Inspection on 12/07/04 for 5 Seafield Road

Care Homes For Adults (18 ­ 65)5 Seafield RoadSeaton Devon EX12 2QSAnnounced Inspection12th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 5 Seafield Road Address 5 Seafield Road, Seaton, Devon, EX12 2QS Email address Tel No: 01297 22423 Fax No: 01297 24641Name of registered provider(s)/company (if applicable) Sense Name of registered manager (if applicable) Mr Philip John Welsford Type of registration Care Home No. of places registered (if applicable) 6Category(ies) of registration, with (number of places) Learning disability (6), Physical disability (6), Sensory impairment (6) Registration number D060000506 Date first registeredDate of latest registration certificate 20th December 2002Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionyes NO 29/01/04 If Yes refer to Part C5 Seafield RoadPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 312th July 2004 09:20 am Belinda HeginworthID Code097628Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr Philip Welsford5 Seafield RoadPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers Agreement5 Seafield RoadPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of 5 Seafield Road. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.5 Seafield RoadPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 5 Seafield Road is a converted terraced property close to the centre of Seaton. Bedroom accommodation for service users is on the ground and first floors with one bedroom on the second floor. Also on the second floor there is a sensory room and the office. The home cares for service users with significant sensory impairment who may also have a learning disability, challenging behaviour and/or a physical disability. Considerable attention has been paid to design features to assist service users to maximise their independence. The home has two ground floor bedrooms that are suitable for wheelchair users. However, the home does not have a lift and therefore the first floor rooms are unsuitable for anyone with mobility difficulties. Wheelchair users cannot access the sensory room or the activities room, although these facilities are available at Providence Court in Exeter where service users can attend day care sessions. There is a ramp to the dining room to enable wheelchair users easy access to this room, but there are two steps down into the kitchen that cannot be ramped, and therefore wheelchair users can only access this room via an outside ramp. To the front of the property there is a small garden area and to the rear there is a pleasant, paved patio area and a sensory garden with raised flowerbeds and swing bench.5 Seafield RoadPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The service users living at the home have severe learning disabilities and sensory impairments. On the day of the announced inspection there were 6 service users living at the home. The inspector saw all of the service users but was unable to communicate fully with them, due to their extremely limited communication and understanding of the inspection process. The manager was able to interpret on one occasion, through sign language, which enabled the inspector to briefly speak to one service user. The inspection was completed over 5 hours. The manager Philip Welsford was present throughout the inspection. The evidence throughout the inspection was gathered through talking with staff, management, observations made, the pre-inspection questionnaire and the reading of documentation. The atmosphere in the home was very relaxed, welcoming and friendly, and the service users appeared to be very content, relaxed and happy. The administrative work and the care provided in the home are of a very high standard. The staff team are caring and highly motivated. The staff and manager were very helpful of the day of the inspection and a lot of positive discussions, advice and suggestions took place throughout the inspection. The home has a minimum of two inspections per year, one announced and one unannounced. Not all of the standards were inspected on this occasion, or not all were inspected fully. Over the inspection year (April 2004 to April 2005), those standards not inspected during one visit will be looked at during the second inspection, therefore both reports would be needed to have all of the information about the home. Three requirements and seven recommendations were made during this inspection. Two recommendations were carried forward from the last inspection. One of these was partly met but additional information was necessary to meet the standard fully. Listed below is a summary under each section of the standards, of what was found during the inspection.5 Seafield RoadPage 6 Choice of Home (Standards 1-5) The five standards in this section were inspected. Four standards were met fully. The home has a Statement of Purpose and Service User Guide that provide good information about the services and facilities that the home offers. The home carries out good assessments with service users prior to admission that covers all areas of need. It was clear through inspecting service user files and observations made throughout the inspection that the home fully meets the needs of the current service user group. No service user contracts were available for inspection. The inspector was told that Sense is trying to obtain these from each placing authority. Service users have a statement of Terms and Conditions of living at the home. This document provides good information about the homes facilities and services, including fees. However, it does not state the arrangements for transport, the costs and agreements necessary. Individual Needs and Choices (Standards 6-10) Four out of the five standards in this section were inspected. Two standards were met fully. The home has detailed care plans with goals / targets, and actions on how to achieve them. The care plans include detailed information about service users likes, dislikes and guidelines, to enable carers to support service users in all kinds of situations. The targets are reviewed regularly and the home holds annual reviews with the care manager, relatives and service users where appropriate. The home uses monitoring devices at night, in the bedrooms of two service users. This is because of medical conditions that require careful monitoring. Parents and Care Managers have been consulted about their use and have agreed to the home using them. The home has a detailed protocol for staff to follow when using the monitoring devices. However on the day of the inspection a monitoring device was being used in the