Inspection on 07/06/07 for 3a The Droveway

This inspection was carried out on 7th June 2007.

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

The inspector 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

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

CARE HOME ADULTS 18-65 3a The Droveway Hove East Sussex BN3 6LF Lead Inspector Niki Palmer Key Unannounced Inspection 7th June 2007 3:20 3a The Droveway DS0000068868.V337517.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 3a The Droveway DS0000068868.V337517.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. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3a The Droveway Address Hove East Sussex BN3 6LF 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) 01273 541229 www.caremanagementgroup.com Care Management Group Limited Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is three (3). Service users to be aged eighteen (18) to sixty-five (65) on admission. Service users with a learning disability only to be accommodated. Date of last inspection This is the service’s first inspection Brief Description of the Service: 3a The Droveway is a care home, which is registered to provide personal care and accommodation for up to three people with learning disabilities. The home is owned and run by Care Management Group (CMG) who are a large national organisation. The home is a newly purpose built two storey property, which has been designed and adapted specifically for one named person. It is located in Hove, near Brighton. There is nearby access to some local amenities and public transport. A small car parking area is available at the home, although on street parking is permitted in the surrounding areas. Accommodation is provided over two floors, although individual bedrooms, bathrooms and communal areas are on the ground floor. All bedrooms have en-suite facilities. The home provides personal care and support to people who are funded by Social Services and/or the local primary health care team. The home’s fees as of 07 June 2007 range between £1800 - £6700 per person per week. Additional costs are charged for hairdressing, toiletries and external leisure activities (£ variable). Written information regarding the services and facilities provided at the home are available on request. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 07 June 2007 and lasted four hours. This enabled the Inspector to observe the evening routine. One person was accommodated on the day of the inspection. In order to gather evidence on how the home is performing, individual discussions took place with two members of staff, whilst the majority of the inspection was undertaken with the acting Manager of the home. One care record was examined in some detail for the purpose of monitoring care. Other areas and documentation inspected included: the home’s Statement of Purpose and Service Users’ Guide, pre-admission assessment procedures, medication practices, the provision of activities, quality assurance systems, complaints procedure and the systems in place to safeguard people using the service from harm, staffing levels and the provision of relevant training. Most communal areas and individual rooms were seen. A detailed Annual Quality Assurance Assessment (AQAA) was completed and returned by the acting Manager of the home prior to the inspection. This provided the CSCI with comprehensive information in respect of how the service ensures that people using the service views are upheld and incorporated into what they do, how equality and diversity issues are promoted, identify any barriers to improvements that have been faced over the past six months and how the service plans to make improvements within the next 12 months. Following the inspection, telephone contact was made with a relative, a Care Coordinator from the Community Learning Disability Team (CLDT) and a Community Nurse. Their views have been reflected throughout this report. What the service does well: 3a The Droveway is a well managed service that has been specifically tailored and individualised to meet the assessed needs of one named person. This was achieved through careful planning during the initial building plans for development and close professional working relationships with health and social care professionals and relatives. The home’s comprehensive care planning procedures support care staff well to begin to work towards improving the person’s overall quality of life and opportunities for meaningful daily activities. The home is staffed by a dedicated, well trained and knowledgeable staff team, who have worked hard to develop close and professional ways of working with 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 6 the person who uses the service. It was evident throughout the inspection process that positive relationships have been formed. Comments received from others include: “I couldn’t have wished for better, [the person] has made excellent progress” “I was really impressed with how [the person’s] transition was handled. The staff team worked well with [their previous place of residence] and really took on board some positive working strategies”. “The staff team are wonderful and have an excellent understanding of [the person]. This has undoubtedly reduced [the person’s] frustrations” “The overall management is very good. The Manager is enthusiastic and he listens to me” What has improved since the last inspection? What they could do better: Five requirements have been made as a direct result of this inspection: In order to ensure the health, safety and welfare of the person using the service is the Manager is required to seek further advice in respect of providing personal care (cutting nails). In addition, all staff must receive the appropriate training in order to safeguard people using the service from potential harm, neglect and abuse. The home’s policies and procedures for the safe handling of medicines need to be reviewed. This will help to ensure the health and welfare of people using the service. The Manager must ensure that no person is employed to work in the home without two satisfactory and professional written references being obtained prior to employment. The acting Manager is required to begin working towards a qualification in Management in order to evidence that he is committed and competent to manage a care home. 3a The Droveway DS0000068868.V337517.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. 