Inspection on 08/08/07 for 41 Birdwood Grove

This inspection was carried out on 8th August 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

41 Birdwood Grove 21/08/06

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 41 Birdwood Grove Fareham Hampshire PO16 8AJ Lead Inspector Tim Inkson Unannounced Inspection 8th August 2007 08:55 41 Birdwood Grove DS0000067325.V343225.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 41 Birdwood Grove DS0000067325.V343225.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. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 41 Birdwood Grove Address Fareham Hampshire PO16 8AJ 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) 01329 221623 F/P 01329 221623 Hampshire Partnership NHS Trust Mrs Paula Thane Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: 41 Birdwood Grove is a semi-detached property situated in a residential area between Fareham and Portchester and is undistinguishable as a care home from other homes in the street. Hampshire Partnership NHS Trust (“the Trust”) manages the service providing the care and support for people living there. Downlands Housing Association, a registered social landlord, owns the premises, and people accommodated there are tenants/licensees of the landlord. The establishment is registered to accommodate 3 people under the age of 65 with a learning disability. Each person has a single bedroom. Communal space includes a lounge cum dining room, a kitchen and a large conservatory, although the service users rarely use the latter. Information about the service provided at the home will be made available to people wishing to live there by providing them with a copy of the home’s Service Users Guide and Statement of Purpose. A copy of a report the most recent inspection of the home carried out by the Commission for Social Care Inspection (“the Commission”) is available in the home. The organisation providing the care and support was not willing to inform the Commission of the weekly fees. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of the process of at key inspection of the home. It was unannounced and took place on 8th August 2007, starting at 08:55 and finishing at 13:35 hours. During the visit accommodation was viewed including bedrooms, communal/shared areas and the home’s kitchen and laundry. Documents and records were examined and staff working practice was observed where this was possible without being intrusive. People living in the home and staff were spoken to in order to obtain their perceptions of the service that the home provided. At the time of the inspection the home was accommodating 2 people, both female and their ages were 51 and 53 years, neither was from a minority ethnic group. The home’s registered manager was present during most of the visit and was available to provide assistance and information when required. The relatives of and care managers for the people living in the home were telephoned for their views about the home following the site visit and their comments have been taken into consideration when producing this report. Other matters that influenced this report included: An Annual Quality Assurance Assessment completed by the registered manager in which he set out how he believed the home met and planned to exceed the National Minimum Standards (NMS) for Care Homes for Adults (18 –65) and evidence to support this. A “dataset” containing information about the home’s staff team, and some of its managements systems and procedures. Information that “the Commission” had received such as statutory notices about incidents/accidents that had occurred. What the service does well: There was detailed written information about the needs of the people that lived that enabled the staff to provide the help and support that each individual required. The home’s registered manager was perceived as a strong advocate for the people living there. The home promoted equality and diversity and its routines were flexible. Individuals were encouraged and supported to make choices for themselves and use the amenities in the local community. The building was comfortable, well furnished and decorated. Confidence in the home’s management was expressed by people working there, relatives of people living in the home and social care professionals. There was a strong commitment to staff support, training and development to ensure that they were able to fulfil their roles and responsibilities and meet the complex and diverse needs of people living in the home. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems and procedure in place to enable the help people needed was identified before they moved in to ensure that the home could properly provide it. EVIDENCE: At the time of the site visit there were only 2 people accommodated in the home both of them had lived in the home for some years. They had both been living there at the time of the last inspection of the home on 21st August 2006. The home’s registered manager said that there had been no new admission to the home since about 1993. She added that the procedures for arranging for a person to move into the home were comprehensive and such a move would be carefully planned. It would include a multi- disciplinary assessment of the persons needs as well as visits to the person in the place where they were living, and short stays in and visits to the home. This would promote a successful transition and ensure that the staff team were fully able to meet the person’s needs. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems and procedures in place for planning the care and support that people received. People were helped to exercise choices about day-to-day life. The potential of harm to individuals was identified and plans were put in place to promote responsible risk taking. EVIDENCE: Documents examined during the site visit included comprehensive plans setting out details of the support that each person living in the home needed and how it was to be provided. They had been produced in the “first person” and in a simple format/style using some symbols and diagrams to assist the persons concerned understand their contents as much as possible. The plans were focussed on the choices and wishes of the individual, demonstrating that “person centred planning” was the principle upon which they were based. They indicated how the person communicated e.g. “I point to my choices for lunch”. The home used flash/picture cards to assist people to make choices and communicate. All the staff working in the home had received training in 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 10 appropriate forms of communication such as “Makaton” and some had completed advanced training in the subject. The home’s registered manager said: • “We encourage them to make choices as much as possible, getting up and going to bed, etc. We know M likes going out to the forest but we