day- time for another service user. Discussions took place about alternative devices that could be more appropriate to use and would maintain service users privacy. The manager agreed to look into this and agreed to discuss and review the protocol with staff. The current service users living at the home have severe learning disabilities and sensory impairments. Decisions about their lives are based on the staffs knowledge and understanding of the service user. Relatives and care managers are also involved in some of the decision-making processes. The front door of the home is always kept locked; service users are unable to manage a key. The door from the dining area into the kitchen is a stable door. The bottom half is kept locked. The inspector was told that this is due to potential hazards for service users. It was 5 Seafield Road Page 7 recommended during the last inspection that this be added to the statement of purpose and service users care plans where appropriate. The manager has added this to the Statement of Purpose and Service User Guide, but not to the care plans. The manager agreed to ensure this work is completed. Due to the communication difficulties and a limited understanding of the current service users, consulting and including service users in all aspects of life at the home, is extremely limiting. The home works hard to offer service users the opportunity to be involved in their own reviews but this is rarely taken up. The home has detailed risk assessments for each service user. They are generated from individual care plans and cover all areas of need, and include all environmental factors. Lifestyle (Standards 11-17) Six out of the seven standards in this section were inspected and were found to meet the standards fully. The home works hard to encourage and support service users in gaining independent living skills and communication methods. The service users, with the support of the staff, use the local facilities. The inspector was told about shopping trips, outings to the pub and cinema, and the regular use of the local library. The home is very near to the town centre. Service users are supported by staff when walking to the town. The home has a mini bus and a people carrier for trips further a field. The inspector was told that all of the current service users have a minimum of seven days holiday per year. The holidays are normally taken over two shorter periods rather than one seven day holiday. This is due to the needs of the service users. Each service user has a holiday allowance of £300 built into their basic contract price. The inspector was told that Sense provides staff to attend holidays but only for three and a half days. The manager has enough money and flexibility within his budget to provide the staff for the other days. Service users contribute towards their holiday if the amount exceeds the £300. The home maintains contact with relatives on a regular basis, through meetings, care plan reviews, telephone and e-mail. Personal and Healthcare Support (Standards 18-21) The four standards in this section were inspected and were found to meet the standards fully. The home has an intimate care policy that pays particular attention to maintaining service users privacy and dignity. This was not inspected on this occasion. The pre-inspection questionnaire provided the evidence that the policy has not changed. The inspector was told that times for getting up and going to bed are flexible. Most activities 5 Seafield Road Page 8 start mid-morning to enable service users to get up at a leisurely pace. Service users preferences in relation to how they are moved, guided and transferred are obtained through staff observation and knowledge. An assessment is completed with guidelines for staff to follow. All the current service users are registered with the same G.P.; the Manager advised that they could see any doctor in the practice. Medication is reviewed annually by the G.P and consulting psychiatrist. Medication records were found to be accurate. Medication was stored securely. Concerns, Complaints and Protection (Standards 22-23) The two standards in this section were inspected. One standard was met fully. The complaints policy had all of the information necessary to meet this standard. A Sense Adult Protection policy is in place, which includes the DOH guidance on `No Secrets. Staff have received training in abuse awareness. There is a staff `whistle blowing policy and care staff were able to confirm to the inspector that they understood the policy. Good financial procedures are in place with evidence of receipts obtained and 2 staff signatures for all transactions. Daily checks are completed on service users monies. The inspector found that the monies balanced with the records. Senses regional financial officer is appointee for all of the service users. Benefits for all but one service user, are paid into individual, named bank accounts where three staff are the signatures that operate the accounts. The records of all transactions were clear and accurate. The inspector was told that the home has been unable to open a bank account for one service user. The benefit books are kept at the main Sense office. The appointee cashes them each week. From this, the fees are paid and the remaining monies are kept at Sense but are available to the home during office hours. The inspector was unable to audit this account because no records were kept in the home, of the money held by Sense. Issues relating to the amount of cash held by Sense, on behalf of the service user were discussed. For example, the loss of interest by not being in a bank account, the amount of cash that must accumulate and so on. The manager agreed to discuss these issues with Sense and the bank, and make accounts available for inspection. The home has two vehicles to transport service users. Until recently service users were not charged for this service. Sense now charges approximately £98 to each service user. This money comes from service users disability living allowance. Relatives and care managers were consulted about the charges and agreements were reached. The inspector was told that in the past the fees included a contribution towards transport costs. This was unable to be inspected as no contracts were in the home (See standard 5). 