Inspection on 12/09/06 for 40 Spiders Island

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

40 Spiders Island 15/07/09

40 Spiders Island 03/07/07

40 Spiders Island 14/02/06

40 Spiders Island 22/07/05

40 Spiders Island 01/02/05

40 Spiders Island 07/05/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Spiders Island (40) Grimstead Road Whaddon Salisbury Wiltshire SP5 3BG Lead Inspector Alison Duffy Key Unannounced Inspection 12 September 2006 10:15 th Spiders Island (40) DS0000028453.V302177.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 Spiders Island (40) DS0000028453.V302177.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. Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spiders Island (40) Address Grimstead Road Whaddon Salisbury Wiltshire SP5 3BG 01722 710072 01722 710072 alderbury@scope.org.uk 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) SCOPE Mrs Jacqualine Irene Tolley Care Home 5 Category(ies) of Physical disability (5) registration, with number of places Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: 40 Spiders Island is a residential care home registered to care for five adults with a physical disability. The home is situated in Whaddon, a small village near Salisbury. The home is managed by SCOPE and the Registered Manager is Mrs Jacqueline Tolley. Mrs Tolley, however is currently on long-term sick leave. Another Home Manager provided management support for a time, but now Ms Sandra James is undertaking the role of Acting Manager. Ms James was previously the Team Leader within the home. She is therefore experienced and has a clear awareness of service users’ needs. 40 Spiders Island is a purpose built bungalow, with full disabled access. Private accommodation consists of five single rooms. There is a spacious lounge with dining area and an adjoining kitchen. Bathing facilities consist of an assisted bath and shower. A range of specialised equipment is provided in relation to individual need. Staffing levels are maintained at generally four members of staff during the day. At night one member of staff undertakes a waking night and another provides sleeping in provision. An on call management system is also available. Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on September 12th 2006 between the hours of 10.15am and 5.30pm. Ms James, Acting Manager, was available throughout and received feedback at the end of the inspection. The Inspector was able to meet with all service users and members of staff on duty. A number of staff members discussed their designated area of responsibility such as menus and medication systems. Due to complex disabilities, service users were unable to give feedback about the service received. Various interactions between staff and service users were observed. All service users appeared relaxed and content. Staff were fully engaged with service users and one service user, in particular, was actively responding to staff banter. Positive relationships were evident throughout the inspection. Discussion took place with Ms James regarding current care provision and the developments that have been made since the last inspection. It was apparent that Ms James and the staff team have worked extremely hard to address shortfalls identified at the last inspection. Staff have also identified aspects that they felt needed development and have completed the work. A tour of the accommodation was made and varying documentation was viewed. This included care planning information, health and safety material and staffing documentation. Comment cards were forwarded to each service user’s primary relative and a number of health and social care professionals. Three comment cards were returned, which demonstrated satisfaction. One relative reported ‘We visit the Bungalow – Spiders Island often – without notice and are always welcomed with a cup of tea/coffee. Our XX and the other residents always look very well and happy.’ A GP also reported satisfaction with the care provided to service users within the home. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the service and taking into account the views raised on behalf of service users. What the service does well: Ms James and the staff team have worked well together to address a large amount of work in a short period of time. A range of information has been updated and is now of a good standard. The team appears motivated and willing to attempt further developments within the home. Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 6 Through discussion and observation it was evident that the well being of service users is paramount. Staff engage well with service users and are service user focused. Priority is given to encourage decision-making. Care planning has recently been significantly developed and is of a good standard. Activity files are well designed; demonstrate individuality and the intention of enhancing quality of life. A high level of personal care in relation to very complex need is given. Regular consultation and input from specialised health care professionals is received. The environment is well maintained and decorated and furnished to a good standard. Private accommodation is personalised showing individuality. Established well-managed systems such as recruitment and the complaints procedure are in place, which demonstrate a commitment to service users and service provision. Training is given high priority and therefore staff are up to date with various topics. What has improved since the last inspection? What they could do better: Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 7 Considerable work has been given to generic risk assessments and areas such as activity. Further focus however, is needed to address potential risks to service users in relation to their individuality and complexity of need. Although Ms James is clearly aiming to develop the service, a formal structured quality assurance system is not available. Record keeping is of a good standard yet guidelines to use when evaluating forms such as food and fluid charts would be of benefit. 