also need to find a way of knowing what she actually wants to do because she is quite happy to go along with whatever is arranged, whereas K will make very definite choices and make it very clear when she wants to do something or not. She takes the lead on what she wants”. The plans of care and support were supplemented by daily notes and a summary of the daily routine for each person. There was evidence that care plans were reviewed regularly. The home’s registered manager indicated that arranging for the involvement of other interested parties in formal reviews of peoples’ plans was difficult. • “There is no care manager/social worker unless there is an emergency and there are less and less people to invite to reviews, everyone seems to busy”. A range of assessments of potential harm to each person had been completed and informed the plans of care that included strategies about how these risks would be managed. The risks identified included the following; accessing the home’s kitchen; road safety; exposure to the sun; communicating pain; refusal of medication; money management; and abuse. The home’s registered manager said: • “At one time K was not allowed into the kitchen because of perceived dangers, but now we have a strategy. I think it was over protection by staff. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home promoted the right of people living in the home to live ordinary and meaningful lives. They were supported to take part in social and recreational activities and to develop life skills. EVIDENCE: It was apparent from records kept by the home that individuals were able to pursue their own particular interests and these were noted in their care plans Daily notes and individual weekly activity plans indicated that individuals were also supported to use amenities in the local community such as libraries and banks and went out regularly for meals and to venues such as cinemas, bowling alleys, pubs and social clubs. Both of the people living in the home at the time of the site visit went to a day service provided by the local authority 2 or 3 times a week at which they were helped to develop social and life skills. Outings were arranged to places of interest and people living in the home also benefited from going on holiday. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 12 The home’s registered manager said: • “We have a library card and M will go out on a one to one day and choose music CDs from the library”. Staff working in the home indicated that people living in neighbouring properties were supportive of the home and said: • “We have wonderful neighbours, we have a new one on one side who pops in with her little boy”. Regular contact was maintained between people living in the home and their relatives. One individual ‘s relative who was spoken to confirmed that her daughter spent most weekends at home with her. Another relative said that visiting the home was not a problem. • “The staff treat us like their family. We are always made welcome. Relatives also confirmed that the social life and leisure interests of people living in the home were a priority and that there were frequent events to which they were invited. • “We are always invited to parties the last one was her birthday in June and there are not only people like her there but other friends that she has made and the house was full”. Individuals living in the home had their own single rooms promoting their right to privacy and staff were clearly expected to knock on bedroom doors and seek permission to enter them. They were offered key to enable them to lock their own rooms if they wished to do so. A person’s preferred form of address was noted in their plan of care. There was no routine or planned menu as individuals decided what they wanted to eat each day. The home’s registered managers said: • “Often they will have separate meals. The food provided each day was recorded as well as an indication of the amount each person consumed and the weight of individuals was monitored regularly. It was evident that the food provided as varied and took into account individuals’ preferences that were recorded in their care plans. The home attempted to promote healthy eating and there was fresh fruit readily available and evidence that fresh vegetables were used in meals. On the day of the site visit there were some blackberries in the kitchen that had been picked in the home’s garden. A member of staff said that the intention was to make a fresh blackberry and apple crumble. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received was based on their individual needs and their medication was managed safely. EVIDENCE: The care plans examined set out in detail how the help and support an individual needed was to be provided e.g. use of toilet; support with cleaning teeth; or managing oedema. The home’s staff team was very stable and the shortest time that anyone of them had been permanently employed there was 2 years. They knew the needs of the individuals living there “intimately” and were able to describe how they were met in accordance with the plans. Records examined concerning the people living in the home indicated that They received visits from or made visits to healthcare professionals when necessary. The home had successfully supported individuals to overcome their reluctance or fear of attending healthcare appointments for necessary help with things such as oral hygiene and also for surgery that included a cataract removal. A referral had been “recently” made to an occupational therapist to seek advice about the specific needs of an individual and subsequently grab rails and a shower had been installed in one of the home’s bathrooms to meet that persons requirements. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 14 The gender of staff providing help with intimate personal care was discussed with the home’s registered manager and she said that if it were ever a contentious issue then the home would respond appropriately. A social care professional who was spoken to about these matters said: • “ … They notify us of important issues … I have never had any cause for concern …”. The home had written policies and procedures about the management of medication. Medicines were kept in suitable locked metal cabinets and the home used a monitored dosage system with most prescribed medicines put into blister packs for a period of 28 days by a pharmacist. The exception being those items that would deteriorate when removed from their containers or liquids. Records that were kept of the receipt into the home, administration (giving out) and disposal of unwanted medicines were accurate and up to date. There were clear instructions for the use of medications that were prescribed for use on occasions that it was required (PRN). It was suggested that when such medication was given out that the outcome i.e. effectiveness was also noted. All staff working in the home had received comprehensive training in the management of medication and received an annual test of their competency in this area. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 15 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. People living in the home had access to a complaints procedure that would enable the home to address their concerns and independent advocacy services could be used to represent the concerns of people if necessary. There was a system in place in the home to protect vulnerable adults from harm. EVIDENCE: People living in the home had been given a copy of the home’s Service Users Guide in a format that included pictures and symbols to explain to individuals their rights in as simple a form as possible. It was kept in their in their bedrooms and it included a copy of the home’s complaints procedure. The home’s registered manager acknowledged that with limited understanding of the concept of complaining that it was difficult for some individuals to raise concerns or know that they had a right to do so. The home also used the services of an independent advocate. • “We struggle with trying to ensure that they understand their rights and we can’t be sure that they actually know how to complain which is a problem. We would like them to complain if they feel they have a complaint, but we do complain on their behalf sometimes about things that go wrong … we do not use independent advocacy routinely but for specific issues and major decisions such as health care or finances”. The home had a system for recording complaints and how they were dealt with but it had received no complaints in the previous 12 months. “The Commission” had received no complaints about the home during the same period. Relatives that were telephoned for their views about the home said they knew how to complain if they were dissatisfied with the service that was provided and were confident in the manager’s abilities to deal with complaints. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 16 There were written procedures readily available in the home for the guidance of staff, about safeguarding vulnerable adults. These included a copy of the local authority’s adult protection procedures. All staff had received training in the subject of adult protection and those spoken to knew what to do if they suspected or knew that it had occurred. People living in the home were supported by staff to manage their financial affairs and individual savings accounts had been arranged for them in building societies. Their benefits were paid directly into their accounts and staff helped them withdraw cash when it was required. The home kept some money on behalf of the individuals living there and accurate records were kept of all incomings and outgoings. A representative of “the Trust” regularly audited these records. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment was comfortable safe, and well-maintained for the benefit of the people living and working in it. EVIDENCE: A registered social landlord owned the premises and the people living in the home were the tenants of that organisation. It had a management arrangement with the Hampshire Partnership NHS Trust (“the Trust”) to provide the care and support that their tenants required. The landlord was responsible for the maintenance and upkeep of the building and its major systems and was regulated by and consequently had to comply with the expectation and standards of the Housing Corporation concerning such matters. The home’s registered manager said: • “They respond quickly to emergencies such as blocked drains and so on … they are pretty good and some one visits regularly”. “The trust” was responsible for the soft furnishings and at the time of the visit the exterior (with the exception of the conservatory) and interior of the home was in good decorative order and its furnishings and fittings were in good repair. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 18 There had been water ingress in the conservatory and it is suggested that the appropriate personnel from “the Trust” seek to get the landlord to take necessary remedial action. The landlord had a programme for redecoration of the interior that allowed for one room a year. The lounge and dining room had been redecorated in the previous 12 months and a matt finish had been used in order to reduce the potential for glare because one of the people living in the home was sensitive to light. The bedrooms of the people living in the home had been personalised and the relative of one said: • “She was allowed to choose her own furniture for her room”. The home had infection control policies and procedures and staff had received training in the subject. There was a utility area in the home’s conservatory that was equipped with a commercial washing machine that had a sluice programme. It was accessed through the dining room and there had been some discussions in previous years about the risk of cross infection. A report from the local environmental health officer in October 2003 stated, “ the procedure for managing soiled laundry was more than adequate”. This procedure required such items to be enclosed/sealed in a purpose-designed bag before conveying them to the utility area. The bags were put straight into the washing machine on an appropriate setting and they were designed dissolve. There were adaptations, fittings and equipment in place for an individual with specific needs as a result of the involvement of the occupational therapy services of the local authority. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The recruitment, training, deployment level and skill mix of staff ensured the needs of people living in the home were met and their safety was promoted. EVIDENCE: At the time of the site visit the home’s staff team comprised the manager and 5 others and of these 4 (i.e.66 ) had obtained a relevant qualification that indicated that they were competent i.e. National Vocational Qualification (NVQ). Another had a degree in the subject of Learning Disabilities and another was due to start working towards an NVQ. “The Trust” had robust employment procedures that precluded someone from working in the home until all the necessary checks into the suitability of a person to work with vulnerable adults had been completed. The staff group in the home was however very stable and there had been no new staff employed in the home for 2 years. The home’s registered manager said that they were looking into ways of including people living in the home in the interviewing/appointment of new staff. The home was using a volunteer for 6 weeks who had been placed with them by an agency that was assisting people with a variety of problems to get some work experience. The agency had received a satisfactory protection of 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 20 vulnerable adults check