3a The Droveway DS0000068868.V337517.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 3a The Droveway DS0000068868.V337517.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, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 3a The Droveway offers an individualised service that has been adapted and tailored to individual needs. EVIDENCE: A copy of the home’s Statement of Purpose and Service Users’ Guide was forwarded to the CSCI following the inspection. The Statement of Purpose provides the reader with an introduction to CMG including the home’s aims and objectives, details of the Registered Provider and Manager, organisational and staffing structure and colour photographs of the accommodation provided. The Service Users’ Guide offers a good level of information regarding the services and facilities provided, residents’ charter, contact details of the Commission for Social Care Inspection (CSCI) and the arrangements in place for health and social care support. Both documents are presented in an easy to read and understand format, which incorporate the use of colour pictures and symbols. Health and social care professionals and relatives told the Inspector that 3a The Droveway was specifically built for one named person and tailored to their individual needs. One relative spoke about how they ‘literally watched the home being built and the service designed’. They confirmed that during this time, they met regularly with representatives of CMG and were consulted 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 10 about the services and facilities that were to be provided. Written information about the organisation was also made available. CMG employs a team of centrally based assessment referral officers, who are responsible for considering and assessing all initial referrals for each of the services across the South East region. The first person moved into the home in December 2006. A detailed preadmission assessment form was seen for this person. It was noted to be exceptionally detailed and covered the following areas: general background, physical and emotional healthcare, communication, activities of daily living, community presence and participation, occupational education, relationships and spiritual needs. There was clear evidence to demonstrate that this had been undertaken with the person’s previous place of residence, family members and multidisciplinary team. Discussions with the staff team, relatives and health and social care professionals confirmed that this transition period from children’s to adult services was handled exceptionally well. Staff confirmed that during this transition, they worked alongside the person’s previous place of residence in order to get to know the person well and gain a thorough insight into their needs. They explained how they had facilitated frequent visits to 3a The Droveway in order to familiarise the person with their new ‘potential’ home. This process took several months to complete. One professional spoken with said: “I was really impressed with how [the person’s] transition was handled. The staff team worked well with [their previous place of residence] and really took on board some positive working strategies”. Although the home is registered to provide personal care for up to three people, the Manager explained that due to the complex needs of the one person accommodated, the home will only consider admitting one other person. He demonstrated that he had a clear understanding of what the home is able to provide, based on the assessed needs of individuals. Completed copies of terms and conditions of contract were seen. These provide the person and their representatives with information regarding what the person can expect for the fee they pay and sets out the terms and conditions of occupancy. 3a The Droveway DS0000068868.V337517.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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The person who uses the service is supported well by the home’s comprehensive care planning procedures and are supported well to make decisions in all aspects of their lives to the best of their abilities. EVIDENCE: Individual needs and choices are clearly documented within an individual plan of care called ‘All about Me’. There was clear evidence that this had been devised based on a comprehensive assessment of need. At the front of the plan can be found a personal profile with an up to date photograph. The personal profile is written in the first person and gives an overview of the person’s background, their needs and likes and dislikes. Clear guidelines are in place for staff to follow based on detailed risk assessments. These are aimed at supporting staff to meet the person’s needs whilst helping to promote and maintain their independence. Examples of guidelines seen include: supporting a person with their preferred daily routines 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 12 such as how they communicate, bathing, activities, going out in the car, mealtimes, making choices and watching TV. Staff commented during the inspection that they find the care plan to be very informative and easy to read and follow. ‘Care group reviews’ take place on a monthly basis. This provides the opportunity for carers, relatives and health and social care professionals to meet and review the person’s progress. Care plans are amended and updated accordingly. Staff confirmed that these are shared with the staff team during handovers and team meetings. It was evident throughout the inspection that care staff have worked hard to support the person to make decisions in most aspects of their life. The staff team is innovative in using photographs, pictures and objects of reference to help the person make informed choices such as what they would like to eat and drink and activities that they would like to take part in. Additional daily records are kept, however these were noted to be brief and in some instances irrelevant to the person. It is recommended that the Manager consider reviewing the current format to record activities of daily living in accordance with Person Centred Planning. 3a The Droveway DS0000068868.V337517.