Inspection on 18/07/08 for 30 Mill Road

This inspection was carried out on 18th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 30 Mill Road 30 Mill Road Sharnbrook Bedfordshire MK44 1NX Lead Inspector Sally Snelson Unannounced Inspection 18th July 2008 09:30 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 30 Mill Road DS0000071553.V368649.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. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 Mill Road Address 30 Mill Road Sharnbrook Bedfordshire MK44 1NX 01234 782806 01234 783 108 manager.30millroad@fremantletrust.org 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) The Fremantle Trust Miss Helen Louise Casbolt Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 6 07/06/07 2. Date of last inspection Brief Description of the Service: 30 Mill Road is a home for up to six adults with learning disabilities managed by the Fremantle Trust, in partnership with Bedfordshire Pilgrims Housing Association. The Housing Association is responsible for the maintenance and upkeep of the building. The home is situated on the outskirts of the North Bedfordshire village of Sharnbrook, which is approximately 9 miles from Bedford town centre. The home provides its own transport. The home is a large bungalow, with individual bedrooms for each of the residents. Communal space consists of a lounge, dining room, kitchen, bathing/shower facilities, and a separate laundry room. Doors lead out onto patio areas and paths round the bungalow. The home is set in very large gardens. The garage, which is a separate building, has been converted into an activity centre. The home is set back from the main road up a steep slope and there is adequate parking space. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Up until 1st March 2008 30 Mill Road, a home for up to six adults with learning disabilities, was managed by Bedfordshire and Luton Partnership NHS Trust (BLPT). Fremantle now runs it in conjunction with Bedfordshire Pilgrims Housing Association - who are responsible for the maintenance of the building. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection was a key inspection, was unannounced and took place from 09.30 am on 18th July 2008. On the day of the inspection the registered manager, Helen Casbolt, was on leave and the deputy was on the first day of annual leave before starting maternity leave at the end of the month. An agreement had been made that if needed, and at all possible, the deputy would help with the inspection so she came on duty for some of the time and Liz Harris, the operational manager joined the inspection. Feedback was given throughout the inspection and at the end. During the inspection the care of two people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home were observed for their reaction to situations and staff were spoken to and their opinions sought. None of the people living at the home were able to communicate verbally but clear descriptions in care plans of their behaviours and what they meant, enabled us to judge reactions. Any comments received about the home, plus all the information gathered on the day was used to form a judgement about the service. One staff member and three relatives had completed surveys, and the manager had completed an AQAA in advance. We would like to thank all those involved in the inspection for their input and support. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Following the last inspection we made 22 requirements of the service. The manager, along with the staff team, has worked hard to ensure that most requirements have been met, or were being worked towards. These improvements have been aided by moving a person with severely challenging behaviours to more suitable accommodation. Since the last inspection the staff had • • • Demonstrated that residents were supported in the way they choose; Made sure residents’ healthcare needs were fully met; Kept accurate records of medication; DS0000071553.V368649.R01.S.doc Version 5.2 Page 7 30 Mill Road • • Completed risk assessments for all identified risks; Shown that residents were given opportunities to make decisions about some aspects of their lives; • • Made sure the complaints procedure was accurate and that residents were supported to complain if they wanted to; Made sure that all staff have had training in POVA (Protection of Vulnerable Adults) so that residents could be confident they would be protected from harm; Made sure that the statement of purpose and service user guide was up to date in a format suitable to the residents of this home. What they could do better: There are some areas where we have made requirements that need to be addressed in order to improve the lives of those living at30 Mill Road. The recommendations made at the end of this report should also be given consideration for the same reason. These include:The manager must ensure that information about people living at the home is available to staff at all times. The must be evidence that the staff team have the competencies to meet the needs of the people using the service. This refers to providing the documentation of the needs of the residents and also refers to standard 3. The staff rotas must ensure the staff team on duty can respect the privacy and dignity of the people living at the home, while ensuring there are sufficient numbers of staff on duty to keep the residents and the staff team safe. All staff records must be available at all times for inspection by us. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 8 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. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 9 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 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4,5 People who use this service experience adequate quality outcomes in this area. Information about the service that could be given to the people living at the home, or to stakeholders, had been produced and updated. This information was in a suitable format for those it was intended for. However missing documentation to support a new person who had moved into the home, meant that all the staff team may not have the same understanding of his/her care needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Statement of Purpose and the Service Users Guide had both been written in an easy to use format. The documents had been updated and reviewed since the home had been taken over by the Fremantle Trust. There had been one new person admitted to the home since the last inspection and we were told that the manager was currently considering another person to join the home. The vacancy was as a result of the staff team successfully supporting a resident whose needs were not being met, and who did not live 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 11 happily with the other people at the home, to move to more suitable accommodation. Unfortunately the manager was on leave at the time of the inspection and the staff did not have access to the pre-admission assessment or information about this new person. However we were told that he had come on a number of visits and that the staff team had met him in his own home, and his respite accommodation, before he moved in. There had been a variety of trial visits that had gradually lengthened to include over night stays before he moved in permanently. His family, the people living at 30 Mill Road, the staff team and the house advocate had been involved throughout the admission process. The staff team kept themselves updated with mandatory and specialised training. This is referred to within the staffing section of the report, but without detailed information about the new person at the home it was not possible to assess if the staff teams collective qualification and experience met needs. After the inspection the registered manager informed us the people using the service had been given new contracts; one copy was kept in their room and the other in the office. Unfortunately staff on duty were not ware of this so we could not view them and left the inspection believing they had not been issued. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 12 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): 6,7,8,9 People who use this service experience adequate quality outcomes in this area. Staff were aware of the needs of the people using the service and how they liked their care, but at the time of the inspection the documentation to support this was being reviewed, and as a consequence documentation was inconsistent and not always complete. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We requested to look at the care plans for two of the people using the service, including the person who had most recently moved into the home. Staff were unable to find any of the information relating to this person other than a hand written page with contact telephone numbers and details on. Staff believed the manager had been working on the care plan and it may be on the 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 13 computer. After the inspection the manager confirmed that the information from the assessment, that would be used to write the care plan, had been made available for staff to read. It was disappointing that staff could not locate the documentation to support the care they were giving to this person as it suggested care plans and other documentation were not used as a working tool. The second file sampled provided evidence that staff had been reviewing and updating plans and that care plans had been written for all areas of care provided. Care plans were also supported by any necessary risk assessments. We were also shown a file that had been written in ‘the Fremantle style’. This file was user-friendly and easy to follow, included the evidence that the person and/or a representative had been included in the plan and evidence of a person centred approach to care planning. Care plans did not always indicate the goal or the intended outcome for the person. Again after the inspection the manager confirmed that care plans were ‘work in progress’. There was nothing in the care files of the people at the home to suggest that they had any preference for the gender of the staff that cared for them. We were particularly interested as both the staff on duty were male and one of the residents remaining at the home was female. This would not be a usual situation as the ratio of male staff to male carers was generally low. Staff reported that one of the residents currently on holiday, preferred to have her care provided by female members of staff but none of the other residents had shown any preferences. We witnessed staff asking people to make choices and how they communicated back. For example, when being asked if he would like a cup of tea or coffee, a person was taken into the kitchen to look at the items to help him make the choice. Staff told us that because four of the five people using the service had no verbal communication, it was often necessary to make choices or decisions on their behalf and then record in the daily log any positive or negative reactions and build up a picture of their preferences. Possible risks and how they should be managed were recoded and documented with care plans to ensure that people could be offered as independent a life as possible. Staff documented how residents used actions and non-verbal communications to indicate what they wanted or thought about situations in their daily logs. The home had an advocate and people were supported at residents meeting by this person. Each service user had a key worker and link worker who got to know them very well and would eventually support the manager to produce and review the plans of care. Staff told us that recently all the staff were discussing a care plan when it needed reviewing or changing, to ensure that everyone interpreted the care needs in the same way. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 People who use this service experience adequate quality outcomes in this area. Day care activities had increased but were limited. The manager had plans to work on these with the company’s development officer. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: As already stated because the people living at 30 Mill Road could not communicate verbally, it was difficult to provide the evidence that choices had been made about the way they spent their time and the activities that they participated in. Staff continued to seek a range of different activities that may be of interest and involve them in the community. Staff recorded how the resident accepted and reacted to these. There was no staff member employed at 30 Mill Road who was solely dedicated to activities. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 15 None of the people living at the home were able to work or attend regular educational courses. The new person into the home attended a day care centre and staff had been told that this would continue. Staff provided the transport to and from the centre, and often used the journey as an opportunity to take other people out for a ride in the car if they wanted to go out. Each individual had an activity plan, however we noted that this was often not adhered to, as the person did not wish to engage with the planned activity. In each case it was documented what and how the activity had been offered and what alternative was offered. The home had an additional building that was used as an activity room. At the time of the inspection this was used as a “chill out” room or to give people the opportunity to be away from each other. Staff supported the residents to keep in contact with families and friends and made them welcome into the home. One relative survey told us they appreciate the birthday and Christmas cards their relative sent them with the help of staff. People living at the home had a key to their bedroom and the door could be locked when they were out if they wanted. Folders to receive post were attached to each persons door and we noted that unopened post for those on holiday was in the folder, awaiting their return. It was very apparent that people had a good relationship and felt confident with staff and would hold their arms and hands to take them around the home to what it was they wanted. One person spent a lot of time taking staff to the front door to go out to the car. This will be discussed in the environment section of this report. We were disappointed to be told that a person who should have gone to a specialist club on the afternoon of the inspection had had to have it cancelled because it was not possible, with only one car and driver, (the other car was being used for the holiday) to get to the club and pick up someone from the day centre. We believed this should have been identified earlier and a possible solution found rather than cancelling a planned regular activity. As already mentioned two of the residents were on holiday in Cornwall with two staff. The staff on duty told us that they had not been able to ascertain that this was exactly where they wanted to go but hoped it would be suitable. Two other people were going away the next week, and then the holidays would be reviewed. The inspection spanned lunchtime. This was a very relaxed time with staff sitting to eat with the people living at the home. Menus were worked out from peoples known likes and dislikes. On the day of the inspection the two residents at the home had a baked spicy omelette, with the option of baked beans. This was well cooked and nicely presented and additional equipment to 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 16 support mealtimes, such as plateguards were used correctly. None of the residents were seen to help with meal preparation. We were told that one of the residents enjoyed watching staff work in the kitchen, but no one helped with cooking. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good quality outcomes in this area. Robust medication systems and regularly auditing of the procedures ensured that people received the correct medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each person had been registered with a local GP and there was evidence that community health staff attached to the surgery were available for advice and support. Specialist equipment such as walk-in baths, hoists and wheelchairs were available and were used appropriately. The manager was aware of the need to support the residents to attend ‘well person clinics’ so that any conditions that did not exhibit obvious symptoms, such as raised cholesterol levels, could be identified early. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 18 There had been a huge improvement in the management of medication within the home. Most of the staff had been trained to administer medicines and regular auditing of the documentation ensured that any errors were identified immediately. All medications were correctly accepted into the home, administered and stored. At the time of the inspection the home did not have any one taking controlled drugs but there was no storage system or record book for these types of drugs. It would therefore be illegal to store them in the home if they were prescribed for use. The home had recently changed the supplying pharmacy and was experiencing some ‘teething’ problems. However because staff were vigilant about checking the medication arriving into the home these were identified in time to be rectified. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 19 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 this service experience good quality outcomes in this area. A clear complaints policy, in formats suitable for all those that have contact with the service, ensured that people were aware of how, and to whom, to complain, and what outcomes to expect. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: An easy to read complaints policy was included in the Statement of Purpose and the Service Users Guide. All of the three relatives we heard from prior to the inspection informed us that they were aware of how to complain and who to. One family went on to tell us that they had not had cause to complain. The manager informed us in the AQAA that there had not been any complaints made to or about the home in the last 12 months There had been an improvement in the staff teams understanding of safeguarding vulnerable adults (SOVA). This had come about as the result of additional SOVA training and a better relationship with the safeguarding team. Any allegations of abuse, including service user on service user were now being correctly reported to us via Regulation 37, and to the safeguarding team at the Local Authority. The SOVA file included details for staff about filling in documentation and the latest (2008) multi-agency policy. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 20 Service users monies were now being appropriately held on their behalf and used correctly. Staff were checking the balances of service users monies at the change of every shift. The manager was aware that this needed to be assessed and reduced if at all possible. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 21 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): 24,25,28,30 People who use this service experience adequate quality outcomes in this area. 30 Mill Road was in need of some redecoration, but it was clean and tidy and provided the people living there with a fairly homely environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was clean, tidy and no offensive odours were noticed. Some areas of the home were in need of decorating and were looking shabby. Staff and residents had been painting samples on walls to help them choose what colour they all liked the best. It was hoped that the redecoration would take place soon. Over the past few years many of the carpets in the home had been removed 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 22 and replaced with wooden floors. The manager stated that some senior managers felt this was not appropriate. She was reminded if it was suitable for the people living at the home, we considered it appropriate and did not insist on carpets. The aim was to have the home looking clean and homely and a safe place for people to live in. Since the last inspection the office had been moved and the original office converted into a dining room. A high low bath had been installed and the bathroom refurbished. Bathrooms and corridors had been made more homely by adding pictures etc, but still needed fresh paintwork. The bedrooms had been decorated to the tastes of the individual and there was evidence of personal belongings in bedrooms and throughout the home. The kitchen and laundry was well equipped and people living at the home were supported to use the facilities. It had been hoped that a ramp would be fitted outside the laundry room door to give access to the garden and a safe accessible fire exit. There was evidence that this had been discussed with the housing association. Following the last inspection the front door was unlocked and a buzzer connected to alert of coming and goings so people could be supported if they choose to go out. This had not been all together successful and staff felt that one person in particular would benefit from free access to the front garden, but was hindered by the risk from the main road. It was hoped that a fence could be put in around the garden to support this. Despite residents having free access to the back garden one resident appeared to want to spend time in the front and was constantly having to be supervised by staff due to the dangers of the busy road. At the start of the inspection the grass in the back garden was very long, but the maintenance people arrived to cut it. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 23 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): 32,33,34,35,36 People who use this service experience poor quality outcomes in this area. There were enough qualified, competent and experienced staff to meet the health and welfare of people using the service, but staff rotas did not always take this into account. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: When we arrived to start the inspection there was only one member of staff at the home with two residents. A second staff member had taken a third resident to a day centre, and two staff were accompanying two residents on holiday in Cornwall. The manager was on annual leave and the deputy manager was on the first day of her maternity leave. The deputy manager had agreed to work part of her first days leave, as there were no medicationtrained staff on duty in the evening. She had also agreed to be part of an inspection if one took place when the manager was unavailable. We were concerned that the one staff member left was in the bathroom with a resident who we were told could not be left in a bath of water alone so he was unable to answer the door immediately and consequently was not available for the 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 24 second resident who was out in the garden. We were also concerned that a male member of staff had put himself at risk by being alone providing personal care to a female. The homes training matrix included mandatory training such as moving and handling, food hygiene, medication and fire training, all of which had recently been refreshed for the staff