Inspection on 01/03/07 for 5 Priory Drive

This inspection was carried out on 1st March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

5 Priory Drive 13/12/05

5 Priory Drive 08/06/05

5 Priory Drive 09/12/04

5 Priory Drive 20/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 5 Priory Drive 5 Priory Drive Totnes Devon TQ9 5HU Lead Inspector Judy Cooper Key Unannounced Inspection 1st March 2007 11:20 5 Priory Drive DS0000003633.V324626.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 Priory Drive DS0000003633.V324626.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 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Priory Drive Address 5 Priory Drive Totnes Devon TQ9 5HU 01803 867554 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) enquiries@comae.org.uk Mr Simeon James Antony George Ramsden, The Very Rev Archpriest Benedict Ramsden, Katherine H L Finnigan, Mrs Lilah Ramsden Miss Tamsin Jane Pope Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: Five Priory Drive is a small residential home, set close to the centre of Totnes providing care for up to three service users with mental healthy needs. The home is one of a number operated by the Community of St Anthony and St Elias, a partnership providing care in small domestic settings in the Totnes or Plymouth areas. (For ease of reference The Community of St. Anthony and St. Elias will be referred to as the Community throughout this report). The home is a domestic property, adjacent to two other properties owned by the Community. Three single bedrooms are provided for service users, with bathroom/shower and toilet facilities, a kitchen, a conservatory/dining room and a small lounge. There is an attractive small garden and limited parking. Service users have access to the services of the Community such as an extensive outdoor activities programme, arts and crafts activities and work placements. The current rate of weekly fees range from £1597.32 to £2039.40 The inspection report is made available to all interested parties and is kept in the manager’s office. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a Thursday between 11.20 a.m. and 6.00 p.m. The service users at the home have very varied routines. However most service users were available at different times to talk with, which ensured that this inspection involved them as far as they wished to be involved. During the visit the opportunity was also taken to tour the home, examine appropriate records and policies and talk with the manager and several staff members. Additionally, one of the service user’s details were inspected in detail to ensure all care needs were being met from the time they came to live at the home to the current day. Other information about the home, including the receipt of questionnaires from all of the three the clients and a verbal conversation with a service user’s family member, have provided further feedback as to how the home performs and all of this collated information has been used in the writing of this report. All required core standards were inspected during the course of this inspection. What the service does well: The management and staff work very closely with each service user to allow them to work through, and understand their mental health problems/illness and to understand how best they may live with their illness. The manager and staff also ensure all care/support is delivered in a way that is acceptable and agreeable to the service users. The home provides a relaxed yet structured environment where service users have the time, support and the space, required to address their mental health problems. Service users’ individuality and a respect for their rights to privacy and confidentiality is upheld by all staff which resulted in the service users confirming that they felt they felt very well cared for at the home. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 6 Both staff and service users are treated equally i.e. using the same facilities, eating at the same time, having a say in the running of the home etc. This helps break down any barriers that may exist between staff and service users, with all working toward one goal, which is the eventual best mental well being that each service user can attain. The management and staff, in conjunction with the Community itself, continue to facilitate a very broad range of activities for service users, which they are both encouraged and supported in undertaking. The staff team are mostly very well known to the service users and confident with their needs, therefore consequently providing a very professional level of care. What has improved since the last inspection? What they could do better: Any verbal reference obtained, in relation a newly recruited member of staff, should be recorded to ensure that the Community can evidence that all service users remain cared for an appropriate staff group. The Community should continue to work towards ensuring that there is the required fifty percent of trained staff working at the home, who have achieved a nationally recognised qualification in care. This is so that the service users can be assured that an aware and experienced staff group are always available to provide for their care needs. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 7 The manager should document the supervision given to staff so that any identified strengths or weaknesses are recorded and evidence provided as to how these skills and needs are then used/addressed. This is to ensure that the manager can demonstrate that staff are aware of the expectations of their role and that they feel confident to deliver a good quality of care to the service users. The Community should ensure that all staff fire awareness training is provided as per the recommendations of the local fire and rescue service to ensure that service users remain protected. All recording, appertaining to service users, should be undertaken individually so that any service user, requesting their right to view the information held about them by the home, can easily access their own care records. This is not possible when personal details regarding other service users are recorded on the same page, which currently happens on the handover sheet, used by staff at change of shift. 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 Priory Drive DS0000003633.V324626.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 Priory Drive DS0000003633.V324626.