for the person who did not have unsupervised access to anyone living in the home. There was evidence from examining staff records and discussion with staff on duty that there was strong commitment to staff training and development and also to ensuring that all staff received regular training and updates in subjects that were regarded as core or essential i.e. • Food hygiene • Moving and handling • Fire safety • Adult protection • Communication (Makaton) • Medication • Health and safety • First aid • Strategies for Crisis Intervention and Prevention (SCIP) At the last inspection of the home on 21st August 2006 it was noted that none of the staff had received training in first aid. On this occasion it was noted that 3 staff had attended a 4-day first aid course and the rest of the staff group were booked to attend a course in November 2007. The level of staff on duty when people were in the home was always at least one person. The departure of one individual from the home to alternative accommodation in the previous 12 months had according to the manager and staff that were spoken to enabled more flexibility in staffing levels. One member of staff said: • “There is always 1 on duty and when we have 2 on we take them out and make the most of it”. The basic minimum rota was as follows: 07:30 to 09:30 1 09:30 to 21:30 2 21:30 to 24:00 1 24:00 to 07:30 1 Sleeping Comments about the qualities and approach of the staff team from a social care professional and relatives included the following: • “The team is very strong and very close …they are like an extended family and it is sometimes difficult for them to stand back professionally, but I am glad because of their persistence they can achieve more when dealing with the bureaucracies and obstacles they sometimes have to face on behalf of the people living there … ”. • “The staff treat them lovely … I can’t praise them enough”. • “All the staff are lovely … M looks forward to going back after she has been home with us … she is so happy there .. I can’t find any fault with them …”. 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s registered manager provided effective leadership There were systems and procedures in place for monitoring and maintaining the quality of the service provided and also for promoting the safety and welfare of everyone living and working in the home. EVIDENCE: The home’s registered manager had worked with people with learning disabilities for some 25 years and had been responsible for the day to day running of the home for approximately 10 years. She had qualifications that indicated that she had the necessary knowledge and skills to manage a care home i.e. NVQ level 4 in care and the Registered Managers Award (RMA). She also kept up to date by attending updates of subjects considered core or essential training for all staff. Observation, discussion with her, the home’s staff, relatives and social care professionals indicated that she was; knowledgeable, highly motivated, and 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 22 enthusiastic and sensitive to the needs of both the home’s staff team and the individuals accommodated there. Comments about her qualities included: • “ …She is unique … we have supervision once a month, but we can go to her at any time … she is very flexible … she fights big time for the residents and for us … she is passionate about her work … she fits peoples individuals needs into the staff rota …”(group of staff). • “ … She is lovely … ” (relative). • “ … She seems to know her stuff and knows the needs of the residents and is a very strong advocate, really strong voice and has their best interests at heart … “ (social care professional). There was an open management style in the home and monthly staff meetings were held at which individuals could readily voice their opinions. One member of staff said: • “I have worked in loads of places but nowhere like this, the whole ethos is so different ... our manager’s manager sometimes comes to our staff meetings and says that she has never gone anywhere like it, we all feel free to put our opinions across”. “The Trust” carried out annual surveys of all the people that used its services including the people living in the home in order to ascertain what they felt about the quality of the care and support that they received. The most recent survey had sought the views of 73 people and around 30 did not or could not respond. The responses were collated and were largely positive and comments included: • “I like the meals” • “I have no problems with the staff” • “Staff help me with my holiday” • “I like to go to the pub” “The Trust” had developed an action plan based on the outcomes. There was some discussion with the home’s manager about a methodology developed by The British Institute for Learning Disability” (BILD) for assessing the quality of life for people in care homes. Representatives from “the Trust” and the landlord visited the home regularly to check on the homes management systems and also to obtain the views of people living in the home. Regular individual reviews were held at which the needs of the people living in the home were discussed with them and their representatives. They also provided opportunities for any concerns about the management of the home to be discussed (see also section “Individual Needs and Choices” above). The home had a range of policies and procedures available that were readily accessible to staff and informed their working practice. They included the following: • Lone working 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 23 • SCIP • Relationships and sexuality • Gender sensitive care • Equality and diversity • Management of service users money and valuables The home’s registered manager said that in promoting equality and diversity the home used independent advocacy services for the people living there and that they kept anti-oppressive practice at “the centre of all things that we do”. Records seen and discussion with staff indicated that safe working practices were promoted in the home. Up to date certificates were on file concerned with gas safety and electrical wiring. Records and discussion also indicated that fire safety systems and equipment were checked and monitored and staff had received fire and other health and safety training. The home had implemented a system for alerting an individual with a hearing impairment in the event of a fire. 41 Birdwood Grove DS0000067325.V343225.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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 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 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 41 Birdwood Grove DS0000067325.V343225.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 41 Birdwood Grove DS0000067325.V343225.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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