Inspection on 25/11/08 for 51 Chapel Park Road

This inspection was carried out on 25th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

51 Chapel Park Road 04/01/07

51 Chapel Park Road 19/07/05

51 Chapel Park Road 22/02/05

51 Chapel Park Road 12/10/04

51 Chapel Park Road 31/01/02

Similar services:

Thorndene

Insight - Eastchurch

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Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 51 Chapel Park Road 51 Chapel Park Road St Leonards-on-sea East Sussex TN37 6JB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Michele Etherton     Date: 2 5 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: 51 Chapel Park Road 51 Chapel Park Road St Leonards-on-sea East Sussex TN37 6JB 01424201340 Telephone number: Fax number: Email address: Provider web address: sgardhouse.evh@tiscali.co.uk Name of registered provider(s): Name of registered manager (if applicable) East View Housing Management Ltd Type of registration: Number of places registered: care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Residents must be aged between eighteen (18) and sixty-five (65) years on admission. Residents with a learning disability only to be accommodated The maximum number of residents to be accommodated will be four (4) Date of last inspection Brief description of the care home 51 Chapel Park Road is situated in a residential area of St Leonard?s on Sea. It is a short distance from local amenities and shops. The home is owned and run by East View Housing Management Limited (EVH). It is registered for up to 4 adults with learning disabilities. The building is a detached two-storey older style house. It has a reasonably sized garden to the front and side of the property. 4 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: A key inspection of this service has been undertaken, this has taken account of information received about the service and from the service since the last inspection and includes an annual quality assurance assessment completed by the manager to a reasonable standard this tells us most of what we want to know about the service illustrating how it operates on a day to day basis, its compliance with regulations and standards and future plans for service development. Our inspection of this service includes an unannounced site visit to the premises on 25th November 2008 between 9:40 am and 15:40 pm. During our visit we were able to spend time with and speak to all the residents living at the home and also speak with three staff on duty in addition to the manager. Surveys have also been distributed Care Homes for Adults (18-65 years) Page 5 of 32 to residents and staff and their responses have been helpful in inspection planning and compiling this report. We have assessed all key standards during this inspection in addition to any where inspection findings highlighted outcomes in those areas. During our visit were were able to tour the premises in the company of residents viewing communal areas and bedrooms with residents permission, we examined a range of documentation including resident assessment, support plan and risk information, staff recruitment training and supervision records, a training matrix, staff rota, complaints information, and some health and safety records. In arriving at our judgment of the service we have tried to be proportionate in considering history of compliance with regulation and standards and outcomes for residents alongside the overall impact and risks to residents of identified shortfalls. What the care home does well: What has improved since the last inspection? What they could do better: Whilst the service is generally well managed and outcomes for residents are positive, shortfalls exist some of which will impact on residents given time and if not addressed. We have issued requirements that the service ensure that staff recruitment files contain the documentation required under legislation and also good practice so that a thorough recruitment process is implemented consistently. We require that the provider ensures a structured programme of induction in keeping with skills for Care common induction standards is implemented to ensure staff have the necessary Care Homes for Adults (18-65 years) Page 7 of 32 knowledge and skills in the early stages of their employment to support residents appropriately and effectively, we also require the provider to ensure that staff receive statutory training in a timely manner following employment and all staff receive updates as required. We are aware of mitigating factors in the delay of a registered manager application being made to CSCI but now require this to be progressed. We require confirmation from the service that the electrical installation is not overdue servicing and if it is that this is arranged within the timescales given at the end of the report. We have also made a number of good practice recommendations where we consider the current performance of the service can be improved upon, particular areas highlighted are the development of a more accessible terms and conditions document format. That the content of risk information is reviewed, we would like to see the development of medication profiles for individual resident, behaviour guidelines for those residents where staff are managing behaviours as this will improve consistency of support. There is a need for fire alarm testing to be more frequent and for the manager to ensure that all staff participate in a minimum of two fire drills annually, we would recommend the review of the present arrangement for securing the fridge and freezer as this is unsightly and gives a negative perception of residents to visitors, we would also recommend that the provider or manager review Sunday staffing levels to ensure residents routines are not unduly restricted, and we recommend the development and implementation of a system for the quality audit and review of the individual service that takes into consideration the views of its residents and reports on the overall findings annually. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents benefit from an individualized assessment and admission to the service but documentation to support practice and judgments needs improvement. Information is made available to prospective and existing residents but this is not always in a format they understand and this needs to be reviewed. Evidence: No new residents have been admitted to the home since the last inspection, the service has previously been commended on its individualized assessment and admission process but our examination of records pertaining to the last resident admission indicated these to be lacking in the expected level of assessment detail by the service itself and recording of outcomes from trial visits and stays to inform the final decision to admit. This has been discussed with the manager during our visit with suggested improvements that should ensure assessment is undertaken to a consistently comprehensive standard. We noted when examining resident records that they are made aware of what their Care Homes for Adults (18-65 years) Page 10 of 32 Evidence: residential fee includes and what they are expected to pay for in addition to this, there are household rules displayed on the notice board and all residents have a terms and conditions document that makes clear their rights and responsibilities and what they can expect from the service, it is not however provided is a format that is easily understandable for them and those viewed are unsigned, the service itself has already identified a need to develop information into more accessible formats and we would recommend that the terms and conditions document is revised with this in mind, all of the residents have the capacity to understand such information in the right format and should be signing their agreement to the terms and conditions of being a resident. Care Homes for Adults (18-65 years) Page 11 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are actively involved in their support plans which more accurately reflect their preferred daily routines and support. Residents are able to exert control over their lives and make daily decisions for themselves. The current arrangements around risk assessment need review to better safeguard residents and others. Evidence: We looked at support plans for three of the current residents these have been revised into a person centered format that also incorporates picture prompts, the content of plans is more reflective of individual resident preferences around daily routines and how they would like support delivered, residents were able to talk about the things they do for themselves and those areas where they sometimes or always need staff support, plans indicate the service is prompting the development of increasing independence for residents in areas of their day to day lives. Residents indicated through discussion and survey feedback that they make the Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: majority of decisions and choices about their everyday lives and routines except where this may impact on their own health and safety or that of others. After speaking with residents and staff we examined some of the risk assessments in place to safeguard individual residents and others, we found that risk information relating to individual residents is not always kept as one would expect with their files and this can be confusing and subject to oversight, from what we had learned about some of the residents we felt that risk information is not always completed to evidence all risk reduction measures in places, and in some instances some risks had no supporting risk information, we recommend that the service review its existing risk assessment and recording process to ensure it can evidence that risk is assessed in depth and where there are risks e.g self harm, harm to others these are clearly recorded and subject to regular review not only at local level but with funding authority representatives particularly where some restrictions may be necessary to safeguard the resident and others Care Homes for Adults (18-65 years) Page 13 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents lead a full and active lifestyle and are supported to live the life they choose, maintain links with important people in their lives and maintain a healthy lifestyle. Evidence: Residents are supported and encouraged to make use of the local community facilities, have access to day care if they want to and are provided with opportunities to attend further education courses or participate in activities that are in keeping with their own interests and hobbies, they have access to evening clubs and this provides opportunities for them to make contact with a wider circle of friends. Residents we spoke with told us about the contact they have with their families, for the majority this is limited but residents are supported to write letters and cards to family members and to visit from time to time where possible. Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: The service promotes independence of residents and they take an active role in household tasks, the service is also being proactive in providing residents with the means to store safely their own medications and money and to work with staff to develop increasing independence in these areas, all have keys to their rooms, residents we spoke with were happy and confident about showing us around and were happy with their rooms which they had been involved in decorating to their own taste. The manager and staff work with residents to develop a full and interesting lifestyle but recognize that for some residents motivation levels are lower and ultimately the residents choices to participate or not must be respected. The service has been instrumental in promoting and maintaining a healthy eating plan for all residents to support weight loss where obesity has been an issue. Residents are consulted about what they like to eat and menus developed with these preferences in mind, residents are able to make drinks for themselves and some will be able to make snacks for themselves with staff support, food is an issue for some people in the house and has necessitated the locking of food cupboards and fridge/freezers, the impact on those residents who are able to make their own snacks unsupported is minimal and none of the residents we spoke with commented that this was an issue. Support plans make clear individual dietary needs e.g cutting up food to reduce risk of choking, diabetic diet. Care Homes for Adults (18-65 years) Page 15 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical emotional and mental health needs of residents are met Evidence: Staff understand and support appropriately the preferred daily routines of individual residents, systems are in place to ensure that routine and more specialized health care appointments are accessed and each resident has a health plan in place. The service is working with residents to enable increased control over daily medication regimes by residents and eventual part or full self medication where possible, to support this the service has installed individual medication cabinets in resident bedrooms and changed the medication system used to medisure. At present only one resident is prescribed PRN medication and a strategy is in place for its administration, we would recommend that the service develop individual medication profiles for residents to inform staff e.g what the prescribed medications residents take are for, possible side effects, if there are foods that must be avoided, preferred administration times, before or after food, what homely remedies can be taken safely Care Homes for Adults (18-65 years) Page 16 of 32 Care Homes for Adults (18-65 years) Page 17 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel listened to and are provided with opportunities to express their views, some improvement is needed in the training of staff to understand their responsibilities in respect of adult protection and to standardize their response to behaviour issues Evidence: Residents are provided with opportunities to express their views and opinions about the service through resident meetings, 1-1 sessions with key workers, highlighting minor concerns and irritations in their own record, they have told us through survey responses that they know who to speak with if they are unhappy and understand how to make a complaint, to date no new complaints have been received either by the home or by CSCI since 2005. Staff demonstrate through their survey responses an awareness of what to do in the event of residents raising concerns but the majority have not received training in Protection of vulnerable adults, the manager received training in 2006 and this is now in need of updating to ensure that she is aware of any changes to the agreed multidisciplinary protocols surrounding adult alerts. We consider this training to be mandatory for all staff and delays in ensuring staff understand their roles and responsibilities in protecting vulnerable adults is unacceptable, we will require the provider to ensure all staff have received training within the timescales given at the end of this report, and thereafter every two years and this has been addressed within Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: the staffing section of this report. A review of staff meeting minutes highlights some confusion as to what constitutes abuse between residents and we have discussed this misleading information with the manager and reminded her that in the event of one client assaulting another however minor this should be referred to the CLDT for discussion and decison as to whether it constitutes an alert. Our examination of resident records and discussion with staff highlighted a range of behaviours managed by staff, staff demonstrated awareness and understanding of the behaviours and how they are managed but no written guidelines are in place for most behaviours that occur although some reference is made within risk information, we would recommend that to ensure staff responses are consistent and are to an agreed procedure written guidelines are established. Residents have been provided with safes in their bedrooms to keep their personal monies in they do not at present have free access to this and balance sheets are maintained by staff of money in an out of the safe of individual residents, the manager has been reminded of the need to provide capacity assessments for residents who do not have free access to their money. Care Homes for Adults (18-65 years) Page 19 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents enjoy living in a comfortable, homely and well maintained environment, they are able to personalize their own space to their individual tastes and are consulted about decoration and planned works in their home Evidence: The house is maintained to a good standard of cleanliness and decor, a programme of upgrading is underway and remedial works are planned where water damage has effected decor in the main lounge and a resident bedroom, as a result of a leaking shower and problems with the roof, these issues have now been addressed. We viewed the fire log and this indicates that fire alarm and fire equipment is tested and maintained regularly we would recommend that the frequency of fire alarm point testing is reviewed. Residents were confident about showing us around and were happy to show us their bedrooms, these have been decorated to reflect their own interests and hobbies, bedrooms are personalized and spacious. Communal areas are comfortable and homely with the lounge in particular being a Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: very pleasant and relaxing space, the kitchen has been upgraded but owing to some residents having food related issues food cupboards are kept locked and the fridge and freezer are secured by visible chain and lock arrangements, this is unattractive and conflicts with the otherwise homely setting and the perception visitors may gain of the home and residents, we have discussed with the manager alternative options whether a similar outcome could be achieved by a different locking arrangement and would recommend this be reviewed. Residents survey feedback indicates they feel the home is always fresh and clean, all staff have now received training in infection control. Care Homes for Adults (18-65 years) Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to support residents on most days but reduced staffing on Sundays should be reviewed. The service may have achieved 50 of staff trained to level 2 NVQ but cannot evidence that equivalency of other qualifications has been established. Recruitment has improved but the content of staff files needs to be consistent to ensure recruitment is robust. A programme of training is in place but