Inspection on 13/09/07 for 4a Telegraph Road

This inspection was carried out on 13th September 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

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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 4a Telegraph Road West End Southampton Hampshire SO30 3EJ Lead Inspector Janet Ktomi Key Unannounced Inspection 13th September 2007 11:30 4a Telegraph Road DS0000069828.V344956.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 4a Telegraph Road DS0000069828.V344956.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. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4a Telegraph Road Address West End Southampton Hampshire SO30 3EJ 01420 542447 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) People Potential (UK) Ltd Stewart Charles Akass Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: 4a Telegraph Road is a detached family house located in a residential area of mixed properties in Westend on the outskirts of the city of Southampton. Local amenities consist of those that can be expected and access to public transport is good. The use of the building as a care home is not obvious and it is domestic in scale. It is registered to accommodate and provide personal care and support for up to four people between the ages of 18 and 65 with learning disabilities. The home has bedroom accommodation on two floors with two bedrooms located on the ground floor and two on the first floor. All bedrooms have ensuite facilities including either bath or shower. There is a large communal lounge and separate dining room on the ground floor as well as a communal WC, utility room and kitchen. To the rear and side of a building is a good size secluded, enclosed garden and at the front there is space for up to four cars. All people intending to live in the home move in through care management arrangements with the support of a social worker/care manager and usually also involving other interested persons i.e. relatives. Information about the service that the home provides is made available during the moving in process that is carefully planned. Individuals are provided with a personal “welcome pack” telling them about the service the home provides before they move in. This is produced in a language format suitable for that person e.g. symbols and pictures. At the time of a site visit to the home on 13th September 2007 the fees ranged from approximately £1300 to £1800 a week depending on the level of support that the individual concerned required. This did not include toiletries, newspapers and magazines; confectionary; hairdressing; podiatry; and the entrance fee to places of interest/entertainment 4a Telegraph Road DS0000069828.V344956.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 the first key inspection of the home that was registered in April 2007. The home was telephoned the evening before the inspection to determine a suitable time for the inspector to visit based on the planned activities of the people living in the home. The inspector arrived at 11.30am and completed the visit at 4.30 pm. During the visit accommodation was viewed including bedrooms (with the permission of their occupant), communal/shared areas and the home’s kitchen and laundry. Documents and records were examined. People living in the home were met and one chose to join the inspector and manager for much of the inspection visit. 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 were male and neither was from a minority ethnic group. The home’s newly appointed manager and the providers training/quality assurance manager were present during the visit and were available to provide assistance and information when required. The relatives of and care managers for the people living in the home were canvassed for their views about the home using questionnaires, before the site visit took place. Their responses were taken into consideration when producing this report. Other matters that influenced this report included: An Annual Quality Assurance Assessment completed by the previous 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 for Social Care inspection had received such as statutory notices about incidents/accidents that had occurred. What the service does well: The home has a comprehensive pre-admission procedure to ensure that appropriate people are admitted to the home. There was detailed written information about the needs of the people who live at the home that enables the staff to provide the help and support that each individual required. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 6 The home promotes 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. Despite only moving into the home in May 2007 both people living at the home had a holiday this summer. The building was spacious, comfortable, well furnished and pleasantly decorated. Relatives of people living in the home and a care manager expressed confidence in the home’s management. 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. 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. 4a Telegraph Road DS0000069828.V344956.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 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems and procedure in place to enable people that intend to live there to make an informed choice about whether to do so. The help that they need is identified before they move in to ensure that the home can fully provide it. EVIDENCE: The records were examined of the two people living in the home at the time of the site visit. It was apparent from the records and comments from relatives and a care manager that the individuals concerned had both been provided with some information about the home before they moved in. A welcome pack, which was produced in a format suitable/personalised for the individual concerned, had been provided to them. The inspector viewed a copy of the welcome pack. A letter was seen from one relative expressing her satisfaction with how well her son had settled into the home. It was also clear from the documents seen and the comments of a social care professional that the level and type of support that individuals required was 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 9 identified in great detail before moving in. The pre-admission procedure was explained by the newly appointed manager who stated that the provider’s head of care was supporting him with pre-admission assessments. Discussions with the new manager indicated that compatibility with the existing people would be an important factor in determining if a new placement would be made. There was a “transition” period as part of the process of moving into the home with transition plans for both people living at the home viewed. These included staff visiting the person at their current accommodation, visits by the person to the home, and overnight stays. One care manager stated ‘I have been very satisfied with the detailed pre-placement assessments, transition and review arrangements’. Due