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. Spiders Island (40) DS0000028453.V302177.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 Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The admission process is detailed, organised and well managed thus minimising the possibility of unmet need. EVIDENCE: There have not been any new service users since the last inspection. It was not possible therefore to assess the admission procedure in practice. Detailed admission procedures however, devised by SCOPE, are available as required. Ms James expressed the importance of clear, detailed information before admission. She also referred to the difficulties with a recent admission whereby this information was not forthcoming. Service users are informally assessed within the home and if they attend a day service, further structured reviews are held. An annual formal review is also undertaken. Within the assessment process, advice or intervention is often gained from specialised personnel. For example, there are some physiotherapy programmes on file, which are out of date. Ms James confirmed that some areas remain relevant although she believes each service user should be reviewed as their condition may have deteriorated. Such reviews have therefore been arranged and new programmes will be devised. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and after the visit to the service. Care planning has developed significantly enabling staff to have the information required to meet service users’ needs. Decision-making is fully promoted yet may be restricted for some, due to complexity of need. Service users’ safety is given priority, yet further safety would be assured through individuality within risk assessments. EVIDENCE: At the last inspection it was noted that while a significant amount of information was available, care plans were limited in their content. The plans did not reflect individual need and it was difficult to find specific information as required. A requirement was therefore made to ensure each plan was signed, dated and contained sufficient detail in order to meet individual need. In response to this Ms James and the staff team have reviewed all plans. All are now organised, well written, easy to read and contain clear guidelines of care required. Ms James has consulted with service users’ representatives and signatures demonstrate this involvement. Daily routines are documented in detail. This information includes for example what items of equipment are Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 11 required and how they should be used. Some plans have photographs to ensure a visual demonstration. At present a specific part of the plan has been designated to any changes in the care required. Ms James was advised to ensure staff also document if there have not been any changes. Ms James and Ms Griffiths, Acting Team Leader are currently reviewing the formats for monitoring service users’ bodily functions. It was agreed that such monitoring should continue to ensure wellbeing. It was also recommended that Ms James should discuss the charts with specialised health care personnel. Specific guidelines, when evaluating the information should also be developed. Epilepsy charts have been reviewed in order to give better accessibility to information. Guidelines in relation to peg feeding have been further developed. Ms James reported that she is waiting for the specialised nurses to assist with further information and to confirm existing documentation. All manual handling assessments have been updated with the input of specialist health care personnel. All risk assessments have also been fully reviewed and re-written. These give good detail yet refer to issues related to all service users. Ms James was therefore advised to consider individuality and those risks specifically associated to individuals. Ms James confirmed that while a level of risk-taking is promoted in order to offer opportunity, health and safety guidance sometimes restricts practice. For example, involvement with fairground rides would be undertaken with caution due to specific health conditions of service users and manual handling procedures. Service users are encouraged however to maintain preferred activity despite the possibility of having a seizure for example. Matters such as not being left in the bath unattended are clearly stated. Through discussion with staff and viewing care-planning information, decisionmaking is clearly important. One member of staff confirmed that some service users are able to express their wishes by gesturing or nodding. This is encouraged during instances such as choosing breakfast whereby cereal packets are place on the table. Other service users may use specific movements, facial expressions or sounds to indicate their wishes and general wellbeing. One member of staff reported that some service users require staff to make all decisions on their behalf. At times, it can also be difficult to assess need. In such instances it may be a process of elimination. Food preferences may be slightly easier, as refusal obviously shows dislike. It was agreed that positive relationships and experience are essential factors to enable decisionmaking with existing service users. Ms James and the staff team have developed a board in the dining room with signage in order to enhance communication skills. Service users have access to communication groups within their day service. Specialised health care personnel facilitate these forums and develop programmes accordingly. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are assisted to undertake meaningful activity and maintain important relationships. Meal provision has recently been reviewed to ensure healthier eating and greater choice. EVIDENCE: Some service users continue to attend the local SCOPE day service on a Monday to Friday basis. Others attend on a sessional basis and spend the majority of time within the home. Ms James reported that during this time, staff ensure service users receive one-to-one time. This may include a hand massage or a trip out. Ms James reported that an activity area in the lounge is being developed. Visual stimulation has been applied to this area. Staff encourage involvement with the local community through the use of local facilities. The home has its own transport to facilitate journeys as required. All activities are linked to individual need and interest. Recent trips have included shopping for toiletries, Bournemouth, the Sea Life Centre at Weymouth, the New Forest, Salisbury Show and local pubs. Staff have recently developed activity folders. These are service user focused and display photographs of Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 13 recent outings and events. Ms James reported that they are invaluable as they enable communication with service users about events. In time it is hoped that family members for example, will also become more involved with contributing to the file. Staff, were observed to be very friendly, committed and motivated. Through discussion it was evident that staff members have built established relationships with service users and their families. The involvement of parents is viewed as paramount and therefore regular discussions take place. Three relatives within comment cards confirmed that the owners and staff make them feel welcome and they can visit in private. As stated earlier in this report, service users are encouraged to make decisions in relation to their ability. The home is very service user focused and staff appear committed to developing practice to ensure service users’ wellbeing. Ms James reported that staff are excellent and work hard. She also confirmed that staff are thinking much more about service users individuality and the implication of this in practice. Preferred routines are now clearly identified within care planning information. Privacy is maintained through established practices of undertaking personal care in private accommodation or specialised bathrooms. A member of staff has recently been designated the responsibility of menu planning. As a result of this, the menus have been reviewed to promote healthier eating and greater choice. At breakfast and lunchtime, options for the meal are not stipulated. Service users have a choice of what they would like. If service users are unable to choose, staff will prepare something that is a known to be enjoyed. The evening meal is now varied with examples being tuna pasta and vegetable chilli. Mealtimes are flexible and full assistance is given to all service users. Special requirements are stated within care planning information. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Health and personal care are well managed with regular input from specialised services. Clear, organised medication systems minimise the risk of error. EVIDENCE: Service users require full assistance from staff in all aspects of daily living. Since the last inspection, Ms James and the staff team have worked hard to ensure that all assistance required is fully documented within plans of care. As stated earlier in this report, such information is now well written, detailed and informative. All service users have a range of individualised specialised equipment. This is monitored and serviced regularly and staff receive full instruction regarding its usage. Service users are unable to express how they wish their care to be delivered. In such instances staff rely on their experience to recognise gestures, facial expressions, general contentment and individual communication systems. The home operates a key worker system and facilitates one-to–one work with service users. Ms James has also introduced key teams in order to ensure greater consistency. Discussion with staff demonstrated that all are very aware of service users needs and productive, trusting relationships have been Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 15 established. Staff were seen to engage with service users and a light hearted manner was evident. Service users are unable to manage their health care needs and therefore rely on staff to recognise any signs of ill health. Within discussion with staff and viewing daily records it was evident that matters are identified at an early stage and appropriately addressed. All matters such as scratches and marks are documented and monitored accordingly. Those service users who attend day services have regular access to specialised services. This may include physiotherapy, occupational therapy and speech and language therapy. Ms James is currently looking at how to best access services for those service users who do not regularly attend day services. Appointments with other specialist services, including the dietician are made as required. Ms James reported that regular consultation is held with the nurse who has designated responsibility for peg feeding. In addition to existing detailed information that is already available, care plans specifically for peg feeding are being devised. These are being undertaken with involvement from the specialised nurse. Ms James has also researched various conditions on the Internet. Information regarding conditions such as cerebral palsy and epilepsy is therefore available for staff to access. The home has one member of staff responsible for the medication systems. This includes ordering, organised storage, receipt and disposal of medication. A monitored dosage system is used and all medication is delivered on a monthly basis. Documentation demonstrated that all medication is checked on receipt. Within the drug round, two members of staff sign to identify that the medication has been administered. The medication administration sheets were satisfactorily maintained. All staff have received recent medication training and have access to documented medication policies and procedures. Due to complex health conditions, service users are unable to manage their medication or give consent. Guidelines are in place for those service users receiving their medication by specialised means. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The home has a clear, well-managed complaint procedure that encourages complaints to be successfully resolved at an early stage. The risk of abuse to service users is minimised through the home’s adult protection systems. EVIDENCE: The home has a detailed complaints procedure devised by SCOPE. Copies of the procedure are located next to the visitor’s book in the entrance area. A complaints book for any comments is also easily accessible. Formalised systems are in place for documenting any concerns. Staff have undertaken complaints training which forms part of SCOPE’S training provision. Ms James reported that there have been no formal complaints. Care provision is regularly discussed with service users’ representatives. If there are any problems, issues are generally resolved at an early stage through general discussion. Ms James reported that staff also aim to keep representatives up to date with information and ensure involvement. It is anticipated that such strategies minimise any forms of discontentment and escalation. The home has detailed adult protection policies available to staff for reference. It was recommended that contact details of the local Vulnerable Adult Unit are prominently displayed on the notice board in the staff sleeping in room/office. Specific staff have the designated responsibility of adult protection. They also attend regular refresher courses. Adult protection training for all staff is planned for the end of this month. Staff appear attentive and record any bruising or marks on service users. Ms James has recently developed an observational sheet whereby staff monitor such matters. Through discussion it Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 17 was evident that significant bruising with an unknown cause would be referred for investigation. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26,28 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The environment is well maintained, cleaned to a good standard and conducive to service users’ needs. Service users also benefit from private accommodation, which is decorated to a good standard and equipped to meet individual need. EVIDENCE: 40 Spiders Island is a detached, purpose built bungalow with full disabled access. All service users have a single room, which is decorated and furnished to a good standard. Despite varying levels of specialised equipment, all rooms are personalised and reflect personal preference and interest. All are individual in style and address aspects such as visual stimulation. Rooms do not have ensuite facilities yet an assisted bathroom is located within close proximity. The facilities meet the needs of service users and the room is also warm, lockable and comfortable. As with private accommodation, attention has been given to visual stimulation within the room. There is a large lounge with dining area that has ample room for service users to move around freely and use items such as wedges and beanbags. Ms James Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 19 has removed various files from the top of the sideboard so that the whole area is portrayed as service users’ space. Sensory lighting has been applied to one area, which brightens the room and creates additional stimulation. At the last inspection it was identified that the lounge area, would benefit from redecoration. Although it was reported that the money had been allocated in the budget, the work has not as yet been undertaken. There have been no changes to the laundry facilities. Ms James reported that the facilities continue to be adequate to meet existing need. Although small the area was clean, tidy and ordered. The laundry is located next to the office. Soiled linen does not therefore need to be transported through any communal areas. All areas of the home were cleaned to a good standard and odour free. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels are maintained in line with the previous Registration Authority. Training is given priority and service users are protected through an efficient, well-managed recruitment procedure. EVIDENCE: Staffing levels continue to be maintained at either three or four support workers on duty in the morning. During the evening there are four. At night, there is one waking member of staff and another provides sleeping in provision. An on call management system is also available. Staff continue to be responsible for all housekeeping arrangements such as cooking, cleaning and the laundry. Some service users are spending more time in the home due to attending their day service on a sessional basis. In addition to this, complexity of need has increased. Through various discussions it was evident that staff work well as a team and are flexible in their roles. One-to-one work with service users is considered an important factor. The home has not been fully staffed for a long period of time. There are four agency staff which are regularly used. One member of staff reported ‘they are like are own staff which gives consistency to service users.’ Through discussion it was evident that agency staff have a clear understanding of service users needs. They also undertake all training that contracted staff are expected to do. Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 21 Since the last inspection, one member of staff has commenced employment. Ms James confirmed that a full induction has been undertaken. Documentation demonstrating the recruitment procedure of this member of staff was clear and organised. The required information and checks were in place before the member of staff commenced employment. Documentation also contained details of identity, a health declaration and equal opportunities information. In the event of any health care issue being identified, Ms James was advised to further investigate the implications of this. The decision to employ should then be documented within recruitment information. Training is given high priority. At present 17 out of the 19 staff have an NVQ qualification. It is expected for the remaining staff to commence their training shortly. Ms James is an NVQ Assessor. All staff except the home’s driver have recently completed medication and infection control training. In August 2006 all staff updated their manual handling training. All have completed health and safety training and are up to date with first aid and food hygiene. Ms James confirmed adult protection training is booked for September 2006 and disability awareness is booked for October. It was reported that three staff have undertaken supervision and appraisal training. Although positive, it was felt more training was required and therefore additional sessions have been booked. Spiders Island (40) DS0000028453.V302177.