some shortfalls in key areas could compromise resident safety. Staff have opportunities to meet with their manager on their own and as a group on a regular basis. Evidence: There are enough staff on duty most of the time to support residents, the reduction in staff to two on Sundays will impact on what activities can be undertaken as none of the residents can go out unescorted and this should be reviewed and is a recommendation. Some of the staff team have achieved NVQ2/3 and other staff have qualifications in other areas, there is no evidence as to how other qualifications have been assessed and what elements of the common induction standards staff may have had to repeat to satisfy the manager that the full induction standards and NVQ 2 equivalency has Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: been established. We do not therefore consider at this time that the home has achieved 50 of NVQ2 trained staff. We spoke with newer staff and confirmed the recruitment process and the involvement if somewhat informally of residents in that, we examined staff records these are now available on site and noted that 2 references are now routinely in place for new staff, we discussed with the manager the need to monitor the quality of references and what is considered acceptable. We found that recruitment files are inconsistent in content and do not comply with the required content under regulation 19 and schedule 2 of the care homes regulations 2001, there is evidence with the most recent appointment that the manager has tried to implement improved recording of interviews and establish a format for staff files but this has not been rolled out across all files and interview records still fail to record that gaps in employment have been explored thoroughly or verification sought from applicants about reasons for leaving previous care roles. Confirmation of CRB status is also unclear with files viewed, we require that the content of staff files is consistent and compliant with legislation and that the service can evidence that they have explored with applicants their work history to help inform overall judgments. Staff surveyed and those we spoke with confirmed induction but our examination of recruitment files for new staff failed to indicate a structured induction in keeping with skills for care. LDAF training is offered but, for staff new to learning disability this is not available to them in a timely manner to aid their induction and practice in the early months of their work in the home, there is no evidence that staff with qualifications other than NVQs in care have had the equivalency of these assessed and have repeated some elements of common induction to satisfy the manager that they do not need to undertake the full range of induction training. We require the provider to ensure that a structured induction programme is in place for new staff that is compliant with LDAF based common induction standards developed by Skills for care. There is a programme of mandatory core and specialist training in place and most staff have completed first aid, moving and handling, infection control and food hygeine, however completion of fire training is outstanding for the manager, team leader and two other staff and refreshers overdue for three other staff, additionally Protection of vulnerable adults training is outstanding for five staff and the manager is now due to attend refresher training we consider these key areas to safeguard residents from harm and require the provider to ensure that all staff are brought up to date in these areas within the timescales given in this report and thereafter annually for fire training and two yearly as a minimum for adult safeguarding. Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: Staff surveyed and those spoken with confirmed they meet with their manager regularly and that they feel well supported, staff confirmed they receive 1-1 time with their manager monthly, and records of these sessions confirmed that these are wide ranging but the quality of recording in those examples viewed indicated the recording of sessions is not always to the same standard and this should be reviewed. Staff told us that they have regular staff meetings and feel able to express their views, they feel listened to and that action is taking to address big issues but sometimes smaller issues that arise from internal team personality clashes and irritations are not addressed and this can be a source of ongoing frustration. Staff generally felt well supported and able to call for support from out of hours and on call staff if needed. Our observations of staff indicated a good awareness and understanding of individual residents support needs, staff were relaxed and confident in discussing their role and individual residents they support, Care Homes for Adults (18-65 years) Page 24 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. management of the home at local level is good but would be enhanced and better safegurad residents by implementing the suggested improvements Evidence: The present manager has wealth of knowledge and experience in the social care sector and has participated in a range of training to support and expand her personal knowledge and development. She has been the manager for the past two years but is still to make an application to register, we have discussed this and understand some mitigating factors have influenced this previously, but, now require the provider to pursue registration of the manager within three months of this inspection in compliance with legislation. The AQAA was completed to a reasonable standard and provided us with most of the information we needed, our visit to the service made clear how the service promotes independence of residents and respects and supports diversity. The service has aspirations for the development of residents, the manager demonstrates insight into Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: shortfalls within the service and where these fall within her control is undertaking to address them. Residents are provided with opportunities to express their views through 1-1 meetings with key workers, resident meetings, personal record books in which they can reflect on issues that concern or bother them. Residents also are able to vocalize