Inspection on 31/10/07 for 32 Mays Lane

This inspection was carried out on 31st October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

32 Mays Lane 28/10/08

32 Mays Lane 15/01/07

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 32 Mays Lane Stubbington Fareham Hampshire PO14 2EW Lead Inspector Christine Walsh Unannounced Inspection 31 October 2007 10:00 st 32 Mays Lane DS0000067610.V347577.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 32 Mays Lane DS0000067610.V347577.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. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 32 Mays Lane Address Stubbington Fareham Hampshire PO14 2EW 01329 668833 01329 668833 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.caremanagementgroup.com Care Management Group Ltd Sandra Mullins Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2007 Brief Description of the Service: 32 Mays Lane is registered to provide care and accommodation for five adults with a learning disability. The service is provided in a bungalow within a residential area of Stubbington. The home is a short car ride away from the local shops and transport links. The home has a car for service users with designated staff drivers. All service users have their own room. The home has a hydro pool and a sensory room within the building. It is owned and run by Care Management Group and fees range from £1819.32 to £2478.97 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit formed part of the key inspection process and was carried over two days by Mrs C Walsh, regulatory inspector. The manager completed an Annual Quality Assurance Assessment (AQAA) document, which was returned to the Commission for Social Care Inspection prior to the visit to the home. In addition “Have Your Say” resident and relatives comment cards were sent of which a small number have been received. The information obtained to inform this report was based on viewing the records of the people who use and work at the service, where possible speaking with the residents and staff and observing care and support practices. A tour of the home took place and documents pertaining to health and safety were viewed. The manager was absent at the time of the inspection, however the visit took place with the aid of a senior support worker and a registered manager from another Care Management Group home. What the service does well: With the support of the manager, staff and families the residents are involved in regular reviews and assessment of their needs and planning their future using a person centred approaches. The home is working towards supporting residents to be more independent and encouraging them to make choices and decisions about their future. This is clearly detailed in the resident’s personal plans and provides specific information to enable staff to provide a consistency of care and meet the needs of the residents in the way they prefer. The home supports the residents to have active lifestyles encouraging them make choices and explore new activities including accessing their local community, attending social and leisure events such as going to the pub, swimming and going on holiday. The home ensures that regular checks with health care professionals such as GP’s and specialist health care professionals are maintained. The home supports residents with their medication using safe administration practices. Each resident has a bedroom of their own that has been decorated and personalised to reflect the residents’ individuality and personality. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 6 The home as far as feasibly possible provides a safe environment for the residents to live, this includes undertaking individual risk assessments, employing staff using robust employment procedures, training them to meet specific care needs such as the administration of medication, autism and safeguarding adults. . The home is maintained to a high standard of cleanliness and regular health and safety checks are undertaken including weekly checks on fire safety systems and equipment. What has improved since the last inspection? What they could do better: The home is identified as having a number of areas, which require improvement and seven requirements have been issued following this visit. These include: Keeping under review the residents daily activities, daily routines and health action plans, those seen at the time of visit did not provide evidence that they had been reviewed and had not been signed or dated. Ensuring new staff receive an appropriate and well-instructed induction and required training. The documents seen at the time of the visit did not provide evidence that the member of staff had received a structured and well-informed induction and training in fire safety despite being in the service for five months. Ensuring the home is well managed and administrative duties are completed as required and residents are safeguarded from financial abuse. The manager was absent at the time of the visit, however records and some practices observed evidenced that improvements can be made in the management and administration of the home. At the time of the visit a handover of information about the residents day so far took place in a communal area and included the passing on confidential information. The handover was poorly organised and provides evidence to substantiate the concerns raised by a relative in respect of poor communication between staff. And: To ensure a monthly-unannounced visit from a senior manager in the Care Management Group (CMG) takes place in the home to ensure a quality service 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 7 is being provided to the residents. There was evidence that quality audits took place but provided evidence that this was not on a monthly basis as required. 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. 32 Mays Lane DS0000067610.V347577.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 32 Mays Lane DS0000067610.V347577.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home does well in ensuring the people who use the service have their assess needs kept under review. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that the home has good systems in place for the assessment and admission of prospective residents, including the use of transition diaries and the prospective residents and families visiting the home. This was tested by viewing three residents’ personal plans, speaking with staff and viewing comments cards received from relatives. The home does not currently have any permanent vacancies and therefore no new referrals have been made to the service. The home demonstrates that it keeps the assessed needs of the residents under review and when necessary in conjunction with social services, health care professionals and relatives will support residents to move to alternative services in order their needs can be appropriately met. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 10 The staff expressed their sadness of a resident who has lived in the home many years having to move on in order that their health care needs can be appropriately met. They are hoping the resident will be able to return. 32 Mays Lane DS0000067610.V347577.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does well to provide clear and specific personal plans and risk assessments in order that staff can appropriately support the people who use the service. The people who use the service are supported to make decisions using a person centred approach. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that they identify, review and involve the residents in the development of their personal plans and promote independence and develop daily living skills. This was tested by viewing two residents personal plans, speaking with staff, observing practice and interactions of residents and staff and viewing comments cards. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 12 Each resident has a personal plan of their own which provides information on their daily routines, personal care, diet, continence and communication. Care plans are detailed and specific providing clear information on how the residents wish to be supported, allowing for a consistency of care. Care plans are linked to risk assessments and provide detail of the risk and action required by staff to minimise the risks. The information is written in plain English and easy to follow. A senior support worker stated the home provides a person centred approach and is actively seeking ways in which they can involve the residents more in the development of their plans, making decisions and taking ownership of their plans. This is work in progress. A relative said: “The home does a good job” And another member of staff was proud to say that they feel the home meets the needs of the residents and provides them with opportunities to grow and are supported to make choices and decisions. The majority of the residents living at 32 Mays Lane have some form of communication difficulty or learning disability that prevents them from engaging and expressing their needs and desires. The home has developed alternative communication tools to support the residents to have an understanding of their environment and what is going on day to day and there are specific care plans that provide staff with guidance on how to support the residents to make choices and decisions. The use of Makaton, objects of reference and pictures symbols assist with this process. Staff were observed to offer choices in the form of meals, drinks and activity, and a member of staff demonstrated how she would support a resident to make a choice about what to wear. In terms of supporting the residents to explore their future dreams and aspirations the home is in the process of looking into how they can do this successfully. 32 Mays Lane DS0000067610.V347577.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 and 17. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home does well to provide the people who use the service with opportunities to take part in age appropriate, peer and community based activities, however further consideration must be taken to ensure all residents are equally actively involved in activites. The home supports the people who use the service to eat healthy, nutritious and wholesome foods. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that each resident has an activity plan for both in house and community based activites, which reflects their interests, hobbies and likes and dislikes. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 14 This was tested by viewing two residents’ personal plans, comment cards received from relatives, observing activity over the period of the visit and speaking with staff. At the time of the visit all four residents were at the home and throughout the day were observed to be involved in various activites including assisting with the cleaning, listening to and playing music, and staff were observed reading to and playing puzzles with a resident. Each resident has a weekly activity plan, which includes attending music sessions, community based activities, using the homes sensory room and hydro pool, going on holiday once a year. At the time of the visit the home was preparing for a Halloween party where residents from another home were attending. The home is currently putting together scrapbooks for each resident with post cards and pictures of places the residents have visited and activities they have engaged in. A member of staff stated that these are being developed to provide the residents with a tool to reflect on what they like doing and what they have done. Each resident has a weekly personal activites allowance; this is easily accessed by staff and checked daily. A comment card received from a relative identified concerns that their next of kin did not appear to go out or engage in stimulating activites, the resident’s weekly activites record demonstrated that the resident does go out, but to set sessions and over the two day visit the resident was not observed to go out. The home is situated on the outskirts of the