team. There was evidence of more specialist training such as understanding the Mental Capacity Act, Boots medication system, autism and challenging behaviour. We felt confident that the staff team had the collective training to meet the needs of the residents but we were concerned that the duty rota was such that at times some skills were missing. For example the need for the deputy to return because no one on a particular shift was medication trained. There had been no new permanent staff employed under the new providers, but the manager was in the process of interviewing. Five staff had been employed on zero hour contracts and could be called upon as necessary. Where possible staff worked as part of the bank staff in the first instance to ensure that they were suitable for the work and fitted in with the rest of the staff team before becoming permanent. The staff files sampled were well kept and included all the necessary checks to ensure that a person was safe to work with vulnerable adults. We were however concerned that we could not access the personal file of the manager, the deputy and at least one other staff member whose files were kept separately and only the manager had the key. We were however given access to some staff files. It is a requirement that staff files can be made available to us during an inspection. According the AQAA 11 of the 12 staff team had completed or were completing an NVQ level 2 or above. Staff were being regularly supervised by the manager and subsequent inspections would indicate if the 6 supervisions a year were in place. 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 25 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, 40.42 People who use this service experience adequate quality outcomes in this area. The manager had shown an understanding of the needs of the people using the service and how the staff team needed to be supported to ensure that this happened. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection the manager had settled into the role and had continued to demonstrate that she had the skills necessary to manage the home. It was apparent that she had embraced the Fremantle Trust’s way of working as all information and documentation relating to the old providers had 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 26 been destroyed and everything in the office was pertinent to the new providers. She had taken advantage of the opportunity provided by Fremantle to ‘buddy-up’ with one of their exsisting homes to see how Fremantle’s documentation and policies worked. When Fremantle took over the management of 30 Mill Road a quality audit was carried out. This audit was detailed and referenced back to the last report and the National Minimum Standards. The service must now continually monitor, assess and plan. We must also see evidence that all stakeholders have been involved in quality reviews. The manager had ensured that there were regular staff and residents meetings and that minutes were taken of these meetings. As already identified the manager must ensure that all the documents relating to people living at the home are available at all times to staff and that all staff files can be made available at any time for inspection by us. Individual staff were allocated to complete health and safety audits and take action if necessary. Checks were up-to-date but we could not see any evidence that staff and people living at the home had undertaken a fire drill. The staff member in charge of the fire checks told us that drills had taken place but had not been documented. 30 Mill Road DS0000071553.V368649.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 3 2 1 3 2 4 3 5 3 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 1 25 3 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X 2 2 X 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 28 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 YA2 Regulation 14(1) Requirement The manager must ensure that information about people living at the home is available to staff at all times. This relates to staff have no documentation about the new person living at the home. The must be evidence that the staff team have the competencies to meet the needs of the people using the service. This refers to providing the documentation of the needs of the residents and also refers to standard 3. The staff rotas must ensure the staff team on duty can respect the privacy and dignity of the people living at the home, while ensuring there are sufficient numbers of staff on duty to keep the residents and the staff team safe. All staff records must be available at all times for inspection by us. Timescale for action 10/09/08 2 YA32 18(1)(a) 10/09/08 3 YA33 12 (4)(b) 18(1)(a) 04/08/08 4 YA34 17 (3)(b) 10/09/08 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 29 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 YA6 YA8 YA12 Good Practice Recommendations There must be evidence that care plans in place for all aspects of care and are used as a working document. There should be evidence that staff are involved or have been advised about all decisions that affect them. Opportunities for residents to take part in meaningful daytime and leisure activities, in and out of the home, must continue to improve, and must include the documentation to support how decisions were made. Some areas of the home need to be redecorated to provide a more homely environment. Consideration should be given to enclosing the front garden. All service users should be able to leave the home via the laundry door if necessary. The quality audits should be built upon and show stakeholder involvement. Evidence of any fire drills be available. 4 5 6 7 8 YA24 YA24 YA24 YA39 YA42 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 30 Mill Road DS0000071553.V368649.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!