clear and supportive attitude of the Registered Manager. The environment is of a good quality. Overall the home presented as well looked after, clean and well equipped for its purpose. The (relatively) new Registered Manager of 3 Hesding Close is commended for the resourceful and efficient way in which she has brought the home back to a good standard of care. What has improved since the last inspection? The Trust has provided the home with an impressive new and updated range of policies and procedures. The home has focused on issues relating to the management of aggressive incidents and their assessment and recording. A requirement from the last inspection has been partially addressed. The staff group is commended for the way it has developed and improved the behaviour management strategies of two of its most challenging residents. The home is commended for the way it supports an all important daily rhythm and routine for these residents as a way to stabilize emotions and behaviours. The home has begun to adopt the Person Centred Planning process. This has already started to influence recording and assessment processes positively. The tracking of health care appointments was now found to be excellent. Resident’s health needs are now well recorded. Although still not within the expected monthly frequency, Regulation 26 visits and reports are now more regular. Detailed risk assessments have been put in place explaining the use of electronic devices on resident’s bedroom doors. The home’s consultation with residents on the matter is well recorded and was conducted in an exemplary fashion. The home has improved its continence management and issued better procedures for the guidance of staff. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 7 The home has improved its recording tools for documenting incidents of physical intervention and issued better procedures for the guidance of staff. 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 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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, 3, 4, 5. The Trust issues a clear and accessible Statement of Purpose and Service User Guide. Prospective residents are well informed before admission and their needs well assessed. Written contracts and Terms and Conditions are of a high standard and discussions and consultations with residents, friends and advocates are managed well. EVIDENCE: Updated versions of the Statement of Purpose and Service User Guide have been sent to the Commission after recent inspections and placed on file. Both were scrutinised as part of this visit and found to be of a high standard. The Service User Guide is also available in a pictorial format. It is apparent, that the home has addressed all previous concerns in past Commission reports about the way it admits residents and has since significantly improved its admission procedures. 3 Hesding Close has admitted two residents in the past 12 months. National Minimum Standard 2 expects the home to assess the needs of residents prior to admission and some very good examples of initial assessment work were found. In keeping with its own procedures, the residents were only admitted after completing at least 3 visits and one additional overnight stay. The two residents in question were spoken with as part of this inspection and were positive about the way they had been welcomed and been supported to settle down. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 10 Good written details of newly admitted residents assessed personal, social and healthcare needs were found. These were talked about with the Registered Manager and actions taken by the home to meet individual residents needs were discussed. Ongoing assessment efforts were sometimes scant but mostly well reflected in individual residents Plans of Care. In discussing some of this work with the Registered Manager good and relevant examples were given to demonstrate how the home delivers assessed needs on a day-to-day basis. The Trust has a Statement of Terms and Conditions with each resident, which has been discussed, agreed and signed by both parties. Terms and conditions are in place for all the individuals living at the home and the documents viewed contained all appropriate information including details about financial contributions, what services this covers and what not. The Licence Agreement also informed the individuals how their needs will be reviewed, house rules and how to make a complaint and the services that are provided at the home. This document was also available in pictorial format. All agreements had been signed by or on behalf of residents. There was good evidence that in a significant amount of cases family, friends or an advocate had supported this process. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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, 9. The home is slow in changing to the Person Centred Planning method of assessment. However, most of the individual plans of care are of a good standard. The staff team is providing high quality and attentive care and the complex needs of service users are at present being met. Risk assessments at the home are now of a very good quality. EVIDENCE: In spite of clear signs of improvement at the time, the last inspection had nevertheless revealed some shortfalls in areas of record keeping particularly relating to the somewhat scant assessment of residents. The home is still developing its assessment procedures to adhere to the conceptual framework of the Person Centred Planning model. This has been commented on in a number of previous reports without clear evidence that this intention was becoming a reality and would produce results soon. Again progress was found to be slow, with only one up to date example of a Plan of Care having been produced. However, when scrutinizing this document it was found to be of an excellent quality. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 12 It is still the intention of the Registered Manager to update all of the homes assessment information to conform to the Person Centred model. Additional staff training for this is still needed and further guidance from specialist staff employed by the Trust will need to be obtained more frequently. The home needs to be mindful of the fact that the current transition period results in differing qualities of assessments and that this might lead to an imbalance in the way the staff team views the overall needs of individual residents. This is particularly relevant because individual needs assessments in place for some residents continue to be ‘minimalist’. Only a full and thorough identification of needs will enable staff to demonstrate that these same needs are met by a consistently evidenced method. However, in line with the previous report, this inspection found good evidence from observation and interviews that the staff team is providing high quality and attentive care and the complex needs of service users are at present being met. Staff spoken with clearly demonstrated to be very knowledgeable of the support required by those living at the home. Equally, a health care professional who is in regular contact with the home wrote positively about the “very caring and competent staff group” in a ‘Comment Card’ send to the Commission during the inspection process. The staff team is commended for the way it has studied and deepened its approach to residents on the Autistic Spectrum and has understood certain traits and behaviours. This has been achieved with the help of the South Gloucester Learning Difficulty Service who helped to conduct a detailed strategy assessment for one of the residents. Subsequently, strategies have become more efficient. The Assistant Psychologist involved by the service was very complimentary about the staff teams “thoughtful and reflective manner” in correspondence relating to this complex case of challenging behaviour. During the last unannounced inspection the inspector had raised concerns with regard to the assessment and subsequent management of two residents’ aggressive behaviours. A great number of Regulation 37 notifications had been received by the Commission in March, April and May 2005. All of these related to the challenging behaviours of two of the residents. Behaviour management procedures concerning the individual residents were discussed with a number of staff and were now found to be robust and clear. All concerns by members of the team about the residents’ health and safety have now been addressed. The home has constructed consistent strategy procedures and included these written assessments into their Plan of Care. There was good evidence that the home uses risk assessments in a way that ensures that people can live life to the full. Risk assessments at the home are now of a very good quality. This includes electronic devices that had been installed in order to protect individual rooms from intrusion by others. The way the home has consulted with residents on the matter and has documented this is commendable. In the same way, good evidence for opportunities for 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 13 residents to participate in the day to day running of the home was found in many areas. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 14 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): 11, 12, 13, 14, 15, 16, 17. The home enables residents to maintain appropriate and fulfilling lifestyles. This is achieved by giving residents good opportunities for personal development through participation in a wide variety of activities in the home and in the local community. The home is commended for the way it supports an all important daily rhythm and routine for a resident. There is good support for residents to maintain relationships with friends and family. EVIDENCE: There is good and well-documented evidence that residents are encouraged to participate in a range of activities held in and outside the home. One resident’s daily and weekly routine was studied in some detail. The home has worked hard to provide meaningful day care arrangements for this resident. Unfortunately, this has only lead to a slight increase in the hours granted by the day centre. However, the home is commended for the way it supports an all important daily rhythm and routine for this resident. A balanced and nutritious diet is offered to all residents. This is well recorded. Staff supervision notes revealed good levels of discussion and guidance for staff to address, monitor and document residents individual diets. In one case this was done in considerable professional detail in order to help prevent excessive weight gain and included the support of experts outside the home. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 15 Findings at this visit confirm the positive findings in the previous inspection report. Local amenities are used regularly for shopping trips and residents participate in accessing shops and supermarkets frequently. Residents use their money with support to buy various items and regular trips to the bank are part of the routine. The home has a vehicle. This is used often for service residents to enjoy the locality and trips out further from the home. Anecdotal evidence seems to suggest that the home is well integrated into the neighbourhood and that some of the residents enjoy direct contact with neighbours. Residents are encouraged to participate in the day-to-day upkeep of the home’s environment and there was good evidence from conversations and observations that this includes meaningful tasks designed to enhance individual’s life and independence skills. Families were able to visit whenever they wished. There was good evidence and sufficient recording to deduct that family and friends are welcomed and their involvement in daily routines and activities is encouraged. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Recording, tracking and implementing the health care needs of residents is of a high standard. Recording of medical and health input including medical and general health review sheets was seen to be of a very good standard. Members of the team were well informed about resident’s individual needs. EVIDENCE: In the most recent inspection the home’s pro-forma used to record health needs was found to be incomplete with large gaps not being filled in. There was impressive evidence that the home had fully addressed the requirements and recommendations of the last inspection report with regards to the recording and implementation of health care needs. A number of relevant and related health care topics were discussed with staff and the Registered Manager. These included tracking of appointments, which on this occasion was found to be exemplary. The team has enjoyed a special training day, which focused on the complex health (and other) needs of one particular resident. A number of professionals have been involved in meeting and assessing this residents needs. In this case, the necessary networking and the quality of correspondence with other professional services were found to be of excellent quality. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 17 There was also good evidence that the home works closely with advocates, family and friends and that this is in the best interest of individual residents and with their consent. Members of the team were well informed about resident’s individual needs and reported that internal communication was good. Each individual resident has a key worker, who related closely to him and offers support in maintaining as much independence as possible. Individual working records set out preferred routines and likes and dislikes of residents. No one currently self-administers medication. Recording of medical and health input including medical and general health review sheets was seen to be of a very good standard. The staff team attended a ‘Medication Competency’ training course in June 2005. One particular resident is currently refusing all medication. There was good evidence that the home is aware of all the available strategies and contingencies to ensure that this will not lead to a significant health crisis. The local District Nurse is monitoring and informing this situation. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. A newly revised set of complaints and whistleblowing policies was found to be of an excellent standard. Vulnerable adults protection procedures are robust and sound and staff are aware of relevant content and processes involved. EVIDENCE: A ‘Complaints Book’ was available for inspection. The Trust’s Area Manager views and inspects this on a regular basis together with the Registered Manager. A newly revised Complaints Procedure was found in the recently published ‘Operational Policies Handbook’, June 2005. It was studied as part of this inspection and found to embrace the ideals of a ‘learning organisation’. It encourages residents and staff to “have a say in running or challenging services”. The procedure now includes guidance on a confidential ‘whistleblowing’ reporting procedure for everyone working or living at the Trust entitled ‘Do the Right Thing’. The complaints procedure refers to the Commission if complainants are dissatisfied with any initial outcome of an internal investigation after a complaint. It is in a user-friendly format and available to residents and their representatives. The contact details for the Commission and an updated complaints procedure are included in the Service User’s guide. Details of how to contact the Commission and procedures, which are in a user-friendly format, have also been made available to residents and their representatives. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 19 A Protection of Vulnerable policy was found in the home’s office. This included a flow chart for reporting cases of suspected abuse. Good evidence was found that the Trust systematically trains its entire staff group on this topic. Staff interviewed demonstrated a good working knowledge of current practice and legislation. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30. Service users enjoy a clean, comfortable and safe home, showing a commitment from the staff team in maintaining the environment. However, the decoration and improvement of a bathroom environment is still an urgent matter. EVIDENCE: The home accommodates 5 service users. Except for the downstairs bathroom, premises are suitable for the number of residents, safe, comfortable, bright airy and clean. All of the individual resident’s rooms were inspected and found to be in line with NMS26.2. All rooms were personalised containing photographs, pictures and individual artwork. All were lockable and staff are fully aware of privacy protocols. At the last inspection it was required that the downstairs bathroom should be completely refurbished. This had not been implemented and again it was found poorly ventilated and there was a lingering odour. The same room was also in need of redecoration. The Manager reported that the Trust was finding it 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 21 difficult to fund this project at this current time. In spite of these reasons the same requirement is made again in this report: The bathroom needs redecorating and the lack of ventilation remedied. A second toilet and bathroom facility is located in close proximity to individual rooms upstairs and found to be of a good standard. The last inspection report also recommended that continence management procedures should include the correct use of washing machines (temperatures) and that they be reaffirmed so that staff can use the correct procedures. The Registered Manager was able to evidence that Infection Control Guidance was now in line with National Minimum Standard 30 and followed guidance obtained through the NHS/Avon Health Authority. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36. A competent, dedicated and positive staff team supports the resident’s, which in turn feels well supported by the registered manager. EVIDENCE: The inspection process provided good opportunities for interviewing a number of staff including one of the permanent ‘bank’ staff. All expressed satisfaction with the way the home was progressing particularly since the change of management. In addition, the manager was praised by members of the team for the efficient organisation of staffing rotas. This was confirmed after scrutinizing rota arrangements in some detail. Resident’s benefit from the fact, that the same stable workforce has been present at 3 Hesding Close for some time providing invaluable continuity. This includes a large and reliable group of permanent bank staff. Because of this group the home hardly needed to use agency staff in recent months. Altogether, staff morale appeared very high at the time of inspection. All team members were knowledgeable about the home’s aims and values and in full support of them. Some very good examples of day-to-day interactions between staff and residents were observed. Relationships between individual staff members and residents seemed strong, warm and friendly. Staff members were seen to be skilful, involved and motivated when interacting with residents. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 23 The quality of supervision records inspected was high and the home complied with the expected frequencies. The manager has carried out a training needs assessment for each member of staff. This is updated regularly and evidenced through the ‘Support Worker Competence Pack’. Members of staff interviewed were positive and enthusiastic about training and the way it was supported by the Registered Manager as well as the Trust in general. However, NMS (National Minimum Standard) 32 stipulates that care staff hold a care NVQ (National Vocational Qualification) level 2 or 3. At least 50 should have achieved a care NVQ 2. For the reasons discussed with the Registered Manager the home falls well short of this. It is required that the Trust review this situation and devise a training strategy for the home with regards to NVQ training. A requirement was made at the last inspection that appropriate staffing documentation is held in each home in accordance with the Regulations. Individual files were inspected and found to be partly incomplete. This needs to be audited and files need to be in line with Schedule 2 of the Regulations and NMS 34. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40. The home has now fully recovered from a previous period of instability after times of continuous change in management. The manager needs support to advance her training commitments. The Trust needs to remind the homes appointed visitor to radically increase the frequency of monthly monitoring visits. EVIDENCE: The Registered Manager was extensively interviewed and found to fully comply with the competency essentials required by Standard 37. The home has now fully recovered from a previous period of instability after times of continuous change in management. The current manager has to be commended for her commitment and dedication in her efforts to comply with all Standards and Regulations. Feedback from staff, the residents, relatives, visitors and health and social care professionals all echoed this view. The Manager holds a qualification as a Registered Nurse. She recently (February 2005) enrolled on a Registered Managers Award programme 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 25 provided by the Trust’s own NVQ Assessment Centre. She reported that she has not been able to make considerable progress towards her award and was struggling “to find the time”. A recommendation made in the last report for the Manager to receive continued support while qualifying for the Registered Managers Award is therefore made again in this report. A number of requirements have been made in the past reminding the Trust of its duty to provide the Commission with a monthly written report on the conduct of the home (Regulation 26 ff.) The requirement is made again for Regulation 26 visits to be carried out monthly and in accordance with the regulations. Information gathered during Regulation 26 visits carried out by the homes appointed visitors form an essential part of the internal and external inspection process. The providers appointed visitor carried out the last Regulation 26 visit in August 2005. Only 4 out of the expected total of 12 visits were conducted in 2005. According to records only one visit was carried out in 2004. It is now urgent that the provider improves this frequency substantially. In the light of this it is reassuring that the registered manager provided good evidence that she was monitoring the quality of service delivery through staff meetings, service user meetings and consultation and care reviews. Feedback is actively sought from residents and user satisfaction questionnaires were available for inspection. 3 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 2 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Hesding Close Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 1 3 2 x x DS0000003346.V254123.R01.S.doc Version 5.0 Page 27 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 2 Standard 24, 27 32 Regulation 23 18 Requirement The bathroom needs redecorating and the lack of ventilation remedied. The home needs to ensure that suitably qualified staff are trained in the nationally expected training standards. Staff employment records to be kept in the home as required by Schedule 4 of the Care Homes Regulations 2001. Regulation 26 visits need to be conducted on a monthly basis. Timescale for action 01/04/06 01/04/06 3 41 17 01/04/06 4 39 26 01/01/06 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 6 Good Practice Recommendations The home needs to devise better systems for pre-planning and tracking the reviewing process and more efficient communication with Social Workers, family, friend’s advocates and residents. For the manager to receive continued support while qualifying for the Registered Managers Award. DS0000003346.V254123.R01.S.doc Version 5.0 Page 28 2 37 3 Hesding Close Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Hesding Close DS0000003346.V254123.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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