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): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The person using the service is supported to take part in increased daily activities to ensure their personal development. The provision of food is good. EVIDENCE: Through speaking with relatives, social care professionals and staff it was evident that that home has worked hard to provide increased opportunities for personal development. In addition to attending a local college for five days per week, the person using the service is supported to go out for long drives (sometimes for up to eight hours) in the home’s own vehicle and receive 2-1 support from care staff at all times. This is significant progress for the person using the service. The staff team are keen to develop a variety of different activities, but as the Manager explained: ‘We need to take small steps at a time at a pace that is right for the person’ 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 14 Based on the individual needs of the person, all activities need to be structured and based on routine. It was evident throughout the inspection that care staff have developed a clear understanding of the person’s needs and appreciate the need for routine within the home in order support them well. In-house activities include: watching TV, reading books and doing jigsaws – all of which are important to the person. These activities were observed on the day of the inspection. Relatives commented that they are kept well informed by the Manager and staff either during their weekly visits to the home or via telephone contact should a pressing matter arise. Care staff confirmed that all meals are planned on a weekly basis, based on the preferences and likes of the person accommodated. All meals are prepared by care staff, all of which have received the appropriate food hygiene training. The person using the service is supported to make smaller snacks and on occasions help with food preparation with ’hand over hand’ support. Staff explained that mealtimes have predominantly been quite a stressful time for the person, however over the past six months they have noted a great improvement. Care staff eat with the person around the small dining table in order to offer discreet support and encouragement. 3a The Droveway DS0000068868.V337517.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide sensitive and dignified support to meet individual needs. Good arrangements are in place to meet the emotional and healthcare needs of the person using the service. The home’s policies and procedures for the safe handling of medicines need to be reviewed. EVIDENCE: Care plans clearly identify individual preferences in relation to having personal care needs met. All personal care is carried out in the privacy of the bedroom or in one of the bathrooms. It was noted however that care staff have been cutting one person’s toenails without any additional training or guidance. The Manager is required to seek further advice from a healthcare professional in respect of this. At this current time, arrangements have been made between the home and the local GP surgery for the doctor to make home visits. This is to support one person in managing their anxieties and to keep any potential stress levels to a minimum. It is hoped that in the future all persons will be supported to visit their local GP and dental surgery. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 16 Evidence was provided throughout the inspection process that the home has developed excellent working relationships with the local CLDT. Regular multidisciplinary reviews are held (at this present time monthly), which include health and social care professionals, relatives and any significant others e.g. key worker from college. CMG have provided the home with a Health Booklet, which is aimed at keeping clear and accurate records of all healthcare appointments. It is recommended that in line with Valuing People, Health Action Plans be implemented. The home’s medication systems were inspected. Records confirmed that all care staff have received training in the safe administration of medicines and have been assessed as competent. Due to the preferences of the person accommodated, all medicines are currently prescribed in liquid form. Only senior members of staff are responsible for reordering and returning medicines to the pharmacy. The home has a medication cupboard in the office area of the home, however all medicines are currently being stored in another area of the home. The Manager explained that this decision had been based on the needs of the person accommodated and staff [staff have an allocated ‘safe area’ where they can retreat to in the event of being at potential risk of harm]. This area is always kept locked. All medicines are currently being stored in this area in order to enable care staff to access medication records and medication including those prescribed on an as and when required basis (PRN). It must be noted that although PRN medication is prescribed particularly for managing one person’s behaviour, this is rarely used as staff have clear guidance and therapeutic techniques in place to de-escalate situations as they arise. The home uses individualised medication administration recording sheets (MARS), although it must be noted that these have been taken directly from one person’s previous place of residence. These raised a number of concerns: - The date on the top of each form read 2006. Care staff are therefore required to write over this in pen to read 2007. The Manager was reminded that MARS are a legal document and should not be altered. - Additional criteria for the use of PRN medicines are not included on the MARS, therefore it was not clear that additional medicines were prescribed. - The medication dose was not recorded, only the measurement in (mls). It could not therefore be easily determined what the actual doses of the medicines were. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 17 That Manager is required to review the home’s policies and procedures for the safe handling of medicines. In light of the minor shortfalls that have been identified and the acting Manager’s willingness to address these shortfalls, the CSCI considers the overall outcome for this area to be good. 3a The Droveway DS0000068868.V337517.