Inspection on 24/07/08 for 38a Woolifers Avenue

This inspection was carried out on 24th 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

38a Woolifers Avenue 31/07/07

38a Woolifers Avenue 06/06/06

38a Woolifers Avenue 07/03/06

38a Woolifers Avenue 09/11/05

38a Woolifers Avenue 07/03/05

38a Woolifers Avenue 14/12/04

38a Woolifers Avenue 29/01/04

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 08/11/2008.

CARE HOME ADULTS 18-65 38a Woolifers Avenue 38a Woolifers Avenue Corringham Essex SS17 9AU Lead Inspector Pauline Marshall Unannounced Inspection 24th July 2008 09:05 38a Woolifers Avenue DS0000018119.V368881.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 38a Woolifers Avenue DS0000018119.V368881.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. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 38a Woolifers Avenue Address 38a Woolifers Avenue Corringham Essex SS17 9AU 01375 640292 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.familymosaic.co.uk Family Mosaic Mrs Sarah Ann Burton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2007 Brief Description of the Service: 38a Woolifers Avenue is a detached bungalow situated on a corner plot in a residential area. The home provides residential accommodation for three adults with learning disabilities and is owned by Family Mosaic. The homes facilities include a large living/dining area, three single bedrooms, a shower room and a bathroom. People living in the home are encouraged to access leisure interests and community facilities. The home is situated a short car journey from the local shops, Corringham Town and Lakeside shopping Centres. People living in the home have access to a people carrier and there are bus and train services close by. The home has a pleasant garden, which has a seating area and a swing hammock; a ramped path that has a handrail and lighting to assist people using it surrounds it. There is hard standing at the rear of the garden for parking the homes people carrier and there is ample on street parking for visitors. The Service User Handbook and Statement of Purpose are regularly reviewed and together with a copy of the homes last report they are available from the home manager; the Service User Handbook is also available in a CD format. Charges range from £1, 232.00 to £1, 593.00 per week and people living in the home pay a contribution that is currently £102.90 per week. 38a Woolifers Avenue DS0000018119.V368881.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. This was an unannounced key inspection that lasted six hours and twenty minutes. The process included discussions with people living in the home, the manager and the staff; an examination of a random sample of the files (including those of staff and people living in the home) and some of the records that the home is required to keep. The inspection covered all of the key standards and included a tour of the property. The manager completed their annual quality assurance assessment (AQAA) and information from this has been reflected throughout this report. The AQAA is a form used by the manager to carry out a self-assessment of how well the outcomes of people using their services are being met. Surveys were sent to the manager to distribute to three people who live at the home, three of their relatives, two health and social care professionals and five care staff. At the time of writing this report one person using the service, one of their relatives, one health and social care professional and three staff surveys had been returned. The returned surveys contained mainly positive comments about 38a Woolifers Avenue and comments are reflected throughout this report. What the service does well: The home gives people good up to date information on the service it provides and also provides its Service User Handbook in a CD format. Support plans are written in a person centred way; pictures are used as well as words. People living in the home are encouraged to make decisions about what activities they want to do and where they want to go and they often go out to the local shops and are well known in the area. Surveys retuned from people living in the home said, “I always do what I want and always make decisions about things and staff treat me well”. People have a health action plan which includes details of how to keep them healthy. People living in the home have regular contact with doctors, social workers, nurses and speech and language therapists. The manager listens and acts upon people’s complaints. The surveys returned from people living in the home said “I know who to speak to if I am not too happy and the carer’s always listen to me and act” and staff surveyed said “we 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 6 do well at listening to service users”. Regular staff, which people living in the home know, mainly staffs the home and agency is only used as a last resort. The home is clean and tidy. What has improved since the last inspection? What they could do better: The manager must make sure that the information paperwork includes our contact details. The manager must make sure that staff follow the medication rules and that staff sign and date all opened packets of pills and that they complete all of the paperwork correctly. When the staffs see there are any risks to people living in the home they must make sure that any instructions to lower the risks are dated to make sure they still apply. The home’s complaints rules must have our contact details in them and the safeguarding rules should tell staff whom to contact if they thought someone was being abused. All staff must have a full check carried out before they start work at the home. The owner must carry out a monthly visit to the home to check that it is being run ok. The manager should go over the fire risk assessment to make sure it tells staff what to do now that a new person has moved in and changes have been made to the fire exit and garden. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 7 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. 38a Woolifers Avenue DS0000018119.V368881.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 38a Woolifers Avenue DS0000018119.V368881.