5 Seafield Road Page 9 The home should compile a policy that provides the following details ­ · What is included in the charge. · An auditable breakdown of the costs of running the vehicle. · How the use of the transport will be monitored to ensure there is equitable use. · How often charges will be reviewed. · There should be an option to opt out of the system, and information should be provided about other forms of transport. · It should be clear how the home would manage financially if a service user leaves the scheme, e.g., would the other service users in the home be expected to pay additional costs until a new service user joins the scheme, or would the home have a contingency plan? · The management of rotas to ensure the availability of drivers. · The homes procedure for reviewing the drivers status. Environment (Standards 24-30) The seven standards in this section were inspected. Five standards were met fully. The home is decorated brightly and in a homely fashion. There is a warm friendly atmosphere throughout. There are rails throughout the home to aid service users with visionary impairments to find their way around. All bedrooms are fitted with flashing lights with switches fitted on the outside to ensure service users with sensory impairments maintain their privacy. There was a beautiful tactile picture in the lounge, which had been made by a local lady. There are call buttons on each level of the house and in the bathrooms, in case of an emergency. The home has double-glazed windows that include opening restrictors. On the day of the inspection a pane of glass to the back door had a crack. Plastic sheeting had been put on it to protect service users from cutting themselves. This must be replaced as soon as possible, to prevent injury from the pane breaking further or falling out. All rooms are individual in style and decor and are equipped to meet service users needs. A sink in one of the bedrooms had no taps in place. This was to prevent the service user from flooding the room. There was no evidence in the care plan or risk assessment that this had been agreed within a multi-disciplinary setting. The manager agreed that the use of push type taps might be more appropriate. He agreed to look into this. Some service users are able to lock their door from the inside with an emergency override system that prevents service users from being locked in. Some service users bedrooms were locked with the key by the side of the door. The inspector was told that this was to prevent another service user from entering the rooms. The service users of these bedrooms are unable to access their rooms without the support 5 Seafield Road Page 10 of staff. Discussions took place about alternative locking devices that meet the needs of particular service users but can prevent other service users from entering. The inspector provided contact details of services that might be able to help. All rooms have en suite facilities and there are two communal bathrooms. There is bedroom with an adequately adapted en suite shower but no en suite or communal bathing facilities for the physically disabled. This has been explored at length but due to the size and shape of the property there have been no solutions found. It was felt that the needs of the current physically disabled service users were being met and were happy with the situation. There is a good level of adaptation and equipment for people with sensory impairment. However, there is less provision for the physically disabled. There is no lift, no lowered light switches or work surfaces, no disabled bath, and two steps down into the kitchen. There is no separate storage for equipment, what is used is kept in service users rooms. The inspector was told during the last inspection that, at the moment the physically disabled service users and families are happy with the services provided in the home. The inspector was told during the last inspection that the home was looking into making some adaptations in the kitchen, such as a lowered sink and a covered walkway from the ramped area to the kitchen. No changes have been made yet. Staffing (Standards 31-36) The six standards in this section were inspected. Five standards were met fully. Sense provides good training opportunities for staff that enables them to gain the specialist skills necessary to meet the needs of the current service users. Eight staff, including the Manager and Deputy Manager are in the process of NVQ training and the home is well on target to meet the 50 trained staff standard by 2005. Staff were observed to be patient and caring towards service users and it was clear that the service users had good relationships with them. The staffing levels at the home are very good. In the mornings one to one staff enable service users to go out on individual activities. These activities are set up by carers employed to co-ordinate them. The afternoons and evenings have 3 to 4 staff on duty and 1 waking and 1 sleep in at night. It was clear that the home and Sense operates a thorough recruitment procedure. SENSE has a formal induction programme. Training needs are identified through supervision and all staff receive a minimum of five days paid training per year. Specialist training is obtained as necessary. Sense provides training that benefits service users and meet their needs. It was highlighted during the last inspection that the home should work towards the Learning 5 Seafield Road Page 11 Disability Award Framework (LDAF). The inspector was told during other inspections that Sense are currently researching and developing a similar framework that specifically targets staff working with people who have sensory impairments, as they felt it is more appropriate for their organisation. However, during this inspection, the inspector was told that Sense is applying to become accredited by City and Guilds to enable them to offer the LDAF award. Following accreditation they intend to put staff through the LDAF induction and foundation units by incorporating this training into the current induction programme. The recommendation to work towards using the LDAF award therefore remains. Staff have formal one to one supervision every six weeks covering topics set out in this standard. Staff also receive an annual development appraisals. In addition there are regular meetings in relation to meeting the service users needs. Conduct and Management of the Home (Standards 37-43) Six out of the seven standards in this section were inspected. Four standards were met fully. The Manager has many years of experiences working in care homes. He is currently undertaking NVQ Level 4 in Care and the Registered Managers Award. He is also an NVQ Assessor (D32/33). The staff confirmed to the inspector that the manager gives a clear sense of direction and leadership. The staff spoke highly of his style of management, which is open and transparent and gives a positive and