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 good. This judgement has been made using available evidence including a visit to this service. Relatives and others can be assured that the home will deal with any concerns or complaints that arise. People using the service will be better protected from potential harm, neglect and abuse once all staff have received the appropriate training. EVIDENCE: The home has a detailed complaints procedure in place, which is included within the home’s Statement of Purpose and Service Users’ Guide (in a pictorial format). It gives clear guidance with regards to how a complaint can be made and how the complainant can expect it to be dealt with. No complaints have been received by either the home or the CSCI since the home was first registered. The home has a detailed safeguarding adults and whistle-blowing policy and procedure in place in accordance with local multi-agency guidelines. The acting Manager confirmed that he has recently attended refresher training provided by the local authority, in respect of the newly revised multi-agency guidelines. Not all staff have received the appropriate mandatory training, although those spoken with were clear about the action that they would take in the event of reporting any concerns of suspected abuse and poor practices within the home. The Manager is required to ensure that all staff receive the appropriate training 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 19 in order to safeguard people using the service from potential harm, neglect and abuse. The acting Manager explained some of the difficulties that the home is experiencing in respect of managing one person’s finances. This is largely to do with the transition between children’s to adults’ services and not with the home’s policies and procedures. The Manager explained that CMG, the Care coordinator and relatives are in the process of addressing this. This will be followed up at the home’s next inspection. 3a The Droveway DS0000068868.V337517.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, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 3a The Droveway offers a friendly and relaxed environment that is kept in good decorative order. It presents as clean and well-maintained throughout. EVIDENCE: 3a The Droveway is a newly built and refurbished home. It consists of three bedrooms with en-suite facilities all on the ground floor alongside a kitchen, dining area, living room bathroom and a small office. A staff sleep-in area is on the first floor with it’s own bathroom. There is a small well-maintained garden to the rear of the property. The home has been decorated to a high standard throughout, although there is potential for the home to become more ‘homely’ e.g. with pictures and/or photos around the place. The home is carpeted throughout and is maintained to a high standard by care staff. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 21 The Manager confirmed that people who use the service are encouraged to take with them their own personal possessions. Evidence of this was seen. In order to maintain the health and safety of the person living at the home, most cupboard doors are locked, although one person does have access to their own snacks and drinks cupboard. All areas were noted to be clean and safe on the day of the inspection. 3a The Droveway DS0000068868.V337517.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, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The person using the service is supported well by a skilled, fairly consistent and dedicated staff team. The person using the service is mostly supported and protected by the home’s robust recruitment procedures. EVIDENCE: In addition to the acting Manager the home employs a total of five full-time and one part-time care staff, three of which have obtained at least NVQ Level 2 in Care. A further two are due to commence working towards this qualification in the near future. Staffing rotas confirmed that there are always two members of staff on duty between 7am – 10pm. During the night, there is one waking and one sleep-in person. The Manager said that he will be reviewing staff working hours in order to ensure that the best use of time is allocated e.g. in the daytime when the person who uses the service is at college each day. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 23 In addition to mandatory training courses, staff confirmed that prior to the first person moving into the home and since this time, additional training has been provided by CMG and the local authority including: makaton/communication, working with challenging behaviour and autism and DIGMAN (a form of physical intervention, although this has not been used). Key worker training is planned for the near future. All staff and others spoken with commented that the staff team has been reasonably consistent since the home first opened, however three core staff members will be leaving the team in the near future in order to further their own careers. The Manager stated that the organisation have begun to recruit new staff through adverts in local newspapers, the organisation’s website and job fairs. All initial information is coordinated by the association’s Human Resources department who are responsible for sending out application forms, alongside the required Criminal Record Bureau (CRB) and Protection of Vulnerable Adults First (PoVA) check, health declaration and Equal Opportunities Monitoring Form. The Manager and staff confirmed that there is a selection process in place and that the Manager is involved in this decision making process. It was pleasing to note that the Manager demonstrated a clear understanding of the skills and attributes of staff that are required within the home. Two staff recruitment records were randomly checked on the day of inspection. Whilst it was pleasing to note that application forms were sufficiently detailed and there was evidence of a PoVA First check and Criminal Record Bureau (CRB) check in place, one person had given the names of friends/family members for both references. The Manager is required to ensure that two satisfactory and professional written references are obtained prior to any person being employed to work at the home, one of which must be from the person’s last employer. All staff confirmed that they have clear job descriptions and fully understand their roles and responsibilities. Copies of job descriptions were seen in individual recruitment files. All staff spoken with said that they had received a thorough induction to the home within their first six weeks of appointment. This included watching videos, completing an induction checklist, reading a number of policies and procedures and ‘shadowing’ other staff members in order to ‘get to know’ the person using the service. Positive feedback was given