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Despite being in post for only a short time, Ms James has gained staff support and has developed many areas of practice. While it is clear the home is service user focused, a formal quality assurance system would ensure formalised feedback and development. Recent attention to health and safety systems significantly reduces potential risks to service users. EVIDENCE: As stated earlier in this report, Mrs Tolley is currently on sick leave. Ms Sandra James, previously the Team Leader in the home, has taken the responsibility of Acting Manager until Mrs Tolley’s return. Ms James has worked in the home for a number of years and therefore has a clear understanding of service users’ needs. Ms James is very service user focused and promotes quality of life and opportunity. Although Ms James has only been in post for a short time, many positive developments have been made. These include care plans, record keeping, fire safety, regular staff meetings and responsibilities of staff. Ms Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 23 James has also ensured team development and has highlighted the individuality of service users and their rights. Ms James reported that she is commencing the Registered Manager’s Award next month. Through discussion with Ms James and various staff members, it was apparent that developing the service to enhance service users wellbeing is paramount. Such developments include alternatives to the menus, the communication board, sensory lighting in the dining room and the activity files. Ms James has not undertaken any structured quality assurance work as she has concentrated her focus on the shortfalls identified at the last inspection. It was identified that SCOPE were beginning to research a quality assurance system that would meet the needs of the home. To date however this has not been implemented. Ms James reported that the staff team continue to have good support from family members and therefore feedback is often received informally. At the last inspection it was noted that a fire drill had not been undertaken within the designated period. At the previous inspection the testing of the fire alarm systems were insufficient. In response to these shortfalls, Ms James requested a visit from a company who specialises in fire safety. Within this visit, a new fire book was implemented and all fire procedures were reviewed. This included additional signage to identify escape routes and also the renewal of the fire risk assessment. Ms James was also advised to highlight some wording within the procedure, which she has undertaken. The fire log book demonstrated consistent testing of the fire alarm systems. A fire drill has been undertaken as required and Ms James has documented a detailed account of the process. Staff have received fire instruction as required. The building is well maintained and attention is given to health and safety matters. All staff have had health and safety training and the Acting Team Leader is the home’s health and safety representative. Considerable work has recently been given to updating all generic risk assessments. These, including the manual handling assessments, are detailed and well written. All staff are up to date with manual handling training. Ms James reported that a member of staff has been trained to undertake the testing of the portable electric appliances. Hot water temperatures are also monitored and recorded as required. This documentation was not however viewed on this occasion. Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 3 X 3 X 2 X X 3 X Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 25 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. Standard YA39 Regulation 24 Requirement The Registered Person must ensure that a formal quality assurance system is developed and implemented within the home. Timescale for action 31/01/07 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. Refer to Standard YA6 YA6 Good Practice Recommendations The Registered Person should ensure that when reviewing care plans, a documented entry, such as ‘no change’ is made. The Registered Person should ensure that guidelines are agreed with the District Nurse regarding adequate levels of fluid intake. Food and fluid charts should also be regularly evaluated. The Registered Person should ensure that any risks associated with service users’ complexity of need is fully addressed within the risk assessment process. The Registered Person should ensure that contact details of the local Vulnerable Adults Unit are clearly displayed on the staff notice board. DS0000028453.V302177.R01.S.doc Version 5.2 Page 26 3. 4. YA9 YA23 Spiders Island (40) 5. 6. YA28 YA34 The Registered Person should ensure that consideration is given to the refurbishment of the lounge and dining area. The Registered Person should ensure that any issue of ill health identified within the recruitment process is further investigated and the decision to employ is fully documented. Spiders Island (40) DS0000028453.V302177.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 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 Spiders Island (40) DS0000028453.V302177.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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