Inspection on 01/06/07 for 35 & 37 Britannia Road

This inspection was carried out on 1st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 & 37 Britannia Road 14/07/06

35 & 37 Britannia Road 08/12/05

35 & 37 Britannia Road 16/06/05

35 & 37 Britannia Road 16/12/04

35 & 37 Britannia Road 05/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Britannia Road, 35/37 Kingswood South Glos BS15 8BG Lead Inspector Odette Coveney Unannounced Inspection 1 & 4th June 2007 09:00 st DS0000003398.V336023.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 DS0000003398.V336023.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. DS0000003398.V336023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Britannia Road, 35/37 Address Kingswood South Glos BS15 8BG 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 9618661 0117 9608686 helen.swash@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Miss Helen Elizabeth Swash Care Home 5 Category(ies) of Learning disability (5), Physical disability (5), registration, with number Sensory impairment (5) of places DS0000003398.V336023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 19 - 64 years Date of last inspection 14th July 2006 Brief Description of the Service: Britannia Road is a five-bedroom home in Kingswood, South Gloucestershire, and was established as a care home for adults in 1999. It has been converted from two semi-detached houses, with a connecting corridor to facilitate staff support. The home is based approximately one mile from Kingswood High Street where there is a good selection of local shops. Other Community facilities available in the Kingswood area include Dial-a-Ride bus services, Leisure Centre, Community Centre and Adult Learning classes. Access to Bristol city centre is easy where there is the full range of facilities you would expect in a large city. The home provides placement for individuals with single, or dual sensory impairment, plus additional learning disability. Adaptations include flashing lights, minicom telephones, and tactile surfaces amongst other things. Accommodation is provided for five adults aged between 19 and 64 years. The home is not able to provide nursing care for individuals and is unable to accept admissions on an unplanned or emergency basis. There are currently four individuals living at the home. Fees at the home range from £103,632-£145,824 per annum. DS0000003398.V336023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key standard inspection, it was carried out in two days over an 8-hour period by one inspector for the Commission. This inspection was very positive and overall a judgement of good was made. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for two individuals were reviewed. The registration certificate for the home was reviewed at this inspection and the information contained within it was found to be accurate. Four comment cards were received prior to the inspection, one of these were from relatives of those who live at the home, two were from individual’s who live at the home, the other comment card were from visiting health/social care professional who visits individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the registered manager and have been incorporated within this inspection report. What the service does well: The service provided at Britannia Road is specialist and those living at the home have complex needs. Staff are skilled at supporting individuals on an individualised basis, staff ensure that individual’s are given choices and are empowered to make decisions that will affect their life. The staff team at Britannia Road are caring and have developed good relationships with individuals at the home; they have a sound understanding of the needs of those living at the home. There is a low staff turnover and individual’s can be confident that they will receive support from people they know. It was clearly evident that the management and staff team are committed to ensuring that all of the needs of individual’s at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individual’s. DS0000003398.V336023.R01.S.doc Version 5.2 Page 6 The ways in which staff communicate with individuals at Britannia Road are effective and have been well recorded, techniques used at the home include British Sign language, use of symbols, pictures and photograph’s. Each individual’s method of communication is well recorded at the home with clear direction for staff to ensure that individuals are communicated with and are not excluded in decision-making processes. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000003398.V336023.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000003398.V336023.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is in place about the facilities and services provided at Britannia road and individuals can be confident that there needs will be met. Clear contractual arrangements are in place outlining individuals right and responsibilities. EVIDENCE: There are a settled group of individuals living at Britannia Road, the home is registered to accommodate five adults; there have been four individuals living at the home for some time and there are no immediate plans to fill the vacancy at the home. The manager said that there had been a possibility of someone moving to the home but following a review of their care plan the manager felt that the home would not be suited to the individuals needs. The Statement of Purpose was in place and this has been viewed at previous site visits and was found to be fully comprehensive and contained all of the relevant information required as stated in Schedule 1, Regulation 4(1)(c). The Statement of Purpose contained the aims and objectives of the home and spoke of treating individuals with dignity and respect, to promote independence and encourage individuals to make choices with aspects of their lives. DS0000003398.V336023.R01.S.doc Version 5.2 Page 9 The document also contained the relevant qualification and experience of the manager and staff team. The document outlines the needs that can be supported at the home. Sense ensures that an updated copy of this document is forwarded to the Commission on an annual basis. A pre inspection survey was received from an individual who lives at Britannia Road, they had been supported to complete their form and had recorded that they had looked around the home before being admitted and had been consulted about their needs and wishes prior to moving in. Placement agreements were seen in individuals files evidenced that these documents are reviewed every six months and are signed by both the service user and the manager, the documents contains information about individuals fees and what these do an do not cover. The agreement also outlines the aims of the organisation, the support that individuals can expect, notice periods, visitors and complaints. DS0000003398.V336023.