about the staff team from a number of sources. Their comments include: “The staff team are very tuned in” 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 24 “It’s a very friendly staff team” In addition, it was pleasing to receive positive comments from members of staff about working at the home: “We’ve learned a lot from [the person using the service]. It’s all about the needs of [the person], not the staff” 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 3a The Droveway is a well managed service that has been specifically adapted and tailored to meet the needs of the person using the service. EVIDENCE: The Registered Manager was promoted within CMG shortly after the service first opened. The CSCI were not notified of this, or the arrangements that were in place for the service to be adequately managed. The acting Manager and the Registered Provider were reminded that the CSCI must be notified in writing when either the Registered Provider and/or Manager of the home proposes to be absent from the home for a period of 28 days or more or when there is a change in the overall management arrangements. The acting Manager has been working at the home since it first opened. Initially he worked in a Deputy capacity, but has since taken over as the acting 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 26 Manager. He has worked in care home settings for almost three years with people with learning disabilities and mental health needs, although has not undertaken any additional management training. A requirement has been made in respect of this. He confirmed on the day of the inspection that he hopes to submit an application to the CSCI to become the Registered Manager of the service. This has not been reflected as a requirement at this time, but will be monitored outside of the inspection process. Feedback from relatives, health and social care professionals and staff confirmed that the acting Manager is professional, approachable, supportive and knowledgeable. The evidence and good practice issues that have been noted throughout the inspection process, indicates that the home is currently being managed well. CMG have provided the service with a quality assurance manual, which was seen on the day of inspection. This is very much in its infancy, although the acting Manager has begun to seek feedback from relatives and other stakeholders. Some comments that have been received by the service include: “[The person using the service] appears to be a different person now” “The team are blown away with how the team at 3a The Droveway are doing… fantastic job!” The acting Manager explained to the Inspector that CMG employ their own quality assurance team who have highlighted some areas where further improvement is required in respect of staffing, fire safety, food hygiene and medication. It must be noted that the report that had been written failed to identify who the action was to be taken by and within what timescale. This was discussed with the Manager. As the home has only been open since December 2006, a requirement has not been made on this occasion but will be followed up at the next inspection. All policies and procedures have been devised by CMG and are therefore not always specific or relevant to the needs of the person using the service at 3a The Droveway. It is recommended that the Manager begin to review and adapt the home’s policies and procedures in order to make them specific to the service. Evidence provided within the home’s AQAA identified that all equipment is wellmaintained and regularly serviced including fire equipment and alarms, the central heating and hot water system, environmental health issues and electrical appliances. Whilst all areas of the home were found to be safe and well-maintained, the fire alarm was activated during the inspection (due to cooking). Whilst staff 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 27 were observed to follow the correct fire procedures, it was of concern that the only fire door within the home that did not automatically close was that of the person’s bedroom door as it had been wedged open with a door stop. This is the only door within the home that does not have a self-releasing fire door closure thus posing a potential fire risk to the person. An immediate requirement was issued on the day of the inspection for the door wedge to be removed with immediate effect and the Manager was required to take the appropriate action. The Manager confirmed in writing to the CSCI within the given timescale that a self-releasing door closure had been fitted. As the appropriate action was taken within the given timescale, this has not been reflected as a requirement within this report. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 28 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 4 3 X 4 4 5 3 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 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 3 3 3 X 3 X 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? N/A 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 YA18 Regulation Requirement Timescale for action 31/08/07 2. 3. YA20 YA23 YA32 4. YA34 5. YA37 12(1)(a)(b) That further advice and guidance is sought from a healthcare professional in respect of cutting people who use the service’s toenails. 13(2) That the home’s policies and procedures for the safe handling of medicines are reviewed. 13(6) That all staff receive the appropriate adult protection 18(1)(c)(i) training in order to safeguard people who use the service from potential harm, neglect and abuse. 19 & That two satisfactory and professional written references Schedule 2 are obtained prior to any person being employed to work at the home, one of which must be from the person’s last employer. 9(2)(i) That the acting Manager works towards obtaining NVQ Level 4 18(1)(a) in Management. 31/08/07 30/09/07 31/08/07 31/12/07 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA19 YA40 Good Practice Recommendations That the Manager considers reviewing the current format for recording activities of daily living in accordance with Person Centred Planning. That in line with Valuing People, Health Action Plans are implemented. That the Manager begins to review and adapt the home’s policies and procedures in order to make them specific to the service. 3a The Droveway DS0000068868.V337517.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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