small village of Stubbington, where the residents visit regularly to purchase personal times and take part in village activites. A member of staff said the residents are known by their name in some of the shops and are made very welcome in a local public house. “The local shops are very patient and helpful towards the residents, and the local pub always makes us very welcome”. The home supports the residents to maintain contact with family and friends, during the visit the staff were observed making arrangement to support a resident to go home to visit relatives and informing a resident that a friend would be visiting her. Each resident has a family contact record in their personal plan to reflect any form of family contact, they also have a list of important people in their lives with their contact details and dates of birth in order that the resident can be supported to send letters and birthday cards. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 15 A relative said: “The home is very good at arranging to bring our relative home to see us”. Another said: “The home keeps us up to date” Each resident has within their personal plan a detailed daily routine with emphasis placed on the importance of respecting the resident’s individuality and personal preferences. A member of staff spoke for some time on the homes philosophy of care and the importance of encouraging the residents to develop and maintain their independence, giving examples of these such as assisting them to make their own breakfast, run a bath and choose what they would like to wear and do during the day. Each resident has detailed in their personal plan their likes and dislikes in respect of food and the support they require to eat their meals. Where there are concerns with diet and eating and drinking the resident has a care plan in place to guide staff. On the day of the visit a resident was observed preparing their breakfast and making plans for the evening meal. The home has a menu plan, which appeared nutritious and well balanced. The same resident was supported throughout the day to make drinks for her and others. 32 Mays Lane DS0000067610.V347577.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to ensure the people who use the service are provided with support with their personal care and health care needs including the safe administration of medication. The home must ensure helath action plans are regularly reviewed, signed and dated. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that each resident has an up to date personal care plan, health action plan and that the home has built up good relationships with healthcare professionals. This was tested by observing day-to-day practices in the home, viewing health action plans, speaking with the manager and staff and viewing comments received from a GP, relative and care manager. Through out course of the visit staff were observed supporting residents in various activities, encouraging them to make choices and undertake the activity themselves. A member of staff spoken with said the residents can 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 17 spend their day as they wish but are encouraged to take part in daily activities such as helping around the home, this is recorded in their daily notes and a detailed daily routine describes the support the residents requires to maintain a routine that meets and suits their needs. A relaxed and unhurried approach was observed. Each resident has a health action plan that identifies their health care needs and records outcomes of appointments with health care professionals. Two residents health action plans were viewed and although provided detail of recent appointments with health care professionals they were not fully completed and did not provide evidence that they had been updated or regularly reviewed. A range of health care professionals are involved in supporting the residents and staff to maintain good physical and mental health. Staff receive guidance and training where required from health care professionals. The home has systems in place for the safekeeping, administration and recording of medication. A staff member spoken with at the time of the visit confirmed that she had received extensive medication administration training and her practice is assessed annually. There are currently no residents who self medicate. 32 Mays Lane DS0000067610.V347577.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an accessible complaints procedure for the people who use the service and do well to observe communication through behaviours to establish if they are happy or unhappy. The home must do better in ensuring the residents are safeguarded from potential risk of abuse, such as improving the administration of residents’ monies. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that the home has not received any complaints this year and that the home is currently waiting for a follow up meeting to establish the outcome of a safeguarding meeting. This was tested by viewing the complaints procedure, staff training records, and comment cards recieved from relatives, speaking with staff and observing the residents. Observation of residents made at the time of visit provided evidence that they appear happy with the care they are currently receiving. The home has developed an accessible complaints procedure, however for some residents their cognitive ability limits their understanding and therefore occasionally will express their concerns and displeasure through challenging behaviour. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 19 A relative said: “I have not recieved a copy of the complaints procedure but I would have no problem approaching the manager if I had a concern”. Another relative confirmed they knew how to make a complaint. The home is advised to ensure all relatives are provided with the service complaints procedure. A member of staff confirmed that they had received training in adult protection and that this is a standard and regular training that all staff receive. The member of staff was able to state what she considers constitutes abuse and what she would do if she witnessed an abusive act taking place. The home is currently waiting the outcome of a safeguarding meeting held by social services in July 2007 in respect of an injury sustained to a resident. The home is advised to follow this up and request an outcome. For the purpose of ensuring residents monies are safeguarded the home holds residents personal monies in a secure place, and a record is kept of incoming, expenditure and balance, and receipts are kept. During the course of viewing these records it was established that money from three residents purses did not balance with the record held. Through discussion it appeared the home was reluctant to make a safeguarding referral, as the registered manager was absent, as the facts had been established that money was missing the service was required to make the referral. This was followed up by a safeguarding referral from the Commission for Social Care Inspection. Later it was revealed that the money had been placed in another cash tin. The manager must ensure that the administrations of residents’ finances are correctly managed at all times. 32 Mays Lane DS0000067610.V347577.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, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to ensure the people who use the service live in a wellmaintained, clean and homely environment. However the home must ensure the temperature of the conservatory is maintained at a comfortable temperature for the residents. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that the home provides a safe and secure environment, which is homely, comfortable and well maintained. This was tested by taking a tour of the building, speaking with staff and the manager and where agreed viewing residents individual bedrooms. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 21 The internal environment of the home is well maintained and decorated throughout. Furnishings are domestic and of good quality. The home has an enclosed rear garden, which residents are able to access. Two residents bedrooms were viewed, these were spacious, airy and decorated and furnished to a high standard and reflected the resident’s personality, individuality and interests. A member of staff said that residents were supported to choose colours and furnishings. A resident proudly showed of her room and appeared happy with the way that it looked and was set out. The home has a large conservatory that forms part of the homes communal area and is used as a dining room and also houses the hydro pool, although this is partitioned off. There is evidence that the conservatory fluctuates in temperature becoming very hot in the summer and chilly in the winter, the home must ensure it regularly regulates the temperature of the conservatory. The home is cleaned to a high standard and the staff receive training in infection control and health and safety. The home has a separate laundry facility with semi industrial washing machines that washes to a high temperature and has a sluice action for heavy soiled clothing and linen. At the time of the visit the washing machine was out of action and waiting repair, the home was using another local home to do laundry Staff are provided with protective clothing, liquid soaps and paper towels and the home has a clinical waste contract for disposing of continence aids. 32 Mays Lane DS0000067610.V347577.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, and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does well to ensure the people who use the service have their health and welfare needs met and supported by suffient numbers of skilled and appropriately recruited staff. However the home must ensure new staff are inducted following the Skills for Care guidance. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that the service has a full compliment of staff and training has been accessed to meet additional needs providing a consistency of care. This was tested by speaking with the manager and staff, viewing the homes duty rota, staff recruitment documents and comments received from relatives. The home currently has sixteen permanent staff to four residents. Through observation it was evident that suffient numbers of staff are on duty to meet their current needs and interests. Staff were observed providing one – to- one support, supporting residents to access the community and undertake daily chores such as cleaning and preparing meals. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 23 Data received from the home informed us that six staff have achieved a national vocational qualification (NVQ) at level two or above and three are working towards level two or above. A staff member confirmed that she has undertaken an NVQ and found it very beneficial in providing her with greater knowledge in supporting the residents. A newly recruited staff file was viewed to establish if the home undertakes safe and robust recruitment procedures. Documentation viewed demonstrated that the home take seriously the need to ensure residents are safeguarded from potential risk of abuse. Each member of staff completes an application, attends an interview, provides identification for criminal record bureau (CRB) and protection of vulnerable adult (POVA) checks and provides details of two referees. These were found to be all in order. A member of staff spoken with at the time of the visit confirmed that she had completed an application and attended an interview. By viewing staff training files and speaking with the senior member of staff and a member of care staff it was established that staff receive mandatory training and specific training such as autism to meet the needs of the residents. The senior member of staff confirmed that there is always ongoing training for staff and that all staff receives an induction. It was established through viewing the induction records of a newly appointed member of staff that it did not follow the Skills for Care guidance and there was a discrepancy in the date it was signed off as completed by the manager and member of staff. The manager having signed it off on the day the member of staff started in the home and the carer signing it off in October 2007 five months after her commencement date. The manager must ensure she is undertaking a robust and thorough induction programme for her staff to ensure they are appropriately supported to meet the needs of the residents. The member of staff confirmed that she had received an induction and had attended several training courses since commencing in the home such as safeguarding, food hygiene and health and safety, but it could not be evidenced that she had received fire safety training. 