inclusive atmosphere. Most of the homes policies are produced by Sense; therefore care staff do not get involved in their development. Sense should consider how staff could become involved in the development of policies and procedures. The homes records are kept in a secure setting and are maintained in accordance with the Data Protection Act 1998. The fire logbook, fire safety training and fire equipment checks were found to be accurate and up to date. Fire risk assessments were in place, however, some of these risk assessments should have more details and information relating to minimising the risk of fire.5 Seafield RoadPage 12 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard The home should record instances when decisions are made by others and why. 1 Ya7 Limitations on facilities, choice or human rights to prevent self-harm, or abuse or harm to others, should be made in the persons best interest, and be recorded in individual files. (Partly met) 2 Ya35 Staff working in Learning Disability services should use the Learning Disability Award Framework (LDAF) accredited training to provide underpinning knowledge for progress towards achieving NVQs.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)5 Seafield RoadPage 13 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action Service users must have a contract in place that sets out the provision of services and facilities by the registered person to the service user. 1 5 (1) (c ) (3) YA5 Where a local authority has made 31/08/04 arrangements for the provision of accommodation to the service user at the care home, the registered person must supply a copy of the agreement, to the service user, specifying the arrangements made. The home must have a record of all money deposited by service users for safekeeping or received on the service users behalf. These records must be available for inspection at all times. Unnecessary risk to the health or safety of service users are identified and so far as possible eliminated. YA24 The premises must be kept in a good state of repair. (This relates to the cracked glass panel on the back door) 13/08/04217 (2) (3) (a) (b) (4) Schedule 4 (9) (a &b)YA2331/08/04323 (2) (b) (c ) 13 (4) (c )5 Seafield RoadPage 14 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * Any restrictions on choice and freedom should be discussed and agreed with service users. Where this is not possible a multi-disciplinary approach should be taken and the outcome recorded in care plans and where appropriate the risk assessments. There should be evidence of regular reviews and alternative systems being tried. (This relates to the use of monitoring devices). The home should record instances when decisions are made by others and why. 2 YA7 Limitations on facilities, choice or human rights to prevent self-harm, or abuse or harm to others, should be made in the persons best interest, and be recorded in individual files. (This relates to the locking of the front and kitchen door and the use of monitoring devices) 3 YA23 The home should compile a transport policy that includes the information listed in the narrative of standard 23. Service users bedrooms should have fittings that are suitable to meet individual needs and lifestyles. (This relates to the sink taps in one bedroom, see narrative in standard 26) Staff working in Learning Disability services should use the Learning Disability Award Framework (LDAF) accredited training to provide underpinning knowledge for progress towards achieving NVQs. Staff should be fully involved in developing policies and procedures and wherever possible, service users should help in their formulation. The home should expand the fire risk assessments to ensure that any identified hazards have clear action on how to minimise risks.1YA64YA265YA356 7YA40 YA42* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.5 Seafield RoadPage 15 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO NO NO YES NO YES YES YES YES NO NO NO YES NO YES 1 X X NO YES YES YES 19 X 12/07/04 09.20 5.205 Seafield RoadPage 16 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.5 Seafield RoadPage 17 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 1400 2000 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Transport 3 Key findings/Evidence Standard met? The statement of purpose included all of the information required under schedule 1 of the care home regulations. The service users guide was set out clearly and included the information required in number 5 of the care home regulations and standard 1.2 of the minimum standards. The service users guide is also available in a video format. There home charges extra for the use of transport. (See standard 5 and 23)5 Seafield RoadPage 18 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The home carries out good assessments that cover all areas of need. Sense has a referral system that includes writing to the service user to confirm that the home can meet their needs. Care plans are generated from the assessments. Staff from the home visit prospective service users to complete the assessment. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? It was clear through inspecting service user files and observations made throughout the inspection that the home fully meets the needs of the current service users. Sense provides a good training programme that ensures the staff team have the skills and competencies to deliver quality care that meets the needs of individual service users.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The home has had no new admissions for a number of years. The homes practice is to have trial visits before coming to stay at the home, and a threemonth settling in period before a long-term placement would be offered. The Statement of Purpose and the terms and conditions of living at the home, provides information about the admission procedures.5 Seafield RoadPage 19 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? No service user contracts were available for inspection. The inspector was told that Sense is trying to obtain these from each placing authority. Service users have a statement of Terms and Conditions of living at the home. This document provides good information about the homes facilities and services, including fees. However, it does not state the arrangements for transport, the costs and agreements necessary. (See standard 23) Relatives and care managers are involved in supporting service users in the drawing up and finalising the Terms and Conditions.5 Seafield RoadPage 20 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? The home has detailed care