Inspection on 28/07/08 for 5 High Beech Close

This inspection was carried out on 28th July 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 High Beech Close 19/09/06

5 High Beech Close 04/10/05

5 High Beech Close 05/05/05

5 High Beech Close 13/10/04

5 High Beech Close 20/04/04

Similar services:

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Insight - Eastchurch

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 5 High Beech Close St Leonards-on-sea East Sussex TN37 7TT Lead Inspector Michele Etherton Unannounced Inspection 28th July 2008 08:50 5 High Beech Close DS0000021335.V368688.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 5 High Beech Close DS0000021335.V368688.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. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 High Beech Close Address St Leonards-on-sea East Sussex TN37 7TT 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) 01424 850785 www.eastviewhousing.co.uk East View Housing Management Ltd Sharon Kathleen Fisher Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated will be four (4). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 19th September 2006 Brief Description of the Service: 5 High Beech Close is owned and managed by East View Housing Management Limited (EVH) and is home to 4 younger adults with learning disabilities and at present are all female. The house is a modern executive style and has four bedrooms. It provides spacious accommodation for four female residents, with a kitchen, utility room off the kitchen, dining and lounge areas. It has a reasonable sized back garden and driveway to the front of the house. The house is situated off the main road, which has bus routes to Hastings and Battle. The service users attend various day services during the week and are supported to pursue leisure opportunities in the evenings and weekends. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A key unannounced inspection of this service has been undertaken, this has taken account of information received from the service and about the service by CSCI since the last inspection, including an Annual quality assurance assessment (AQAA) completed by the manager. The AQAA has been completed to a reasonable standard and provides us with most of the information we need, there are some areas where more supporting evidence would have been useful to illustrate what actions the home has taken to address previously identified shortfalls, the activities of the service and future planning. The inspection includes an unannounced site visit to the home on 28/7/08 between the hours of 8:50 am and 13:20. During this visit a tour of the premises was undertaken, and we consulted with the staff member on duty, a resident who was at home for the day and the manager, their input has been helpful in the compilation of this report, survey responses have been sought from other residents of the house and their representatives and these will be analysed, and incorporated into the report if returned before the final report is issued. All key standards have been inspected some in more depth than others; Standards where outstanding requirements have been issued previously or outcomes became apparent during the site visit have also been included. A range of documentation has also been examined including care records, risk assessments, menus, Medication administration records, staff recruitment, training and supervision records, complaints, accident and health and safety information. We have been advised by the service of an adult safeguarding alert as a result of conflict between residents and this is currently under investigation. In arriving at our judgement of the service we have been proportionate in considering the previous history of the service, compliance with regulation and outcomes for the residents alongside the impact and risks the identified shortfalls pose currently. Generally we consider residents living in the home are safe and systems are in place to protect them from harm, complacency has developed in some areas of practice which if not addressed will impact on the homes ability to maintain standards already achieved and will in the longer term impact on the quality of service delivery experienced by residents. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has addressed all previous requirements issued in respect of shortfalls identified at the previous inspection. The manager has revised the care plan format that will better reflect the person centred style of working with residents and is refining the level of documentation to be maintained for each resident as this has become unwieldy. Plans are underway to develop raised flowerbeds in the garden, but progress has been disappointingly slow. The AQAA tells us that staff’ have worked with residents to give them a better understanding of the complaints process. That the manager has worked with staff to improve their awareness and understanding of how to make referrals to other agencies and the home has also worked on improving working relationships with other agencies. Also communication with senior management has been improved. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 7 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. 5 High Beech Close DS0000021335.V368688.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 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about who the service can support needs updating to reflect the more complex range of needs currently catered for. Systems are in place to assess the care and support needs of prospective residents prior to admission, ensuring these can be met now and in the future through routine reviewing. EVIDENCE: We consulted with the manager and a staff member about the people who live in the house and what support they need, we found that some of the residents needs have changed and that staff are now supporting a range of complex and sometimes challenging behaviours from some residents not currently reflected within Statement of Purpose information. It is recommended that information provided to prospective residents or their representatives makes clear the range of needs catered for within the home. We know from our discussions with staff, a resident and examination of records that no new residents have been admitted to the home since the last inspection, at which time admission and assessment procedures for new residents were judged as good. Without further admissions we are unable to assess this standard at this time. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 10 We are aware from our discussions with the manager and a staff member at the site visit that the home is actively monitoring and reviewing the changing needs of residents and seeks appropriate interventions from other agencies to aid and inform staff support and ensure needs continue to be met appropriately. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff understand residents care and support needs and plans are underway to involve residents more in how this is provided, the independence and skills development of residents is promoted within a responsible risk taking strategy however funding authorities should be pursued to take a more active interest and role in their care arrangements. EVIDENCE: The manager has listened to feedback we have given in respect of other services she manages and has actively pursued the development of a support plan that has a person centred focus and relies heavily on the involvement of residents in its compilation, existing care plans have been removed and the new ones are to be rolled out over the next week, all the staff have been in post for more than one year and are familiar with individual resident needs, we judge that the absence of care plans for a short period should not impact unduly on the support residents receive, information and monitoring in relation 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 12 to health, behaviour and risks has been retained and will be incorporated into the new support plan information. We consulted a resident at home on the day of our visit, who’ told us about what they do from day to day. They told us that they go out on their own into the town and that it had recently been agreed that they could start to spend increasing amounts of time on their own at the house, their longer-term goal being to eventually live more independently in the community. In the absence of support information we are unable to assess frequency of review but from other documentation viewed would judge this to be satisfactory, Unfortunately, there is no evidence of annual reviewing by relevant funding authority staff to ensure placements are externally reviewed, monitored and continue to meet assessed needs, it is recommended that the home manager pursues respective local authorities to fulfil their responsibilities to review funded placements annually. Residents participate in the running of the home and are rostered to undertake cooking and household tasks. The resident we consulted told us about wanting to make changes to their room furniture and that they were consulted recently about redecoration of their bedroom and preferred colour schemes and are pleased with the choices they have made, feeling greater ownership and responsibility for their room now. Resident files examined indicated risk assessments to be in place and these are reviewed, the manager is aware of the need to reduce the amount of documentation kept for each resident and is looking at ways to reduce the number of risk assessments in particular without loss of information, the home actively promotes and encourages independence and development of skills and there will inevitably be some element of risk attached and these are dealt with responsibly. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s lead busy active lives making good use of the community in which they live, staff are encouraging of skills development, personal and group decision making and residents’ active participation in the running of the household. Relationships are encouraged and supported. Residents are involved in menu development and meal preparation. EVIDENCE: On the day we visited only one resident remained at home, they are able to travel independently outside the home and are provided with activity monies to be used flexibly during the course of the week on trips and outings. An activity rota for the week was noted in the kitchen and indicated that most days the other residents are busy with day centre. Additional staffing is available between 4pm and 8pm to respond to resident requests to go out. The resident we consulted told us that home staff had tried to find a job for her but this had not been successful, she told us about a recent holiday to Spain which she had enjoyed but found the overland travelling tiring and uncomfortable, she 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 14 understood that cost is an important factor in the type of holidays abroad people enjoy, and indicated an acceptance about a proposed return to Spain for next years holiday. “We went to Spain on holiday, but I didn’t like the journey, we’re going there again next year.” Several of the residents have interested and involved families and contact and visits with them is supported through goal planning and facilitated for the residents concerned. Similarly a resident without family is being offered occasional weekend breaks away. The manager advised us that all residents have a bedroom door key and also a front door key, post trays were noted on some bedroom doors, money is held on behalf of residents by the home; at present they have limited involvement in their money but the manager is developing capacity assessments to support judgements around this. We asked a resident about how involved they are in menu planning, shopping and cooking, they told us that each Thursday evening the residents meet with a staff member to discuss and develop a menu for the coming week, shopping is done on a Friday, and they are involved in this whilst other residents are at centre. Cooking is done on a rota basis with each resident taking a turn with staff support; some day’s staff’ cook. A resident at home during our visit was welcoming and regularly offered and made drinks for everyone. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive personal and healthcare support that is flexible and responsive to their individual needs and takes account of their own preferences. Residents are enabled to access routine and specialist health care appointments. Thought has been given to providing safe but sensitive medication storage for individual residents, satisfactory medication administration and recording systems in place will benefit from suggested minor improvements. EVIDENCE: In absence of care plans it has been difficult to tell whether they reflect the support residents are happy with, we consulted with the manager and a staff member who told us residents are encouraged to be as independent as possible around personal care but supervision and prompting are provided by staff where necessary. A resident we spoke with told us that they undertake their own personal care, and the new format will more clearly evidence the manner in which individual residents wish to be supported. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 16 Current files examined provided evidence of routine health checks and appointments, health contact sheets are maintained, there is also evidence of the home progressing referrals to specialist appointments where issues have arisen. The Manager has an awareness of the Mental Capacity Act and how this will impact on decisions in respect of medication administration, currently no resident self administers oral medication, one resident looks after a prescribed bath oil and there should be a risk assessment in place for this and this is a recommendation. The home has installed medication cabinets in each resident bedroom, information relating to individuals medication regimes is also stored in these. This allows for greater resident participation and privacy in administration of medication. We looked at medication records for two residents; these contained a photo of the resident, individual PRN guidelines and medication profile. Administration sheets were completed satisfactorily with appropriate use of codes. Handwritten entries are signed for but should also include the date the change is made and is a recommendation. Administering staff’ have received medication training. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has an open culture that provides opportunities for residents to express their concerns and views, Residents are generally protected by the practice and procedures in place and the home understands the procedures for safeguarding adults, but shortfalls in some key areas if not addressed in a timely manner may compromise residents safety from harm or abuse EVIDENCE: The AQAA informs us that no complaints have been received; the manager confirmed this at the time of our visit. The manager has identified a need to provide greater confidentially around complaint recording and will be implementing a new system to facilitate this. A staff member told us that residents have time when they speak with key workers if they have issues of concern. The AQAA states that they have spent time with residents making clear the complaints process, this was not particularly evident with the only resident interviewed who told us she would be selective about who she chose to raise concerns with preferring some staff to others. We were told about behaviours that some residents exhibit and one resident told us what happens when they get angry, an examination of resident records confirmed that staff are adhering to behaviour guidelines, the home does not undertake restraint but has emergency intervention guidelines in place for one resident for reasons of safety for the resident and other people. A reward 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 18 system is also used with some residents, whilst it is clear that there has been involvement of health professionals in determining some guidelines it is recommended that, any restrictive practices and the implementation of reward systems are not decided upon by the home staff or EVH in isolation but agreed as part of a multi disciplinary decision making process, involving not only the resident and involved health professionals but also independent representation from their funding authority or representatives. Shortfalls have been identified in some key areas with staff recruitment and training likely to have the most impact on residents if not addressed, whilst the home demonstrates awareness of adult safeguarding issues and refers appropriately any incidents to social services not all staff have received training in adult safeguarding despite having been in post for more than one year. There is a current open adult safeguarding alert in respect of physical assault by one resident on another, other agencies are involved in resolving this and the home has responded quickly and appropriately in dealing with it. The home operates a satisfactory system for the recording of resident finances that requires two staff signatures as well as a resident signature, receipts of expenditure are retained and a record of income and expenditure maintained for each resident, We checked two resident balances against cash sums held for them and found one cash balance to be short by £5.50, the manager attributed this to an unrecorded receipt, and we have asked them to check this omission and to advise us of the outcome. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant homely environment in keeping with surrounding properties. Generally well maintained but would benefit from ongoing garden works being completed to enable residents to enjoy full use of the garden EVIDENCE: The Home offers residents a small homely environment, maintained internally to a good standard generally, previously identified shortfalls in the kitchen and en-suite shower and bathroom areas have now been addressed. Our tour of the premises enabled us to view resident bedrooms with permission, bath and shower areas and communal space. Examination of records informed us that fire checks of equipment to detect and fight fire are undertaken and fire drills maintained. The fire risk assessment has been updated. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 20 Bedrooms are individually furnished and reflect the interests and tastes of the residents, there is evidence of residents choosing to purchase furnishings for their bedrooms, one resident told us that she had purchased some items of furniture as she wanted to replace what was there with something she liked, although this does not match with other furnishings she feels in control and that she now has a vested interest in the room and helping to make it look nice, she told us that she was consulted about recent redecoration of the room and was pleased with the colour she had chosen. Inventories are maintained of resident belongings. Communal areas provide comfortable well-furnished space for residents to relax in. Progress to develop a raised flower bed in the rear garden has been disappointingly slow and a large mound of earth spoil and an incomplete raised flower bed are the only sign of works underway, a breeze block was noted upright on the patio and we asked that any such debris was removed to ensure residents did not trip up, and this was moved during the site visit. At present there would seem to be no timescale for the completion of the works, whilst this does not impact on residents generally using the garden safely, it is unsightly and the presence of the works for the last ten months means that staff have been unable to work with residents to develop the garden and lessens its attraction as an enjoyable and pleasant resource. It is recommended that a firm timescale for the completion of the work be obtained. The home’ is kept to a good standard of cleanliness by residents’ and staff, with residents taking responsibility for cleaning their own space and actively participating in rosters for undertaking other household cleaning tasks. An upstairs bathroom was found to have no means of hand drying for those washing their hands and fails to promote good hand washing; it is a recommendation that paper hand towels are provided. A laundry area off the kitchen is well equipped and a resident told us they use this to do their own washing. 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is enough competent staff to support residents. A programme of training to provide staff with necessary skills is in place but shortfalls exist within completion of induction and mandatory training. Staff fitness checks are carried out but overall recruitment procedures need strengthening. Staff’ feel well supported and team meetings are provided, opportunities for individual formal supervision however, have slipped. EVIDENCE: We examined the staff rota and found this to be accurate, we consulted with the member of staff on duty and have also received one staff survey response staff tell us that staffing levels are satisfactory for the present needs and number of residents, additional staff’ are provided from the time residents return from day centre to ensure staff support is available if some residents wish or need to go out. Staff’ tell us that they have received an induction and have access to a good range of mandatory, NVQ and specialist courses more than 52 have attained NVQ2 or above. Examination of three staff training records indicates 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 22 that whilst there is evidence of induction this lacks clarity as to whether this is compliant with skills for care and records would indicate induction to be signed off on one date with no evidence of assessment of staff competency over the expected induction period of 12 weeks, the manager told us that one of the staff we looked at is still to do LDAF training, although they have already been in post for more than one year, whilst most mandatory training has been achieved all three staff files examined evidenced that staff are still to complete infection control and POVA training, the delay in new staff completing this training is not acceptable and the provider is required to ensure that all new staff complete induction that is in keeping with skills for care common induction standards including LDAF within the expected timescales, staff should also complete mandatory training and receive POVA training within the first 6 months of employment to ensure they have the necessary skills to provide effective and safe support to residents, this is particularly important as staff spend the majority of daytime shifts on their own. A review of staff files informed us that checks and vetting of staff are being undertaken but evidence of CRB lacks clarity, content of all staff files viewed is not in keeping with schedule 2 of the regulations, there is an overall lack of interview records to evidence that gaps in employment histories and verification of reasons for leaving previous care roles are being sufficiently explored at interview. The shortfalls identified in training and recruitment are consistent across all files examined and would indicate these areas have not been maintained to the expected standard shortfalls in these areas if not addressed could impact on the welfare of residents. A staff member consulted confirmed access to regular team meetings and supervisions, although frequencies of individual supervisions have drifted the quality and comprehensiveness of them is good, it is recommended that the manager reviews individual staff supervision arrangements to ensure that regular monitoring of performance and development is maintained. A staff member we consulted reported that supervision doesn’t just cover work issues but personal well being, staff feel well supported at team meetings, are encouraged to raise issues and ideas “Staff say what they feel”. 5 High Beech Close DS0000021335.V368688.