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Records held about individuals living at the home are formulated in the style most suited to the individual’s communication style. Information is extremely detailed and written in a ‘person centred’ way. Individuals are well supported to take risks as part of an independent lifestyle approach. EVIDENCE: The care documentation written about those who live at Britannia Road is well written. It is clearly evident that care plans have been developed with, and owned by, the individual, based on a full and up to date holistic assessment. The care plans seen are person centred and focuses on the individual’s strengths and personal preferences. The care plans seen record individual’s life experiences and sets out in detail how all their current requirements and aspirations are met through positive individualised support. DS0000003398.V336023.R01.S.doc Version 5.2 Page 11 A variety of different and creative methods are used to help people who live at Britannia House to contribute in the development of their care plan and the ongoing review process, these include ‘my life story’, ‘information you need to know about me’ and individuals preferred routines. Care plans have been recorded not only in written form but have also been produced in widget symbol format; pictures and photographs have also been used. Where able service users sign to say they are happy with the contents of their plan and have a copy of this if they want it. Staff said that it is up to the service user who they wish a copy of their placement review to go to. There was sound evidence in place to demonstrate that the plan is reviewed on a regular basis in order that it is updated when required this is undertaken through review meetings, monthly one to one core team meetings. Through discussion with staff and information seen in staff files showed that staff have had the specialised training and skills to support, engage and encourage individual’s to be fully involved. Staff actively provide one to one support, they keep the care plan up to date and make sure that other staff always know the service users current needs and wishes. Behavioural support guidelines are in place and these are very detailed and record potential trigger factors, early warning signs and staff response, it was noted that not all staff had signed to indicate they were aware of these guidelines and had read them and therefore it is recommended that this is done to evidence that staff are aware of the documents and work in accordance with the information given. Service users are well supported to make decisions about their lives and are assisted appropriately. The manager said that when pending interviews take place for a support workers post that one of the service users will be asked if they want to be involved with the recruitment and selection process. The manager confirmed that house meetings will be arranged for those living at the home that wish to participate, meetings will be arranged when there are specific issues to be discussed; for example forthcoming holidays and redecoration that will be taking place within the house. The care plans at the home all include a comprehensive risk assessment, which is regularly reviewed. The service has a ‘can do’ attitude and risks are managed positively to help people using the service lead the life they want. Any limitations on freedom, choice or facilities are always in the person’s best interests. The individual understands and agrees any limitations; they are fully documented and reviewed on a regular basis. DS0000003398.V336023.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals at the home are well supported to participate in activities of their choice, individuals are respected and responsibilities are recognised in individual’s daily life. EVIDENCE: The manager and staff support service users to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enable individuals integration into community life through knowledge and support to enable individual’s to make use of services, facilities and activities in the local community, such as shops, bingo pubs, college and cinema. Information seen by the inspector, confirmed by staff and seen on individual’s records showed that those living at the home are offered a variety of social, leisure and educational activities. Individuals are able to participate or not, this is dependent on the individual’s choice. Information seen in daily records evidenced that individuals regularly are supported to visits to places of local interest and local community groups. DS0000003398.V336023.R01.S.doc Version 5.2 Page 13 On the day of the site visit individuals were offered the opportunity to attend deaf club. All individuals will be consulted about their choice of a holiday for later this year, one of the service users has decided they want to go to New York and all avenues in respect of this are being explored. Staff confirmed that all service users would be going to ‘Woodlarks’ in Surry for a week’s holiday in July. Seen within individual’s files were ‘session support forms’, these sessions fully recorded the outcomes of activities that had been undertaken for the individual, whether they enjoyed the activity and recorded what they had achieved. A pre inspection survey was received from an individual who lives at Britannia Road recorded that they organise their own timetable every week. They choose where to go e.g. going to the bank to collect their personal allowance, going to the cinema/shops. Service users are involved in the domestic routines of the home; they take responsibility for their own room, menu planning and preparation of snacks. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritional and cater for the varying choices and dietary needs of the individuals using the service. A staff member confirmed that each week individuals are asked if they would like to be involved in the menu planning for the forthcoming week, individuals food likes and dislikes are well recorded. All of the individuals who live at Britannia Road were asked if they would like to spend time with the inspector in order that they could ask questions, and that the inspector would like to ask them about their life in the home. One individual agreed to speak with the inspector and the manager ‘signed’; the individual indicated that they were and that they were happy at the home. In the past one of the service users has been supported by People First, an independent advocacy service, although this is not in place, or required at this current time the manager confirmed that this is a service, which could be accessed for any individual, should the need be identified or requested. The home has a ford focus car to support individuals with their transport needs, some discussion took place about the practicalities of this when all four individuals want to attend the same venues such as deaf club or bingo, the manager explained that not all service users are able to travel together, although other methods are used, it is recommended that a larger vehicle is explored in order to ensure that service users options are not limited. DS0000003398.V336023.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported appropriately in aspects of their personal, physical, emotional and healthcare needs are well met. Medication is dealt with appropriately and individuals are assisted in this area as needed. EVIDENCE: Prior to this site visit a questionnaire was received from a health professional that supports an individuals living at Britannia Road, they recorded that the staff are very respectful to ensure an individuals privacy, they respect him and assist him with his communication The home are in the process of developing health action plans for all individuals living at Britannia road; the inspector saw one in progress and saw that the document was in depth and covered all areas of individuals physical and emotional wellbeing, staff are committed to ensuring this document is completed with the individual and fully reflects their requirements, it is anticipated that these health action plans will be completed for all individuals and the inspector looks forward to seeing these in place for all individuals at the next visit to the service. DS0000003398.V336023.R01.S.doc Version 5.2 Page 15 All service users who take medication at Britannia Road are supported with this by staff. The manager showed the inspector the medication administration systems in place at the home. Miss Swash was fully conversant with her role and responsibility in this area and the importance of adhering to policies and procedures that are in place for the safe administration of medication. A review during the inspection revealed no errors. The medication was appropriately stored and was well organised. All medication records were up to date and in order. All staff handling medication have attended training. Recently the registered manager attended medicines training provided by South Gloucestershire Council, with the Commissions pharmacy inspector in attendance. As well as training provided by the supplier of the medication the organisation also provide medication competency training to all staff. It was seen recorded in heath care records when individuals had refused treatment, for example one person had indicated that they did not wish to visit the audiologist or the dentist, this was respected. Some discussion took place surrounding the issue of balancing the rights of individuals to refuse treatment balanced with the homes responsibility and ‘duty of care’, those spoken with fully aware of their responsibilities. Health records further evidenced that individuals have free access to all medical services; both primary health and complex health needs are well met. During the visit staff were seen to be supporting individuals in a caring, empowering and supportive manner. During the visit there was an occasion where one individuals dignity could have been compromised, staff responded promptly and calmly to ensure that this did not happen. DS0000003398.V336023.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear processes in place in which individuals can raise concerns; individuals are protected from EVIDENCE: A pre – inspection questionnaire was received from a client, this recorded that the individual had the complaints procedure explained to them every three months by their core team and that the individual has made complaints in the past, which had been dealt with and responded to appropriately. Recruitment practices carried out in the home protect residents from abuse, criminal records bureau and protection of vulnerable adults checks are carried out, and two written references are obtained before staff commence employment. Staff at the home have undertaken protection of vulnerable adults training, a staff member spoken with said that the training provided had been useful and provided clear guidance for staff. One of the senior staff members at the home is a trainer for the organisation in adult protection and her knowledge is a valuable resource to staff working at the home. There have been occasions, due to the complex needs of some individuals at Britannia