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): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to receive a thorough pre-admission assessment and up to date information on the home prior to their admission. EVIDENCE: The manager reviewed the Statement of Purpose and Service User Handbook in May 2008 and the handbook is now available in a CD format. There was a copy of the last inspection report in the folder containing the Statement of Purpose and Service Users Handbook. At the last inspection a recommendation was made that the section of the documents referring to the complaints procedure should be amended to reflect that we do not have any statutory responsibilities to investigate complaints; the manager has since removed our details from all documents. People considering using the service need to have adequate information and the regulations state that the complaints procedure must include the address and telephone number of the CSCI. The manager said that she would amend the documents with these details. The most recent person admitted to the home was transferred from another home belonging to Family Mosaic and full assessment documentation was in place for them at the other home. The manager said that she carried out an assessment prior to the move and devised a transitional action plan; a copy 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 10 was supplied to us and she said that the assessment process is on going. The two other care files examined contained evidence of both social services assessments and the homes assessments that were carried out by previous managers. Two of the three care files examined contained copies of the persons license agreement which detailed their terms and conditions with the home. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home can expect to have a support plan that meets their needs and personal goals. People can expect to be supported to take risks and to make decisions about their lives. EVIDENCE: All of the care files examined contained detailed comprehensive person centred support plans that had been regularly reviewed. Each section of the care file clearly identified its contents and support plans were accompanied by risk assessments and management strategies for all of the identified risks. The risk assessments, management guidelines and strategies were not always signed and dated making it difficult to determine if they were current. Staff spoken with was fully aware of the management strategies that were in place for each individual. The manager said that people living in the home are fully involved in the creation and reviewing of their support plan wherever possible. The manager said that regular meetings are held and people living in the home confirmed this; notes are kept of the meetings and cover all areas of the 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 12 running of 38a Woolifers Avenue. Surveys retuned from people living in the home said, “I always do what I want and always make decisions about things and staff treat me well”. The manager said that in the past advocates had been appointed for people living in the home if their relatives did not respond to the homes correspondence. The manager said in her annual quality assurance assessment (AQAA) “one person living in the home has a very structured day, this is their own choice and can impact on other people living in the home so we are looking into ways of positive change to reduce the impact on others”. Staff said in their surveys “the home has a positive “we can” attitude and listens to service users, their relatives and staff”. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to participate in appropriate activities both in the home and out in the local community and they can expect their rights to be respected in all aspects of their daily lives. People living in the home can expect to be provided with a healthy and nutritious diet. EVIDENCE: The support plans examined had details of activities that had been undertaken both in the home and out in the local community. One of the people living in the home said how they enjoyed going food shopping and that they had visited the local charity shop and bought themselves puzzles and books. Staff said that local shops were familiar with people living in the home and welcomed them into their shops. One person returned from a walk to the local charity shop and eagerly showed me their purchases. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 14 The manager said that she was planning more sensory sessions for one particular person and that massage, music therapy and nail painting was amongst the inside activities that took place. There is a sensory garden with strong smelling plants such as lavender for people to enjoy. The home has a rehabilitation budget that is used for accessing the community. The manager said in her annual quality assurance assessment (AQAA) “there are monthly key worker social activity reports in team meetings, so we are able to plan activities that have been identified by/together with the individual”. There was evidence that these meetings have taken place, however they were not always monthly. The home encourages people to keep in contact with their friends and relatives and one person spoken with said how they looked forward to their family visiting. One relative said in their survey “the home always keeps in touch and keeps me up to date, they provide a good family background”. The manager operates a four-week rolling menu that is varied at the request of people living in the home. When there is a variation to the meals offered on the menu it is recorded in the individual persons food diary. There was no alternative choice of the meals offered shown on the menu however staff spoken with said that people may choose from a large range of options that are available and that they would often show people the actual food that was offered as an alternative. The manager said that she had recently obtained an increase in her food budget, which was sufficient to stock a larger range of foods as alternatives to the menu. People spoken with said they were happy with the food and were observed to enjoy it. Staff said in their surveys “the home provides good well balanced diets for service users with good home cooking”. The manager said that she is waiting for additional dining tables to be delivered and that she is reviewing the mealtimes to suit the needs of the people living in the home. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. People can expect that their physical, emotional, health and personal care needs will be met in a way that they prefer. Medication practice could potentially put people at risk. EVIDENCE: All of the care files examined contained a health action plan; there was evidence that people living at the home have access to a range of healthcare professionals including social workers, district and community nurses, consultant psychiatrists and GP’s. The manager said in her annual quality assurance assessment (AQAA) “we have reviewed peoples medication with their individual GP’s and we seek/contact health care professionals as needed; referrals are made to the occupational therapist, community nurse, speech therapist, language therapist and the district nurse for their input and advice; each individual has the community dentist visit”. The care files examined contained full details including the outcomes and any follow up actions that were required of visits to various healthcare professionals. The surveys returned from people living in the home said “I know who to speak to if I am not too happy and the carer’s always listen to me and act” and 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 16 staff surveyed said “we do well at listening to service users”. Although