plans with goals / targets, and actions on how to achieve them. The care plans include detailed information about service users likes, dislikes and guidelines, to enable carers to support service users in all kinds of situations. The targets are reviewed regularly and the home holds annual reviews with the care manager, relatives and service users where appropriate. The home keeps a record of all communications between the home and relatives. The home uses monitoring devices at night, in the bedrooms of two service users. This is because of medical conditions that require careful monitoring. Parents and Care Managers have been consulted about their use and have agreed to the home using them. The home has a detailed protocol for staff to follow when using the monitoring devices. However on the day of the inspection a monitoring device was being used in the day- time for another service user. Discussions took place about alternative devices that could be more appropriate to use and would maintain service users privacy. The manager agreed to look into this and agreed to discuss and review the protocol with staff. Risk assessments cover all areas of need and any environmental risks. The home identifies areas of risks within the care plan and highlights what risk assessment care staff should read in relation to that area of care. The care plans are also cross-referenced with guidelines.5 Seafield RoadPage 21 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 2 Key findings/Evidence Standard met? The current service users living at the home have severe learning disabilities and sensory impairments. Decisions are based on the staffs knowledge and understanding of the service user. Relatives and care managers are also involved in some of the decision-making processes. Areas that may present a hazard to a service user are assessed and action is taken to minimise the risk. The front door of the home is always kept locked; service users are unable to manage a key. The door from the dining area into the kitchen is a stable door. The bottom half is kept locked. The inspector was told that this is due to potential hazards for service users. It was recommended during the last inspection that this be added to the statement of purpose and service users care plans where appropriate. The manager has added this to the Statement of Purpose and Service User Guide, but not to the care plans. The manager agreed to ensure this work is completed. Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Due to the communication difficulties and a limited understanding of the current service users, consulting and including service users in all aspects of life at the home, is extremely limiting. The home works hard to offer service users the opportunity to be involved in their own reviews but this is rarely taken up. The home holds regular relative meetings where the home provides details of all aspects of the home, any developments and any changes. Annual satisfaction audits are sent to relatives as part of the homes quality assurance systems. These were not inspected on this occasion. Quality Assurance will be looked at in depth during the unannounced inspection.5 Seafield RoadPage 22 Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? The home has detailed risk assessments for each service user. They are generated from individual care plans and cover all areas of need, and include all environmental factors. The risk assessments were signed by the manager and included review dates. The use of monitoring devices was discussed in Standard 6. Risk assessments relating to this issue is being addressed. The home has a missing person policy. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not inspected.5 Seafield RoadPage 23 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The home works hard to encourage and support service users in gaining independent living skills and communication methods. Each service user has a target sheet, which includes detailed stages of instructions for staff to follow when supporting service users in these skills. Staff sign each stage, to say if it has been achieved or not. This information is collated monthly and actioned as necessary. Spiritual needs are met when appropriate. The information about each persons spiritual needs is obtained from relatives. The inspector was told during previous inspection that currently the home has no service users with a spiritual need. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? There are no service users living at the home who have a job. The home works hard to provide educational programmes to suit each service users need, through setting targets.5 Seafield RoadPage 24 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The service users, with the support of the staff, use the local facilities. The inspector was told about shopping trips, outings to the pub and cinema, and the regular use of the local library. The home is very near to the town centre. Service users are supported by staff when walking to the town. The home has a mini bus and a people carrier for trips further a field. (See standard 23) The home has a flexible work pattern that includes weekends and evenings. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Each service user attends a variety of social and recreational activities, and their individual interests are supported by staff. Timetables are in each persons service plan. The inspector was told that all of the current service users have a minimum of seven days holiday per year. The holidays are normally taken over two shorter periods rather than one seven day holiday. This is due to the needs of the service users. Each service user has a holiday allowance of £300 built into their basic contract price. The inspector was told that Sense provides staff to attend holidays but only for three and a half days. The manager has enough money and flexibility within his budget to provide the staff for the other days. Service users contribute towards their holiday if the amount exceeds the £300. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home maintains contact with relatives on a regular basis, through meetings, care plan reviews, telephone and e-mail. Most of the service users have regular contact with their relatives. Visits can take place in the privacy of the service users bedroom, or in a number of private rooms throughout the home.5 Seafield RoadPage 25 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users have flashing light doorbells for people to use before entering bedrooms. Some service users are able to lock their door from the inside with an emergency override system that prevents service users from being locked in. Some service users bedrooms were locked with the key by the side of the door. The inspector was told that this was to prevent another service user from entering the rooms. The service users of these bedrooms are unable to access their rooms without the support of staff. Discussions took place about alternative locking devices that meet the needs of particular service users but can prevent other service users from entering. The inspector provided contact details of services that might be able to help. The current service users would be unable to manage a key to front door. Service users preferred form of address is recorded in individual care plans. Some areas of the home are restricted due to risk assessments (See standard 7). Service users are encouraged wherever possible, and with support, to participate in household chores. During the inspection staff were seen to be interacting with service users. The atmosphere was very relaxing and caring. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected.5 Seafield RoadPage 26 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The home has an intimate care policy that pays particular attention to maintaining service users privacy and dignity. This was not inspected on this occasion. The pre-inspection questionnaire provided the evidence that the policy has not changed. The inspector was told that times for getting up and going to bed are flexible. Most activities start mid-morning to enable service users to get up at a leisurely pace. Service users preferences in relation to how they are moved, guided and transferred are obtained through staff observation and knowledge. An assessment is completed with guidelines for staff to follow. Some target sheets within service user care plans indicated that service users wherever possible are able to choose what clothes to wear each day. Each service user has a designated key worker who co-ordinates all aspects of their care. Service user records provide detailed information in relation to preferred routines, likes, dislikes and so on.5 Seafield RoadPage 27 Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX3 Key findings/Evidence Standard met? All the current service users are registered with the same G.P.; the Manager advised that they could see any doctor in the practice. Medication is reviewed annually by the G.P and consulting psychiatrist. Routine health screening is undertaken. Chiropody, dentist, optician, audiologist appointments are all recorded in individual plans. The continence nursing service is used as necessary.5 Seafield RoadPage 28 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Medication records were found to be accurate. Medication was stored securely. Consent to medication cannot be obtained from service users due to their communication difficulties and limited understanding. The home is in the process of providing recorded evidence that the need for medication has been discussed and agreed with the GP, parents and care manager. Letters from parents were seen during the last inspection. The home has received advice from a pharmacy on the life span of opened, liquid medication. The home now keeps a record of when the medication was opened. The home does not normally have homely remedies; all as necessary (PRN) medication is prescribed by the GP. The home provides clear protocols for staff to follow for the use of each PRN medication. All staff that administer medication receive accredited training and have to complete a comprehensive assessment. A record of all medicines received by the home and returned to the pharmacy are kept and signed by a pharmacist. The homes policy on death of a service user includes retaining medication for a period of seven days in case of a coroners inquest. The pharmacist carries out 6-monthly checks. These were not inspected on this occasion. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? The home is unable to establish service users wishes concerning terminal care and death, due to their disabilities, communication difficulties and limited understanding. The home wrote to the relatives of each service user and obtained their wishes on behalf of the service user. The home monitors all aspects of service users health and would refer to appropriate specialists when necessary.5 Seafield RoadPage 29 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The complaints policy had all of the information necessary to meet this standard. The policy was not inspected on this occasion. The evidence was taken from the pre-inspection questionnaire. Care staff were able to confirm that they understood the complaints procedure. The home deals with any small issues raised by service users, relatives and so on, informally, through discussions, telephone calls and so on. The home holds regular recorded meetings with relatives where they have the opportunity to raise concerns.5 Seafield RoadPage 30 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence YESX Standard met? 25 Seafield RoadPage 31 A Sense Adult Protection policy is in place, which includes the DOH guidance on `No Secrets. Staff have received training in abuse awareness. There is a staff `whistle blowing policy and care staff were able to confirm to the inspector that they understood the policy. Service users care plans are detailed and included risk assessments and guidelines for managing aggression. Good financial procedures are in place with evidence of receipts obtained and 2 staff signatures for all transactions. Daily checks are completed on service users monies. The inspector found that the monies balanced with the records. Senses regional financial officer is appointee for all of the service users. Benefits for all but one service user, are paid into individual, named bank accounts where three staff are the signatures that operate the accounts. The records of all transactions were clear and accurate. The inspector was told that the home has been unable to open a bank account for one service user. The benefit books are kept at the main Sense office. The appointee cashes them each week. From this, the fees are paid and the remaining monies are kept at Sense but are available to the home during office hours. The inspector was unable to audit this account because no records were kept in the home, of the money held by Sense. Issues relating to the amount of cash held by Sense, on behalf of the service user were discussed. For example, the loss of interest by not being in a bank account, the amount of cash that must accumulate and so on. The manager