Road, where physical aggression has been displayed. Records seen such as behavioural guidelines, notification of incidences forms and incident reports demonstrated that these behaviours are understood by staff and are dealt with appropriately. DS0000003398.V336023.R01.S.doc Version 5.2 Page 17 Staff have completed non-violent physical intervention training and the inspector saw that staff regularly review techniques used such as blocking and positioning. This area of staff practice is also discussed within supervision sessions and team meetings. The homes policies and practices in respect of service users monies are robust; inventories are in place in respect of individual’s property and valuables. DS0000003398.V336023.R01.S.doc Version 5.2 Page 18 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, 26, 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The quality of furnishings and fittings in the home are good and overall a comfortable environment has been created ensuring individuals needs are met, however the organisation must ensure that the organisation maintain the home to a suitable standard. EVIDENCE: Britannia Road is registered with the Commission to provide a service for up to 5 persons aged 19 - 64 years, currently there are four individuals living at the home, three men and one female. There is a vacancy at the home and there has been one for some time. The home comprises of two houses and has suitable communal and private areas for individuals use. DS0000003398.V336023.R01.S.doc Version 5.2 Page 19 A requirement was made at the last site visit was that attention should be given to the light fitting in the entrance hall; this visit found that the fitting was working. The manager explained that on occasion there has been difficulties due to one individual damaging the fittings and the home are currently exploring other methods of lighting within the home. There is a small ‘domestic’ type kitchen, this was found to be clean and tidy and general well maintained, however it was noted that some of the work tops are damaged and a light fitting had no fitting or cover it is required that this is replaced in order that suitable lighting in this area is provided. There is a spacious dining area that overlooks the rear garden, in this area was a unit in which the door had been removed, it is recommended that the unit in the dining room is repaired or replaced, furthermore it was noted that the rear garden area contained broken garden furniture, a concrete slab and ladders, it is required that this area is clear of ‘clutter’ in order that it maybe safe for service users use. The manager said that there have been issues with cracks appearing and these were noted by the inspector in an individual’s room. The manager said that the damage had been caused by root damage from the trees in the rear garden; a surveyor had visited and has recommended a tree surgeon to deal with the trees. The manager confirmed that she is awaiting a date from the tree surgeon and when they have completed their task work will be undertaken to redecorate the two affected bedrooms. Staff confirmed that the individuals concerned will be fully consulted about the work and will choose the colour for their rooms to be repainted. The manager confirmed information seen in the homes AAQA document that new carpets will be fitted within the house; areas to be replaced include the office, stairs and sleep in room for staff. There are two bathrooms, each area has a bath and shower; it was noted that tiles were missing and in one bathroom the ceiling fan was thick with dust and needs to be cleaned. Within the homes annual quality assurance the home had identified that there are plans for one of the bathrooms to be refurbished, (house 37), it is recommended that consideration should also be given to the re furbishment of the other bathroom, in the meantime however, it is recommended that the missing tiles in this area are replaced. DS0000003398.V336023.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient, staff on duty and staff are qualified to provide good level of care. All staff are clear regarding their role in what is expected of them. Recruitment practices safeguard individuals living at Britannia Road. EVIDENCE: There are clear aims and values in this home, which are individually focused and centre on the choice, rights and wishes of Individuals. Staff were able to clearly demonstrate this philosophy and it was evident that meaningful relationships had been forged between the staff and those living in the home. DS0000003398.V336023.R01.S.doc Version 5.2 Page 21 Prior to the site visit a comment card was received by the Commission from a visiting health professional to the home who said they were ‘very impressed by Becky and Helen’. Becky Light is a senior staff member and Helen Swash is the Registered Manager). ‘Becky, in particular has been highly skilled at communicating with a particular individual and has ensured that they have understood things. I think the staff I have met seem motivated and well experienced’. This same professional recorded that the things they felt the service did well was; ‘communicate’, ‘use sign language’, ‘explain what is going on to visitors’, ‘visitors are made welcome’ and they are ‘respectful to difficult situations’. The home ensures that all staff receives relevant training that is focussed on delivering improved outcomes for those using the service. The home puts a high level of importance on training and staff confirmed that they are supported through training to meet the individual needs of those living at the home; a training matrix and certificates seen evidenced that staff have completed core training in areas such as first aid, protection of vulnerable adults training and basic food hygiene, other specialised training is also provided for staff in areas such as, medication competency and infection control. The home has a sound recording matrix in place to evidence staff training, which has been undertaken, and to record future