people living in the home had limited communication it was apparent from observing them throughout the day that they were content, happy and relaxed and got on well with the staff team. The medication cabinet has been re sited to the office and the person in charge of the shift holds the keys. A random check was carried out on the homes medication administration system and there were some gaps on the medication administration sheets (MARS) and no code or explanation as to why there were gaps. The last inspection identified that packets and bottles of medication were not signed and dated when they were opened; some of the opened packets still did not contain this information. The manager had identified a medication error; medication had been signed for, as administered but the tablets were still in the pack from the night before the inspection. The staff responsible for this error was an agency worker; the manager was in the process of carrying out her investigation at the start of this inspection and provided us with full details of the outcome. All staff has had medication training in the past year. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 17 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. People can expect to have their complaints listened to acted upon and to be protected from abuse or harm. EVIDENCE: The manager reviewed the complaints policy in May 2008; the policy does not include the CSCI contact details as required in the regulations and does not make it clear that people may contact us for further advice but not to make a direct complaint. The manager said that no complaints have been made within the last year and that the last complaint received by the home was recorded in the old complaints book that is no longer used; the home now has a complaints folder and separate compliment book. The last complaint was examined and it was dealt with appropriately. The manager said in her annual quality assurance assessment (AQAA) “staff support people and their families in any area of concern and the complaints procedure is fully displayed”. Relatives of people using the service said in their surveys “I know how to complain and the care home usually responds appropriately”. The adult abuse policy was last reviewed in May 2008 and gives a very detailed account of the signs of abuse, the legal framework and the input of other agencies such as the social services and police. The abuse policy does not provide any contact details for any of the agencies mentioned but it states “it is the responsibility of the Team Leader/Service Manager to ensure that all staff know the reporting procedure and contacts for the particular borough and client group; this will be available in writing for each borough”. The manager said that the home works to the Essex 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 18 Protection Of Vulnerable Adults Procedure (blue book) and the policy confirmed this. The abuse policy included a bullet pointed quick guide. A discussion took place around the recent changes in the Protection Of Vulnerable Adults guidelines and the manager said that she would obtain the new Southend, Essex and Thurrock Safeguarding Adults Guidelines that were published in April 2008. All staff has had training in the protection of vulnerable adults and staffs spoken with were aware of the need to refer any suspicions of abuse. The manager said in her annual quality assurance assessment (AQAA) “all staff have attended POVA training and are aware of the varying forms of abuse and this is discussed during supervision and team meetings”. Notes of meetings confirmed this. People living in the home have their own bank accounts and generally small amounts of cash are held for the purchase of personal items; people had returned from their holiday on the week of the inspection so the amounts held were larger than stated in the homes policy. Cash is kept securely locked away and all three cash transaction records and their corresponding cash were checked and were found to be correct. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a homely, comfortable, safe and clean environment. EVIDENCE: People spoken with said they were happy living at 38a Woolifers Avenue and that they liked the way it was decorated. Two of the three bedrooms were inspected; one contained many personal items, the other had some personal items displayed but as the person was in the process of settling into their new bedroom, there was still some work to do on personalising it. The lounge has recently had new carpet fitted and there is a new leather sofa; people spoken with said they liked the new furniture. The lounge area leads through patio doors into a good sized garden that has recently had a ramped path laid to enable people to access the garden more easily. The path is fitted with handrails and the garden has lighting; there is a grassed area with tables, chairs, parasol, bird table and a hammock. New 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 20 fencing and gates have been installed around the garden area; the people carrier is parked at the rear of the garden on hard standing to allow people living in the home easy access in and out of the vehicle. The laundry facilities including the washing machine and tumble dryer are situated in the kitchen area. The manager said that the kitchen is due to be replaced soon and that the second bathroom that nobody uses will be made into a utility room and that the washing machine and the tumble dryer will be moved into this room. The manager said in her annual quality assurance assessment (AQAA) “we have a cleaning schedule detailing daily and nightly chores also a checklist for staff to sign when tasks are completed all health and safety checks are carried out regularly and documented”. On inspection of the cleaning schedule it was noted that it had not been completed for several days; people living in the home and the homes staff had recently returned from a holiday and the schedule had not been completed since their return. The manager said that she would address the issue with the staff concerned. The home was clean, pleasant and hygienic and it appeared that the work had been carried out despite not being recorded. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 21 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): 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. People living in the home can expect to be supported by well-trained and supervised staff. EVIDENCE: The staffing roster showed that there are two support workers each shift throughout the day and one waking support worker at night. The manager said that either the permanent staff or their bank staff generally covers the home; use of agency staff is minimal; the roster showed eight shifts during the past three weeks that were covered by agency staff. The manager said in her annual quality assurance assessment (AQAA) “we use our own regular team members first to cover annual leave and sickness for consistency and familiarity and continuality of care, we use our regular bank staff; we only use agency as last resort”. Three staff files were examined and they all contained the documents required under Schedule 2 of the regulations. One of the staff files examined contained a criminal records bureau check that was dated after employment begun; there was no evidence of a POVA 1st check having been carried out and the 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 22 manager confirmed that it had not been done. A discussion took place around employment checks and the manager was advised to obtain the CSCI guidelines on Criminal Records Bureau checks. The manager said in her annual quality assurance assessment (AQAA) “recruitment issues have been addressed and a stringent collection of documents are required before commencement of duties”. Some of the homes staff had been transferred from other schemes run by Family Mosaic. The manager said that training has improved recently and that she is in the process of devising a training matrix to assist her in identifying staffs training needs. Since the last inspection staff have received training in medication, first aid, moving and handling, infection control and the protection of vulnerable adults (POVA). The manager said in her annual quality assurance assessment (AQAA) “mandatory training has been addressed so more places are now available and are more local”. Staff spoken with and surveyed said that training had improved however one staff surveyed said “the home could do better on the training for bank staff”. Family Mosaic offer a range of training opportunities throughout the year in various locations; the manager said that personal safety level 2 (includes conflict management) has been requested for all of the staff team for 5th August 2008 at Pitsea and that she is waiting for a response. All of the staff files examined contained evidence that regular supervision takes place and staff spoken with confirmed that they felt well supported in their role. One staff said in their survey that they “meet with the manager often”. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a well run home where their health, safety and welfare is protected. The quality assurance system is basically sound. The practice of the manager preparing her own regulation 26 reports is inappropriate. EVIDENCE: The manager currently works two and a half days each week at 38a Woolifers and the other two and a half days at another scheme; this is a temporary arrangement until a new manager is appointed at the other scheme. The manager works supernumery at present and has said that when she returns full time at 38a Woolifers she will have one day supernumery and the other four will be as part of the shift system. A discussion took place around the managers’ role and the difficulties that arise from having such limited management hours. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 24 The manager has worked in care for the last 19 years and has worked at 38a Woolifers Avenue since February 2007 and became the registered manager in November 2007; she has recently completed the Registered Managers Award. The manager has undertaken appraisal, handling disciplinary and grievance and recruitment and selection training in the past year. All of the policies and procedures were reviewed in May 2008 and staffs are asked to sign to confirm that they have read them. The home holds regular meetings for people living there and people spoken with confirmed that they participate in the running of the home. The manager said that the home seeks the views and opinions of people living there on a daily basis and the managers’ annual quality assurance assessment (AQAA) states “the needs, choices and views of people living in Woolifers are at the heart of running it”. A health and social care professionals’ survey states “the home is excellent and there is very little room to improve”. Family Mosaic carries out regular quality assurance surveys and they publish the results. The manager was recently asked by the service manager to prepare her own monthly report (Regulation 26 visit by the registered provider). The regulations were discussed and it was verified that the registered provider is responsible to carry out this visit at least once a month and prepare a written report if they are not in day-to-day charge of the home. All safety certificates were in place and up to date. Fire drills are carried out regularly and the home has a fire risk assessment dated 15/3/07; the manager said this is due to be updated to reflect the recent changes to people living in the home and the work that has recently been carried out. The manager said that she carries out a regular monthly health and safety check and there was evidence to support this. There are risk assessments in place for the use of all electrical appliances. 38a Woolifers Avenue DS0000018119.V368881.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 2 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 Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4, 5 Requirement To ensure that people receive correct information about the home the Statement of Purpose and Service User Handbook must contain details of the complaints procedure. The complaints procedure must include the address and telephone number of the CSCI and must make it clear that people may contact us for further advice but not to make a direct complaint. To ensure that people are safeguarded from medication errors the medication practice must be improved upon. This relates to the gaps on the medication records, the medication error detailed in the report and the open medication packs that did not indicate the date of opening. To ensure that people are fully protected the manager must carry out robust recruitment checks. This refers to staff that started work without a CRB or POVA1st check. DS0000018119.V368881.R01.S.doc Timescale for action 01/10/08 2. YA20 13 (2) 01/10/08 3. YA34 19 Schedule 2 01/10/08 38a Woolifers Avenue Version 5.2 Page 27 4. YA37 26 To ensure that people benefit from a well run home the provider must carry out regular monthly checks. This refers to the manager being asked to carry out her own Regulation 26 visit. 01/10/08 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 YA9 YA22 YA23 YA42 Good Practice Recommendations To ensure that risk assessments and management guidelines meet people’s current needs they should be signed and dated. To ensure that people have correct information the homes complaints procedure should include CSCI contact details. The abuse procedure should include the contact details of the local social services to enable staff to report any suspicions of abuse. It is recommended that the homes fire risk assessment is updated to include the recent changes to the building. 38a Woolifers Avenue DS0000018119.V368881.R01.S.doc Version 5.2 Page 28 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. 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