well and demonstrated confidence through discussion with us during the inspection and through their survey feedback in being able to approach staff. Surveys conducted by the organization are analyzed at head office but it is unclear from discussion with the manager what happens with this information and how it might influence service development, whilst there may be common themes that may run through all the homes in the organization, much of the feedback from residents will be focused on their own experience of their particular service and it is therefore important that their views are analyzed at a more local level and help to inform development of that service. Currently there are some stand alone audits of systems e;g finances, medication, health and safety but no established quality assurance package that measures and assesses service performance overall and takes account of resident consultation, this now needs to be developed to incorporate some of those forums and systems already in place and is a recommendation at this time. The manager has declared in AQAA information that all health and safety checks and servicing are up to date and there is a sustained history of the service ensuring servicing is maintained, we have examined records and are satisfied that in most instances this is the case, however, we note that the electrical installation was last serviced in 2004 and the manager was unable to provide the documentation for this or the recommended timescale made by the contractor for the next service which may possibly be overdue, the provider has not made this information available within 48 hours of the service as requested therefore we require a copy of this information to be sent to CSCI, in the event that servicing is overdue we will require the provider to arrange for this to happen within 2 months of the receipt of our report. We were unable to review accident reporting as these are sent to head office when they occur, consequently we could not assess the level of individual resident accidents and whether the staff have responded to them appropriately, this is key information that must be available for inspection and the provider is required to review the present arrangements to ensure this information is kept in individual resident files for review. Care Homes for Adults (18-65 years) Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 34 19 The provider is required to 30/12/2008 ensure that staff records are consistent in content and format and contain all documentation required by legislation and good practice So that residents can be confident they are safeguarded by a robust recruitment process and this can be clearly evidenced 2 35 18 The provider must ensure 30/12/2008 that a structured programme of induction relevant to the knowledge skills and experience of new staff is in place and is compliant with skills for care common induction standards (incorporating LDAF for those new to LD services) The provider must also ensure that staff receive all statutory training in key areas i.e Fire safety, food hygiene infection control, moving and handling first Care Homes for Adults (18-65 years) Page 28 of 32 aid, protection of vulnerable adults within the first 3 months of commencing work with regular refreshers as required thereafter ( medication should also be offered for those who administer To ensure that staff have the necessary skills and knowledge to fulfill their role effectively and safely 3 37 8 he provider shall undertake 03/03/2009 to ensure that an application to register the manager with CSCI is undertaken within the given timescales So that we can be assured that the manager is appropriately qualified and the necessary skills knowledge to fulfill their role 4 39 24 The rpovider is required to establish and implement a system of quality audit and review of systems and incorporates the views of residents So that we can be assured that the service monitors its own service quality, listens to residents and their views can influence service development 5 42 23 The provider is required to supply a copy of the last electrical installation service and the contractors recommended timescale for the next service upon 03/02/2009 03/03/2009 Care Homes for Adults (18-65 years) Page 29 of 32 receipt of this report if not before in the event that servicing is overdue the provider must undertake to arrange a service of the installation within the timescale given in this report To protect the health and safety of residents and staff Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 5 Terms and conditions information should be reviewed and developed into a more accessible format for residents to understand and sign agreement to The service is recommended to review the content and detail of risk assessments to ensure all risk reduction measures have been considered and these should be subject to regular review particularly where restrictions may need to be imposed The service should consider the development of a medication profile to inform staff about the medications prescribed to residents,e.g. what are they for, side effects, individual residents preferences around administration, foods to be avoided with specific medication if any, homely remedies that can be taken safely. The service should establish behaviour management guidelines for those residents whose behaviour may impact on others or place themselves at risk of harm to ensure that staff responses are consistent and in keeping with agreed interventions The visible locking arrangement for the fridge and freezer should be reviewed to reduce negative perceptions of residents by visitors. The frequency of fire alarm testing should be reviewed, with consideration given to increasing this. A review of Sunday staffing levels and the impact on residents opportunities to go out is needed 2 9 3 20 4 23 5 24 6 7 24 33 Care Homes for Adults (18-65 years) Page 30 of 32 8 39 The service is recommended to develop further quality assurance systems to quality audit and review systems and incorporate the views of residents for the respective service outcomes from quality assurance for the service should be reported on and made available for inspection. Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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