agreed to discuss these issues with Sense and the bank, and make accounts available for inspection. The home has two vehicles to transport service users. Until recently service users were not charged for this service. Sense now charges approximately £98 to each service user. This money comes from service users disability living allowance. Relatives and care managers were consulted about the charges and agreements were reached. The inspector was told that in the past the fees included a contribution towards transport costs. This was unable to be inspected as no contracts were in the home (See standard 5). The home should compile a policy that provides the following details ­ · What is included in the charge. · An auditable breakdown of the costs of running the vehicle. · How the use of the transport will be monitored to ensure there is equitable use. · How often charges will be reviewed. · There should be an option to opt out of the system, and information should be provided about other forms of transport. · It should be clear how the home would manage financially if a service user leaves the scheme, e.g., would the other service users in the home be expected to pay additional costs until a new service user joins the scheme, or would the home have a contingency plan? · The management of rotas to ensure the availability of drivers. · The homes procedure for reviewing the drivers status. · There should be an auditable process. 5 Seafield Road Page 32 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is decorated brightly and in a homely fashion. There is a warm friendly atmosphere throughout. There are rails throughout the home to aid service users with visionary impairments to find their way around. All bedrooms are fitted with flashing lights with switches fitted on the outside to ensure service users with sensory impairments maintain their privacy. There was a beautiful tactile picture in the lounge, which had been made by a local lady. There are call buttons on each level of the house and in the bathrooms, in case of an emergency. The home has double-glazed windows that include opening restrictors. On the day of the inspection a pane of glass to the back door had a crack. Plastic sheeting had been put on it to protect service users from cutting themselves. This must be replaced as soon as possible, to prevent injury from the pane breaking further or falling out.5 Seafield RoadPage 33 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence All bedrooms meet the standard. YES NO NO 6 6 X X Standard met? 3 6 X1 X X X5 Seafield RoadPage 34 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? All rooms are individual in style and decor and are equipped to meet service users needs. A sink in one of the bedrooms had no taps in place. This was to prevent the service user from flooding the room. There was no evidence in the care plan or risk assessment that this had been agreed within a multi-disciplinary setting. The manager agreed that the use of push type taps might be more appropriate. He agreed to look into this. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? All rooms have en suite facilities and there are two communal bathrooms. There is bedroom with an adequately adapted en suite shower but no en suite or communal bathing facilities for the physically disabled. This has been explored at length but due to the size and shape of the property there have been no solutions found. It was felt that the needs of the current physically disabled service users were being met and were happy with the situation. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is a lounge and separate dining room on the ground floor. The home meets the standard for communal space for able-bodied people, but physically disabled can only gain access to the kitchen by coming through to the back entrance of the house where a ramp is provided. The home was considering covering the ramped area to give protection from the rain. This has not been completed yet. On the second floor there is an educational room and a sensory room. The staff sleeping in facilities are also on the second floor. The home provides a room where relatives can sleep and visit their family.5 Seafield RoadPage 35 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? There is a good level of adaptation and equipment for people with sensory impairment. However, there is less provision for the physically disabled. There is no lift, no lowered light switches or work surfaces, no disabled bath, and two steps down into the kitchen. There is no separate storage for equipment, what is used is kept in service users rooms. The inspector was told during the last inspection that, at the moment the physically disabled service users and families are happy with the services provided in the home. The inspector was told during the last inspection that the home was looking into making some adaptations in the kitchen, such as a lowered sink and a covered walkway from the ramped area to the kitchen. No changes have been made yet.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was clean and there were no unpleasant odours at the time of inspection. There is a written infection control policy. The home contracts with Cannon Hygiene to remove waste. The laundry is situated in the back garden and the flooring is impermeable. There is a covered walkway from the kitchen to the laundry area.5 Seafield RoadPage 36 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? All the staff have job descriptions. There were no volunteers at the time of inspection. Staff were observed with service users and were seen to have a good understanding of their needs and a caring and positive rapport with them. Staff spoken with were able to confirm their knowledge of each service user through telling the inspector about individual targets set. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Sense provides good training opportunities for staff that enables them to gain the specialist skills necessary to meet the needs of the current service users. The home is well on target to meet the 50 trained staff standard by 2005. The home has appointed and NVQ assessor. Staff were observed to be patient and caring towards service users and it was clear that the service users had good relationships with them. No one was under the age of eighteen at the time of inspection.5 Seafield RoadPage 37 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? The new staffing tables have not been implemented; the decision as to the adequacy is based on the previous regulating bodys recommended figure and discussions with the manager. The staffing levels at the home are very good. In the mornings one to one staff enable service users to go out on individual activities. These activities are set up by carers employed to co-ordinate them. Clear instructions are given to staff daily on what activity they are going on and with whom. The afternoons and evenings have 3 to 4 staff on duty and 1 waking and 1 sleep in at night.5 Seafield RoadPage 38 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? It was clear that the home and Sense operates a thorough recruitment procedure. Two written references and terms and conditions of employment were seen in staff files. All new staff receive a three-month probationary period. CRB checks have been obtained for all staff. The manager signs to say he has seen the certificates and confirms that they were acceptable. The home also keeps the original certificates for the first year, to enable inspectors to see them during the inspection process. Proof of identity through photographs and birth certificates are obtained. Again, the manager signs to say he has seen them and that they are acceptable. The home also keeps copies of these certificates in the home. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? The Manager holds a training budget. SENSE has a formal induction programme. Training needs are identified through supervision and all staff receive a minimum of five days paid training per year. Specialist training is obtained as necessary. Sense provides training that benefits service users and meet their needs. It was highlighted during the last inspection that the home should work towards the Learning Disability Award Framework (LDAF). The inspector was told during other inspections that Sense are currently researching and developing a similar framework that specifically targets staff working with people who have sensory impairments, as they felt it is more appropriate for their organisation. However, during this inspection, the inspector was told that Sense is applying to become accredited by City and Guilds to enable them to offer the LDAF award. Following accreditation they intend to put staff through the LDAF induction and foundation units by incorporating this training into the current induction programme. The recommendation to work towards using the LDAF award therefore remains.5 Seafield RoadPage 39 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff have formal one to one supervision every six weeks covering topics set out in this standard. Staff also receive an annual devlopment appraisal. In addition there are regualr meetings in relation to meeting the service users needs. The grievance and disciplinary policy and procedure are kept in the policy manual. This was not inspected on this occasion. The pre-inspection questionaire proved evidence that these polices remian unchanged.5 Seafield RoadPage 40 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO3 Key findings/Evidence Standard met? The Manager has many years of experiences working in care homes. He is currently undertaking NVQ Level 4 in Care and the Registered Managers Award. As the manager of the home he has overall responsibilities for the homes budget and ensuring that policies and procedures are implemented. It was clear throughout the inspection process that he is sucessful at achieving this. The registration certificate was displayed on the wall. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The staff confirmed to the inspector that the manager gives a clear sense of direction and leadership. The staff spoke highly of his style of management, which is open and transparent and gives a positive and inclusive atmosphere.5 Seafield RoadPage 41 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Not inspected.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 2 Key findings/Evidence Standard met? The pre-inspection questionnaire has provided the evidence that the necessary policies and procedures are in place to meet this standard. Care staff sign to say that they have read and understood the homes policies and procedures. The inspector spoke with some staff that were able to confirm they had knowledge of the policies, for example, the whistle blowing policy and the complaints procedure. Most of the policies in the home are produced by Sense; therefore care staff do not get involved in their development. Sense should consider how staff could become involved in the development of policies and procedures. The manager does not sign the policies as he has not compiled them, but he does date them and sign to say he has read them and understood them. The disabilities of the service users make involving them in the formulation of policies extremely difficult. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? The homes records are kept in a secure setting and are maintained in accordance with the Data Protection Act 1998. Some service users do not read their files due to their disabilities and communication difficulties. Service users who can use a symbol system to help them understand the days events.5 Seafield RoadPage 42 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The fire logbook, fire safety training and fire equipment checks were found to be accurate and up to date. Fire risk assessments were in place, however, some of these risk assessments should have more details and information relating to minimising the risk of fire. For example the use of flame retardant materials. The records of accidents and incidents were found to be accurate. The home has risk assessments and safety leaflets for the Control of Hazardous substances (COSHH). The evidence for this was taken from the pre-inspection questionnaire. The home has environmental risk assessments. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not inspected.5 Seafield RoadPage 43 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager Date Public reportsBelinda Heginworth Simon Spoerer 17th August 2004Signature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.5 Seafield RoadPage 44 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: 5 Seafield Road Page 45 Amendments to the report were necessaryYESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 16th August 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NO5 Seafield RoadPage 46 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of 5 Seafield Road confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of 5 Seafield Road am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.5 Seafield RoadPage 47 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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