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): Standard 2. Quality in this outcome area is good. The individual needs and aspirations of any prospective service user are assessed and well known by both the manager and staff prior to any service user’s admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current service users have been together at the home for the past eighteen months, with one having been at the home for several years. There have therefore not been any new admissions since October 2005. A full and detailed admission process was undergone prior to each service user coming to live at the home on their admission. Each service user has a signed statement of their terms and conditions. The individual needs and aspirations of the service users were assessed and were well known prior to their admission. All further subsequent changes to the service users’ needs, since being at the home, have been recorded and met appropriately. 5 Priory Drive DS0000003633.V324626.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): Standards 6,7,and 9. Quality in this outcome area is excellent. The manager and staff are skilled in planning for all aspects of the overall needs and personal goals of the service users. They show both sensitivity and awareness of each service user’s current and changing needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the current three service users have a very in-depth personal file where all details of care given and personal records are kept. Each service user’s individual care plan is equally detailed and is fully updated as required with each service user being involved in this process. Although there is not open access for service users to the entirety of their files they are able to see some details, however the manager stated that the Community felt it may not always be in the service user’s best interests to have open access to more sensitive information. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 11 It was pleasing to note how an area of risk had been successfully addressed both by involving the service user concerned and ensuring the staff provided the increased care deemed necessary at this moment in time in a sensitive and non-obtrusive manner. The Community has recently adopted a new daily recording system which links in with the service user’s care plan objectives. These individual daily records were seen to be in-depth and contained very relevant information. The daily records are kept in an individual folder for each service user along with their care plan to which each service user has open access. The staff members present were seen to be very aware of service users’ needs generally and the majority of the staff were well known to the service users. It was obvious that there were good relationships between staff and the service users with service users trusting the staff with personal details and in return receiving unconditional respect from the various staff members on duty. The manager and staff continually monitor the risks associated with providing care and social opportunities for the service users, which includes taking into account any complex behavioural needs. It remains to the manager and staffs’ credit that, as many opportunities as possible are made available to all the service users, including using every day local community facilities. On the day of the inspection one service user was working at a local charity shop, another returned from using a local college to access an English course and was then going shopping in the local town whilst another was participating in an environmental scheme on a local farm to enhance and protect the natural landscape. One service user is currently training with the St John’s Ambulance and has successfully undertaken first aid, food hygiene and health and safety training with the organisation. The Community also has its own activities programme to which all service users have access. On the day of inspection the manager handed out the activity programme for March. There were opportunities for service users to participate in such activities as singing, art, music workshops, a chess and scrabble championship, walks, cricket, badminton, skittles, surfing, singing, and several others. Times and contact details were also made available and one service user thoroughly enjoyed looking through the programme planning the month’s activities they felt they would like to attend. The service user also confirmed that there were always lots to do and that they enjoyed the activities. A service user’s family member also stated how happy they were with the level of activities and support made available and felt that the care their relative received was excellent. All service users remain free to come and go as they so choose, in line with their individual risk assessment. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 12 5 Priory Drive DS0000003633.V324626.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): Standards 12,12,15,16 and 17. The quality in this outcome area is excellent. Service users’ lives continue to be enhanced by being supported to participate in many varied activities and by making full use of the local, nearby community facilities. All aspects of daily living within the home, continue to be determined, as far as possible, by service user choice whilst healthy and well-planned meals are provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Achievable goals continue to be worked towards, including daily living skills such as shopping, personal hygiene etc and it is to the manager and staffs’ credit that their enthusiasm that they work so positively with the service users in helping them reach their potential. All service users are treated equally and any diverse need they may have were seen to be met appropriately. An example of this was with one service user who has some mobility problems. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 14 The Community has addressed this as best as they can by providing a shower seat to aid the service user when showering and by observing how the service user’s mobility is on a day-to-day basis. If it is not so good all is done to ensure that the service user’s needs are met in a sensitive manner i.e. the service user’s medications are taken to them rather than the service user going to the office to get them. Also if any service user is having a difficult period, staff will work intensely with the service user to help them over this period. The staff consult with all of the service users to ensure that all of their different dietary needs are equally well met and understood. Each service user has an in-put into the daily meals provided and shopping for the meals is done on a daily basis with the service users and staff to ensure that that daily variety and choices are upheld. All service users have individual opportunities to eat where and what they wish to and are not dependent on what others have, i.e. there is always choice and all service users are encouraged to take responsibility for providing meals that are agreeable to all. The management and service users recently together worked on a meal plan for the home, which involved having compiling a list of core meals that are acceptable