training booked such as disability equality. There are two staff who have achieved a National Vocational Qualification at level 3, promoting independence, two staff are currently undertaking this award and one of these staff members will also be undertaking an NVQ assessors training course and has identified two staff members who will be completing this award. Further progress in this area will be reviewed at the next site visit. The inspector spoke individually with a staff member who said they are very happy within their role at the home and said that they felt well supported both by the management and the organisation, this member of staff knew who to speak with if they were unhappy. This member of staff was fully conversant with the in depth and complex nature of the support that individuals require at the home and gave sound examples of how individuals are given choices and how their rights are promoted and how individuals are treated as adults. The recruitment and selection documents for two members of staff were reviewed at this inspection; these staff files evidenced that full and robust practices are adhered to at the home to ensure that those appointed have the qualities and skills to work within this care environment. Appropriate adult protection checks are taken to ensure the protection and safety of service users. DS0000003398.V336023.R01.S.doc Version 5.2 Page 22 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, 38, 39, 40, 41, 42, 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from the home being well managed. There is clear leadership and a strong focus on the outcome for service users in all management and development decisions. The home ensures that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team. EVIDENCE: The Registered manager is Helen Swash; Helen has worked at the home for a number of years and has been the Registered manager for nearly two years. Helen confirmed that she is in the final stages of completing the registered managers award in care. DS0000003398.V336023.R01.S.doc Version 5.2 Page 23 Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment. The annual quality assurance assessment (AQAA), this is a new process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the Registered Manager was fully completed and detailed. Some of the following statements were recorded, in respect of equality and diversity; ‘Sense welcomes the fact that fact that we live in a multi-racial, multi-cultural society. It is committed to celebrating the varied contribution that all individuals and their communities can bring to the organisation and to the services that we provide. Given the specific nature of our work Sense emphasises the positive contributions that are made by people with sensory impairments and other disabilities’. ‘Sense makes a commitment throughout the organisation to provide routes into our services that are suited to the needs of different communities; Senses commitment can only be made a reality through conscious action at an individual and collective level by all of Senses trustees, staff and volunteers’. It was clear that staff are well supported by the management of the home with sound systems in place to support and guide staff practice in order to ensure that all staff are providing a good quality service to those who live at Britannia Road, these include personal development, regular staff meetings and supervision sessions and overall review of staff performances. The home has a number of effective quality assurance and quality monitoring systems in place at home, these include a monthly inspection audit undertaken by a representative of the registered provider, this audit is forwarded to the Commission on a monthly basis, there is a low level of complaints and there is a low staff turnover in this home. The organisation has a sound formalised quality audit programme, this audit was undertaken in October 2006 and the results of this further evidenced that there are high levels of satisfaction with this service; overall quality auditing processes of the service are excellent. The home displays a current certificate of Employer’s Liability Insurance. The home has in place clear policies and procedures in areas of staff employment, individual’s finances and health and safety, all of which have been reviewed and updated. This guidance provides clear information to staff to inform and guide their practice. A review of the fire logbook found that staff are receiving sufficent fire instruction and drills, maintence and equipment checks are undertaken on a regualr basis. It was noted that not all weekly checks have been recorded. It is required that the home must improve upon the recording for weekly fire safety checks. DS0000003398.V336023.R01.S.doc Version 5.2 Page 24 Staff spoken with confirmed that they felt supported and able to approach the manager and the registered providers should they wish to discuss day-to-day running of the home. One staff said ‘I enjoy my job here, I am very happy’. DS0000003398.V336023.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 4 3 3 2 3 DS0000003398.V336023.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA24 YA30 YA42 Regulation 23 (2) (o) 16(2) (j) 17 (2) Requirement The rear garden to be cleared of ‘clutter’ for individuals use. Ceiling fan in the bathroom to be cleaned. Weekly fire checks to be better recorded. Timescale for action 04/07/07 04/07/07 04/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA13 YA6 YA24 YA24 Good Practice Recommendations The home to consider if the current house vehicle is appropriate to meet the needs of service users. All staff should read individuals behavioural reports and sign to evidence they have done so. Tiles in the bathroom to be replaced. Unit in the dining area to be repaired or replaced. DS0000003398.V336023.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 DS0000003398.V336023.R01.S.doc Version 5.2 Page 28 - 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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