to the complexity of needs of the people living at the home it was not possible to discuss their views on their admission. The staff group working in the home had a full week’s induction training as a group before the home began operating in April 2007. They all had relevant experience and their induction and subsequent regular training was in subjects that were relevant to the type of support required and about the needs of individuals who may live in the home e.g. autistic spectrum disorder, epilepsy. The training manager confirmed that both people living at the home had moved into the home through care management arrangements. The home had formal contracts for each person living in the home with their respective sponsoring/funding local authority. The inspector was shown the information about the home that has been made available in photographic and Makaton symbol/easy read format. This is in addition to the more formal, complex information contained in the statement of purpose/service users guide, which is available for relatives and professionals considering placements. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 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 and their relatives are involved in planning the care and support that they received and risks they take and were able to exercise choices about day-to-day life in the home. Sensitive information was looked after properly. EVIDENCE: During the site visit the inspector viewed care plans, risk assessments and information held on both people living at the home. These were discussed with the manager and staff. The 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. These are in typed written English format. The inspector was shown the person centred format the home is planning on using to produce plans more accessible to the people living at the home. These plans 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 11 in formats more suitable for the individual concerned are based on a model called “My Life” using pictures and diagrams. The manager stated that relatives, professionals and the people living at the home will be fully involved with the completion of these person centred plans which will become working documents for the promotion of life skills and choices. Each care plan included risk assessments that identified possible harm to the individual but the home also recognised that some risk taking can have benefits and result in a better quality of life. There was evidence that care plans were reviewed regularly, with this being confirmed by a comment from a care manager. The care manager also commented that the home is good at care planning and the development of person centred plans. During the visit it was noted that staff discussed decisions and choices with people living in the home about a range of matters, such as activities they wished to pursue. Care staff were observed using Makaton signs to communicate the option of an outing and that it was lunchtime. One person chose to join the inspector and manager for much of the inspection. Discussions with care staff confirmed that people’s choices are respected and that efforts are made to increase options for choice and decision making. Care staff identified that they had requested improved access arrangements (ramp) at the back door so that one person could enter and leave the garden unaided. The manager confirmed that this was to be provided in the near future. A new activities recording form shown to the inspector by the manager included space for recording the person’s response to the activity undertaken. The home had policies and procedures about confidentiality and sensitive information about individuals living in the home was kept securely in the staff office. Care staff confirmed that they were aware of confidentiality issues. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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 home promotes the rights of the people to live ordinary and meaningful lives. They are supported to take part in social, educational and recreational activities and to develop life skills. EVIDENCE: Pre-admission assessments included information about people’s social needs, preferred activities and these are included within the fee structure of the home. Both people living at the home have individual weekly plans of activities both in and out of the home. These were seen during the inspection. On the morning of the inspectors visit to the home one person had been swimming and both people went out during the afternoon of the site visit. The home maintains daily recordings that listed what activities people had taken part in. Financial records listed personal money spent on entrance to places of interest appropriate to the people who live at he home such as ‘Monkey world’ and 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 13 Moors valley park. Both people had the opportunity of a holiday on the Isle of Wight in August 2007. The home provides an appropriate car for transport for activities. As previously stated the new manager showed the inspector a new form for recording the weekly activities undertaken by people, this included not only the activity undertaken but had ample space for a record of the persons response to the activity. The manager stated that this information could then be used for planning future activities as well as a record of those undertaken. In house the home has ample communal space and is equipped with home entertainment equipment such as televisions and music systems. The home has a good sized, enclosed, private rear garden where one person was seen to choose to spend his time. The manager confirmed that access improvements are to be undertaken to enable people to use the garden independently. Weekly activity plans and daily recordings confirmed that people can have visitors and visit their relatives as they wish. The inspector was shown the menu sheets and records in care plans stated what people had eaten. These included choice evenings and take away options. Care staff confirmed that they prepare all meals and include the people who live at the home as far as possible. Records indicate a range of healthy foods are provided. The homes annual quality assurance assessment stated that twenty-five percent of care staff have received training in food handling. The training manager confirmed that this would be included in planned training. The home has been assessed by the local environmental health department and received a good rating. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 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 receive is based on their individual needs and medication is managed safely. EVIDENCE: The care plans examined set out in detail how the help and support an individual needed was to be provided. Staff spoken with were able to describe the needs of the individuals in the home and how they were met in accordance with the plans. Staff were required to sign a care plans awareness document to indicate that they had read them and understood their contents. Both people living at he home have moved form other health authority areas and have been supported to access health services provided in their new home area. The home has made referrals to specialist healthcare professionals in order to obtain support and advice about the specific needs of individuals. There was evidence in records of correspondence with relevant specialists about the use and level of certain medication for one person. Discussions with the manager, who is a Registered Nurse for Learning Disabilities, indicated that he was fully aware of how to access local specialist support and aware of 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 15 health and medication issues. The home maintains a record of all contact with health professionals. The care manager for one person stated in her comment card that the home had ‘good contact established with the local community learning disabilities team and registration with local GP carried out promptly.’ Medicines are kept in a suitable locked metal cabinet in the homes office and the home uses 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 that could not be blister packed such as liquids or items that would deteriorate when removed from their containers. Records were kept of the receipt into the home of medicines, giving out and disposal of unwanted items and all were accurate and up to date. The home had specific guidelines for the administration of as required medication with the exception of pain relief (paracetamol). The manager stated that the home did not have as required pain relief for this person although it was listed on the medication record sheet. This absence of guidelines was discussed with the manager, as the person would be unable to state that he had pain. The manager stated that as part of the person centred planning they would aim to establish what behaviours may indicate pain and provide specific guidelines to ensure that the person was able to receive pain relief if required. Neither person living at the home at the time of the inspectors visit was able to selfadminister their medication. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 24 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 and their relatives have access to a complaints procedure that would enable the home to address their concerns. There are systems in place in the home to protect vulnerable adults from harm. EVIDENCE: The welcome pack provided to all people living at the home contains information in a pictorial format, requesting people to say if they are unhappy. A copy of the more formal complaints procedure is included in the written version of the statement of purpose/service users guide. People living at the home at the time of the site visit would have difficulty making a formal complaint due to the level of cognitive and communication needs. The care manager who returned a comment card was aware that a new manager was in post and identified that the home are good at developing and maintaining relationships with families. The compliments letter seen from one relative indicated that the home has a good relationship with families. This open culture would encourage relatives to raise issues should they arise. The home had a system for keeping records of complaints and had received none since it started operating in April 2007. “The Commission” had received no complaints about the home during the same period. 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. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 17 Staff had received training in the subject of adult protection and those spoken to knew what to do if they suspected or knew that abuse had occurred. Appropriate procedures are in place to protect people’s personal finances and to ensure that inappropriate people are not employed at the home. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 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, generally safe, and well maintained and is appropriate for the people who live there. EVIDENCE: The manager introduced the inspector to the people who live at the home and asked their permission for the inspector to be shown their bedrooms. A tour of the home was then undertaken with the manager. At the time of the visit the exterior and interior of the home was in good decorative order and its furnishings and fittings were in good repair. The premises were clean and hygienic and there was evidence that there were systems in place to ensure a regular and routine cleaning schedule was implemented. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 19 The provider has a maintenance person who undertakes decoration and routine jobs with external professionals being contracted for specific jobs. The maintenance workbook was seen and indicated that all staff report jobs that require maintenance work, which is then undertaken. The accommodation is domestic in nature and scale and bedrooms are spacious all with en-suite WCs and either a bath or shower. Occupied bedrooms viewed during a tour of the premises had been personalised for the individual concerned and they were able to decide on their own colour scheme in their bedrooms. Communal space was on the ground floor and comprised a large lounge and separate dining room, large kitchen a WC and a utility room. Externally there is a good-sized secluded, enclosed garden extending right around the home. All windows in the home were fitted with an opening restrictor, hot water outlets were fitted with thermostatic controls to ensure that it was delivered at a safe temperature to prevent scalding and guards had been installed on all radiators. The utility room was clean and tidy and equipped with modern washing machine that had a sluice programme and there was an appropriate system in place for managing any soiled linen. The home has provided some adaptations to support one person who has a physical disability. It has recently been identified that additional adaptations (ramp and hand rails) at the back door to the garden would allow this person to enter/leave the home independently and the manager stated that these will be provided. The front entrance to the home is via a marble floored open porch. Accident reports and staff comments indicate that one person has slipped on this floor on several occasions. At the time of the site visit the marble had been covered with a strip of carpet which is unattractive and will become more so as winter approaches. Care staff confirmed that the person still slips on the marble as his crutches are rubber bottomed and whilst he walks on the carpet they are on the slippery marble. Staff meeting minutes for August 2007 indicate that this issue has been raised by care staff who also confirmed that this has been an ongoing problem since the person moved in. This issue was raised with the manager who stated that the provider has agreed for alternative flooring to be laid and that this would be done within the next four weeks. A requirement is therefore not made. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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 recruitment, training, support for, deployment level and skill mix of staff ensured the complex needs of people living in the home were met and their safety was promoted. EVIDENCE: Information in the homes Annual Quality Assurance Assessment, duty rotas, recruitment files and training records were seen and discussions with care staff were undertaken. The inspector was able to discus training with the providers training manager. Interactions between care staff and the people who live at the home were observed during the inspection and appeared warm and friendly. People living at the home appeared relaxed around the care staff, however due to cognitive and communication difficulties were not able to express their views about the staff to the inspector. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 21 At the time of the site visit the level of staff on duty was in accordance with its published rota with two staff on duty in the morning, two in the afternoon and one awake staff at night. The home’s manager was supernumerary. The manager stated that as new people move into the home staffing levels would be reviewed in line with their assessed needs and planned activities. The home has used some agency staff with care staff confirming that one permanent member of staff is always also on duty if an agency worker is required. Care staff confirmed that they will undertake additional shifts to cover if necessary. Care staff stated that the staffing levels are appropriate to meet the needs of the two people currently living at the home. There was also support for the home and its staff group available from senior staff on call and a central office team that comprised: • Head of care/clinical support • Personnel manager • Training and quality manager At the time of the visit the home employed eight care staff and of these two (i.e. 25 ) had an appropriate National Vocational Qualification (NVQ) at level 3 with the training manager stating that a further two staff are undertaking this qualification. The training manager and homes manager are aware that additional staff need to commence an NVQ of at least level 2 and the training manager stated that this will be accessed from a local college. The training manager is an NVQ assessor and internal verifier. Staff spoken to described the training that they had attended that enabled them to understand and work with the complex needs and behaviours of the people living in the home including e.g. autistic spectrum disorder; epilepsy; and physical intervention. The training manager and homes manger showed the inspector lists of planned staff training and a training matrix recording training staff had attended. Training planned is relevant to the needs of the people who live at the home with the training manager confirming that all training is fully funded. Care staff stated that they felt they had the necessary skills to meet the needs of the people who live at the home. There was also evidence from discussion and records examined that there was a structured staff induction training that complied with the expectations of the social care workforce development body, “Skills for Care”, common induction standards. Induction training included guidance on adult protection and dealing with violence toward staff, racial harassment and equal opportunities. The home had written policies and procedures about staff recruitment and it indicated that staff appointments were subject to satisfactory, Protection of Vulnerable Adult (POVA) and Enhanced Criminal Record Bureau (CRB) checks and 2 references and completion of a 3 month probationary period. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 22 The records of some of the home’s permanent staff were examined. It was apparent that all the necessary pre-employment checks had been completed to ensure that anyone considered unsuitable to work with vulnerable adults was not employed. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 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 is safe and well run and is developing self-monitoring and quality assurance processes. Records are well maintained and appropriately stored. EVIDENCE: The home has recently appointed a new manager who has the necessary skills and qualifications to manage the home. The new manager has only been in post for four weeks and the providers training manager stated that an application for registration will be commenced in the near future. The home was registered in April 2007 and only started operating in May 2007, consequently there was no formal or established quality monitoring system that took the views of people living in the home and other interested parties 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 24 into account. Internal reviews of the service by a representative from the company that owned the home were carried out and comprised visits to the home at least monthly in order to comply with Regulation 26 of the Care Homes Regulations 2001. It was apparent from documents seen that had been produced following these visits that an action plan was developed clearly setting out what had to be done, by whom and when, in order to rectify any matters that were identified as requiring improvement during these visits. The previous registered manager completed the Annual Quality Assurance Assessment that was returned on time and stated some areas that the home has identified that it could improve. All the statutorily required records that the home was keeping that were examined were accurate and up to date. Records seen and discussion with staff indicated that safe working practices were promoted in the home. Records and discussion also indicated that fire safety systems and equipment were checked and monitored. It was identified that the home does not have a policy on moving and handling. The training manager stated that this was being completed and would be available to staff in the very near future. It was also noted on training information that staff have not had infection control training. The training manager stated that this is to be provided via a distance-learning package from a local college. Requirements re these are therefore not made however they will be viewed during the next inspection visit. 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No Score 6 3 7 3 8 3 9 3 10 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING 31 32 33 34 35 36 3 3 3 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 3 X 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? New service 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 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 27 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 4a Telegraph Road DS0000069828.V344956.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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