to all service users and if an individual variation is requested then this is also accommodated. A record is kept of what meals are provided and of who has helped in the planning and preparation of the meal. The manager audits this information regularly to ensure that all service users have an equal share in deciding what meals are provided and also to ensure that all service users take some degree of responsibility for the preparation of the meal. This is seen as a needed life skill and is supported and encouraged by all staff The result is that the service users receive a healthy, varied and individually planned diet. A relative confirmed this saying that they had noted the food to be very varied and appetising, and was enjoyed by the service users. On the day of inspection a cold buffet lunch of various cheeses, cold meats, salad etc was provided, as this had been the choice of one of the service users. Both staff and service users ate together in the pleasant communal dining area, which is also the conservatory area for the home. It was pleasing to note that on the day of inspection that one service user was fully enabled to eat separately as they felt more comfortable with this, on this occasion. Service users’ family links continue to be supported by the staff at the home and the service users’ families visit or contact the home as far as the service user wishes. For instance one service user had recently been skiing with their family. A family member confirmed that they were always made welcome when visiting and offered a meal and drinks. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 15 Holidays are also provided with Community paying for a holiday provided by the Community. Some service users also take additional holidays that they then fund themselves. Comments from the service users included the following about how they felt about living at the home: The staff have encouraged me to get up in the morning, as before I just didn’t want to and do things with my life, they have helped me” “This is the best place I have ever been to, I can do ordinary day to day things. The manager is good as well”. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 16 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): Standards 18,19 and 20. Quality in this outcome area is excellent. Staff provide sensitive and flexible personal support and care to maximise the clients’ rights to privacy, dignity, independence and choice over their own life. Staff have a good awareness regarding the clients’ health and emotional needs which allows them to understand the clients’ illnesses and help the service users to build up their feelings of self worth and esteem. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care provided continues to be tailored to each individual service users’ needs. Service users’ written records contained full details of all care provided. They are encouraged and supported to manage their own health care and take personal responsibility for their own welfare as far as they are able. The home uses a recognised medication administration system and all records inspected were in order, including those where medications were not held in the blister system, and for various storage reasons are kept in original packets etc. The medicine cabinet is secured to the wall and each service user has a 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 17 separate drawer, which not only contained all medications appertaining to each service user but individual medical information regarding to each service user. The home is not holding any controlled drugs at present but has the required recording systems in place if this was necessary. Experienced, trained staff undertake the administration of medication and there are appropriate medication policies and procedures in place. During the inspection the administration of medication was seen and noted to be in order being undertaken professionally, sensitively and knowledgably by an experienced member of staff. Each service user goes to the office, where the medicine cabinet is sited, to receive their medication individually to further reduce the risk of any error. The service user seen taking their medication was well aware of what was prescribed and what effect the medication had. Other professionals are also involved with service users as required; including a psychiatric consultant employed by the Community who sees service users regularly and when there are any concerns. Other specialists involved with the service users include local G.P’s, dentists and specialist nurses. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. There is a satisfactory complaints procedure and arrangements for protecting service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an appropriate complaints procedure, which is available within every service user’s own personal file to which they have regular access. The home also has policies and procedures for adult protection, in line with the local multi-agency code of practice. Any incidents of any untoward nature are fully documented and, when necessary any incident reported forwarded to the Commission to keep the Commission informed. General day to day risk assessments are in place and no regular form of restraint is used within the home, although the manager is trained in the use of any necessary physical intervention/restraint, which ensures should staff have to use such practices they are conducted appropriately. The home does not routinely manage service users’ monies, but will help any service user who may need support with managing money (currently only one client is taking advantage of this facility). Details of any monies managed for individual service users are kept at the Community’s head office, however on the day of inspection it was noted that one service user was waiting for, and promptly received, some of their monies for personal expenditure. All these measures continue to protect clients at the home. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 19 No complaints have been received by the home itself or through the Commission, within the last twelve months. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is adequate. The home is comfortable, clean, and mostly well maintained. It was warm, clean and hygienic and was not institutional in appearance in any aspect. Clients’ bedrooms had been personalised as clients wished. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the home confirmed that some upgrading continues to take place with the provision of a new shower seat for one service user to aid the service users when showering and the provision of new shelving in service users’ bedrooms and in the lounge. The home’s fire logbook was inspected and it was noted that the fire precautions in the home were maintained appropriately. Although all staff receive fire training as part of their initial programme, which was documented, it was not possible to confirm that they then subsequently received fire training updates on a regular basis as per the local fire and rescue service’s recommendations (six monthly for day staff). 