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): 37,38, 39,42,43 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally well managed, the manager has a good understanding of changes in legislation and plans the service accordingly, she demonstrates an awareness of areas where the service could improve, and an open inclusive culture is fostered. Residents are actively involved in the day-to-day running of the home but there is a lack of clarity as to how their views shape service delivery. The service monitors its own practice in respect of service delivery and health and safety but there is a lack of organisational monitoring to ensure standards are maintained. EVIDENCE: The manager is undertaking a diploma in psychology and already holds the required qualifications for a manager; She undertakes periodic training to update practice and to raise awareness of changes in legislation. She 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 24 confirmed that policies and procedures are being amended to reflect legislation impacts. The home is compliant with regulation and has met previous requirements around identified shortfalls. Quality assurance is in place and residents have opportunities to express views in several forums including 1-1’s and house meetings, staff tell us they feel supported and listened to and that they are able to express their views and ideas, questionnaires seeking feedback from residents and other stakeholders have been developed and distributed; it is unclear at this time how this information is to be analysed and will feed into the service development process and inform service delivery. Whilst the manager undertakes a monthly service audit including health and safety checks, there is no evidence that provider visits are being undertaken regularly or documented. The provider is required to ensure that unannounced visits to the property are undertaken in keeping with regulation 26 of the Care homes Regulations 2001, and that a copy of these recorded visits is made available to the link inspector from CSCI monthly until further notice. We are advised from AQAA information that health and safety checks of services and equipment are up to date and were viewed at the site visit, there is no evidence that these are not routinely updated however the electrical installation is overdue an inspection and this would seem to an oversight. The provider is required to arrange for the servicing of the electrical installation within the timescales given in the report and thereafter maintain servicing in keeping with the contractor recommendations. We looked at accident reporting over an 11-month period, this evidenced accidents to be at a minimal level with staff satisfactorily completing accident reports to a consistent standard. The fire log has been examined and evidences that fire checks, drills and risk assessment are maintained and updated. Current Insurance for the service is in place. We asked the manager about budgets and have established that the present budget incorporates both food and expenditure on incidentals, this makes it difficult to ensure a consistent sum is spent on food as there is no indication from week to week what incidentals may also need purchasing e.g. printer cartridges, consideration should be given to making a clear separation between food and incidentals expenditure and in the present financial climate sums available should be reviewed. Generally we consider residents living in the home are safe and systems are in place to protect them from harm, complacency has developed in some areas of practice which if not addressed will impact on the homes ability to maintain standards already achieved and will in the longer term impact on the quality of service delivery experienced by residents. 5 High Beech Close DS0000021335.V368688.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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 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 3 2 X X 3 X 5 High Beech Close DS0000021335.V368688.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation 19 Requirement The provider must ensure that: Information relating to CRB dates; reference number and outcome are made clear within staff files. Staff files must contain the range of documentation and a current Photo as specified in schedule 2 of the care Homes Regulations. Staff files should evidence that gaps in employment histories and verifications of reasons for leaving previous care roles have been explored with applicants. Timescale for action 31/08/08 2. YA35 18 3. YA39 26 & 2, a report of these findings must be The provider must ensure that: 31/08/08 Staff induction is compliant with skills for care common induction standards and is achieved within the timescales set. Staff achieve mandatory core skills training including POVA within 6 months of employment The provider must undertake 31/08/08 unannounced visits to the service on a monthly basis to interview in private staff and residents and assess quality of documentation and premises, a DS0000021335.V368688.R01.S.doc Version 5.2 Page 27 5 High Beech Close 4. YA42 report of findings should be sent to CSCI following each visit until further notice 23(2)(b)(c) The provider must undertake to service the electrical installation of the home and thereafter maintain service frequencies as determined by the electrical contractor 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations Statement of Purpose and user guide information to be updated for prospective residents and /or their representatives to reflect the range of needs supported by the home The home manager should pursue funding authority representatives to fulfil their responsibilities to undertake annual placement reviews and assure themselves that the placement still meets the needs of their resident All handwritten changes to Medication records should be dated as well as signed. A risk assessment is required to be in place for self administration of all prescribed external medications as well as oral medications Any restrictive practices and the implementation of reward systems should be agreed and part of a multi disciplinary decision involving the resident relevant health professionals and independent representation from the funding authority or representatives to ensure the rationale for such practices is clear and supported. The manager should seek to obtain a clear timeframe for the completion of the garden works within 8 weeks Paper hand towels to be supplied in the upstairs communal bathroom to promote good hand washing The manager should undertake to evidence through improved frequencies of recorded formal staff supervision that staff performance, practice and development is routinely monitored. DS0000021335.V368688.R01.S.doc Version 5.2 Page 28 2 YA6 3 YA20 4 YA23 5 6 7 YA24 YA30 YA36 5 High Beech Close Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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