32 Mays Lane DS0000067610.V347577.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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home demonstrates that it working towards meeting the needs, health and safety and welfare of the people who use the service, however it must ensure that their dignity, privacy and confidentiality is maintained at all times. The home does well to listen to the views of the people who use the service by undertaking quality reviews and audits. However it must be evidenced that regulation 26 visits undertaken monthly to ensure the service is providing a quality service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) informed us that the manager has completed her registered managers award, receives regular 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 25 supervision and training and has received good feed back form families about the standard of care the service provides to the people who use the service. This was tested by viewing comment cards, records relating to the management of the service and observing care practices. The manager was absent at the time of the visit; the inspector was supported by the “on call “ senior support worker and a registered manager from another local service. The senior member and newly appointed staff informed that the manager was very supportive, approachable and has the best interests of the residents at heart. During the course of the visit the homes communication systems between carers in respect of the residents was viewed. The home has a communication book, a daily record for each resident and undertakes handovers between all shifts. It was observed that the handover took place between a member of staff from the early shift to the senior member of staff on the late shift, other staff coming on duty did not attend. The meeting took place in a communal area where residents and other staff were located, and staff not part of the handover were talking amongst themselves and distracting the handover. Confidential information about each resident was discussed openly breaching the residents’ dignity privacy and right to confidentiality. A relative raised concerns that communication between him and his family has appeared to have broken down at times and important information has been missed. The manager must address the way in which the handover is undertaken to ensure residents privacy, dignity and confidentiality is upheld at all times. The Care Management Group (CMG) undertake an annual quality review of all its services including 32 Mays lane, the manager of the service then develops and annual development plan, this is undertaken by commissioned external auditors. In addition to external auditing the home undertakes regular team meetings, send newsletters to family and friends and receives regulation 26 visits from a senior manager, although there was evidence to demonstrate that these are not happening on a monthly basis as required. A tour of the building and viewing service certificates demonstrated that the home is well maintained and as far as reasonably practical provides a safe place for the residents to live. All visitors to the home are asked to sign in and out of the building, and corrosive substances hazardous to health (COSHH) are safely locked away and fridge/freezer temperatures are regularly taken to ensure foods are stored at the correct temperature. 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 26 Staff records provided evidence that the majority of them have received training in health and safety, first aid, food hygiene, moving and handling and fire safety. Fire safety records and service certificates demonstrated that the home is regularly monitored to eliminate risks to residents and staff. The manager must ensure all staff receives regular fire safety training. 32 Mays Lane DS0000067610.V347577.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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X 32 Mays Lane DS0000067610.V347577.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. 1 Standard YA6 Regulation 15(2)(b) Requirement The people who use the service must have their needs and daily activites kept under reviewed and their personal plans must evidence that this has been done. All the people who use the service must be supported to engage in stimulating activities on a regular basis. The people who use the service must be protected from the risk of financial abuse. The people who use the service must be supported by competent and skilled staff therefore the service must ensure all staff undertake an induction that is in line with the Skills for Care guidance. The service must undertake monthly-unannounced quality visits to ensure the people who use the service receive good quality care. Timescale for action 31/12/07 2 YA14 16(2)(m) 31/12/07 3 YA23 13(2)(6) 16(2)(l) 18(1)(c) 31/12/07 4 YA35 31/12/07 5 YA39 26(3) 31/12/07 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 29 6 YA42 23(4)(e) The service must ensure the people who use the service are safeguarded from the risk of fire and therefore must ensure all its staff are trained in fire safety. 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 32 Mays Lane DS0000067610.V347577.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 32 Mays Lane DS0000067610.V347577.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. 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