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 21 The manager of the home has recently completed a fire wardens course which she, along with the Community’s health and safety officer, will use to ensure that the home and the Community homes generally are aware of the new fire legislation that has recently been come into practice. A first aid box was available and the manager has recently completed a fourday course on “First Aid at work”. The home was noted as clean and hygienic. Both staff and service users take responsibility for the cleaning of the premises, with a cleaning rota being in operation. One service user was very clear about their responsibility for maintaining a pleasant environment, It was also noted that the way that one service user wished to keep their bedroom had been tolerated, as insisting on changing the environment may cause the service user to be unsettled. The manager stated that the hot temperatures within the home had been regulated to a safe temperature and continued to be risk assessed. To provide further protection all the water temperatures are checked on the change of each shift. The Community employs two maintenance men who will deal with any general maintenance matters that arise on a rolling programme but are immediately available for any emergency. Overall the home was clean, comfortable and provided a homely, warm environment, with little touches such as a music centre, videos and games. A bowl of fruit was available for all service users within the conservatory. The lounge was comfortable with modern furnishings. A large modern television and video player was available. All bedroom doors have a lock to enhance a client’s right to privacy, should this be required. All bedrooms were noted as being very individualised and very much as the service users wanted. The home’s laundry area is equipped with adequate washing facilities and clients have open access to this area, with it being the expectation that service users undertake their own washing as required (with support provided as required). The home’s kitchen is a domestic kitchen and inspection of food stores evidenced that there was plenty of healthy interesting foods available. Service users are welcomed and encouraged in all areas of the home. The home’s garden, off the conservatory, is very pleasant and clients can take advantage of it whenever they wish to. Tables and chairs are also provided in the garden. Necessary infection control practices were in place and there was an adequate provision of anti-bac hand wash at the sinks, whilst disposable gloves and aprons were also easily available. Any clinical waste is disposed of in an agreed manner, using the clinical waste facility of the adjacent home. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 22 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 23 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): Standards 32,34,35 and 36. Quality in this outcome area is good. Clients are well supported by an appropriately experienced staff group. It was not possible to confirm that all staff working at the home had undergone a robust recruitment procedure, which ensures that the clients are fully protected, as not all staff records were available within the home. There are sufficient designated staff on duty to meet the clients’ agreed needs at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were maintained in sufficient numbers to ensure that the service users’ needs could be met at all times. The care staff employed within the Community work a very specific rota, which involves care staff being on duty for a forty-eight hour period, which includes a sleep-in, with a two-hour rest period off. Although staff stated that the length of shift could be tiring they also said it provided consistency and that the two hour rest break refreshed them and the staff were noted as being very able to cope with the demands of their role, given such a long shift time. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 24 Staff also rotates around each of the Community’s houses, which gives all staff an awareness of what care each service user within the individual Community homes needs. Usually a staff member will remain at one house for a period of six months. Even though staff rotate most have worked for the Community for some time and are known to the service users. Also when short staffed due to annual leave etc, staff from other homes are brought in to help. This allows for a degree of consistency within the Community homes generally. Staff were noted as interacting very positively with the clients. Comments received from one service user in written feedback stated: “The whole staff are great with a capital G”. Induction training is provided with the management of the home ensuring new staff members go through an in-depth induction training programme, which ensures that they are fully aware of the expectations of their role and prepared to be able to deliver the required care. It involves an intensive two-week induction programme before commencing duties, which includes health and safety subjects as well as an introduction to mental health issues and adult protection. There is a further induction to individual homes. The Community has recently won a regional award for the delivery of its induction course. This ensures that any new staff are able to both understand and work well with service users suffering with mental health problems. Other regular statutory training is also regularly provided. The managers of all the Community’s homes are provided with a monthly half days training from the Community’s consultant psychiatrist. Training plans are managed centrally by the Community and recent training has included such topics as fire training, physical intervention and medication training. This level of training helps ensure that staff are aware of their role and how to meet the needs of the service users they provide care for. The manager of the home is also the Community’s physical intervention tutor and uses her skills to train other staff within the Community in the appropriate use of any physical intervention or restraint. From information seen, during the inspection, it was clear that the staff having had this knowledge had proved invaluable in dealing with a specific service user at the home who had recently been in a distressed state and had required some form of physical intervention. However, the home does not have the required number of trained staff (to a recognised national level), but there are plans to address this shortfall and staff do receive a wide variety of other relevant training both from within the organisation and from external training providers. Excellent feedback was received from service users in respect of the staff with all service users feeling the staff were supportive, available and understanding. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 25 The manager of the home provides regular staff supervision, however this needed to be documented in some instances. Where recording had taken place, it was noted that the supervision covered all required areas and ensured that the manager had reviewed whether all staff were comfortable within their role and what additional support and training could be made available to enable the staff to be able to offer the most suitable care to the clients. Since the last inspection the home has employed one new member of staff (who was spoken with during the inspection). They were able to confirm that their recruitment process had been thorough and that they had been/were being supported in their role. The staff member stated how much she enjoyed her job. She also stated that she felt the service users were well cared for and that the staff understood them well. Some staff recruitment records were available for inspection, in respect of this new staff member, and indeed other staff members, but they were not fully complete. This is because the full records are held at the Community’s head office rather than within the home and although not available in the home, there is an agreement for with the Commission that they can be brought there on request. In respect of the newly appointed staff member it was noted that there was one written reference. The head office was able to confirm that as second one had been obtained verbally, but this had not been recorded. The staff member was spoken with and did confirm that they had been through a rigorous recruitment process including filling in an application form, providing two references, agreeing to the Community obtaining an enhanced Criminal Record Bureau disclosure as well as attending a formal interview, which was conducted by senior management. Although the community does undertake Criminal Record Checks for new staff, the manager is only provided with the reference number and so the actual check, for the newly appointed staff member was not inspected at the inspection. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 26 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): Standards 37,39 and 42. Quality in this outcome area is good. The home is managed efficiently and well. Management and staff endeavour to ensure that the home is run in the best interests of the service users. The home provides a safe, secure environment where service users’ safety and well-being is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to be managed in such a way that service users’ needs are known and met by a supported and well informed staff group. The management of the home helps create a welcoming, open and positive place to stay and work. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 27 Service users were seen to be relaxed with the management and staff and there was very positive feedback from both staff and service users about the way the manager is both supportive and approachable. The registered manager has worked at the home for approximately two years. She also manages an adjacent home but is supported in this home by a deputy manager at the home. She holds NVQ level 4 in care and the Registered Managers Award. She also periodically updates her knowledge and skills base, which ensures that she is aware of current practice and which she can then pass on to staff at the home and within the Community generally ensuring that staff in turn are able to provide the best care to the service users. Additional management training is due to be provided for all mangers within the Community this month. An informal quality assurance system is currently in place, which includes regular visits to the home by senior management (record of visits seen), regular staff meetings, regular and daily discussions with the service users. The community is now commencing a more formal quality assurance system which will involve obtaining the views of all people who may have some access to the service be they service users, relatives, other professionals etc. It is envisaged that, by obtaining their views in a formal manner as to how they feel the home operates and whether they feel it provides good quality care, feedback can be obtained which will enable the Community to identify any shortcomings and further build on their strengths. With regard to health and safety the manager maintains necessary risk assessments in respect of health and safety issues within the home. The home’s accident/incident recording was in order as was routine health and safety documetation seen. The home’s policies are available for all staff who sign to state they have read them. Most records seen were being maintained in relation to the requirements of the Data protection Act 1998 and were noted as being up to date, concise and professionally maintained. However there is a need to discontinue the use of collective reporting in the staffs’ shift “hand over” sheets. This is because this practice would hinder a service user’s rights to being able to have access to information held about them at the home, as this particular information also currently contains information about all the three service users on the same page, which would therefore not be appropriate to be viewed by any of the service users. 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 28 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 29 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 2 33 x 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 x 3 x x 3 x 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 30 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. 1 2 3 Refer to Standard YA24 YA34 YA32 Good Practice Recommendations The community should ensure that fire training given to staff is in accordance with the recommendations of the local fire and rescue service. Any verbal reference obtained, in relation a newly recruited member of staff, should be recorded. The community should continue to ensure that there is the required fifty percent of trained staff working at the home, who have achieved a recognised National qualification in care. The manager should document the supervision given to staff. All recording, appertaining to service users, should be undertaken in an individual manner. 4 5 YA36 YA37 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 5 Priory Drive DS0000003633.V324626.R01.S.doc Version 5.2 Page 32 - 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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