Inspection on 12/12/06 for 63 Hoveringham Drive

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63 Hoveringham Drive 14/07/09

63 Hoveringham Drive 07/08/07

63 Hoveringham Drive 10/01/06

63 Hoveringham Drive 03/05/05

63 Hoveringham Drive 06/12/04

63 Hoveringham Drive 16/08/04

Similar services:

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

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

CARE HOME ADULTS 18-65 63 Hoveringham Drive Eaton Park Stoke-on-Trent Staffordshire ST2 9PS Lead Inspector Mr Berwyn Babb Key Unannounced Inspection 12 December 2006 11:30 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63 Hoveringham Drive Address Eaton Park Stoke-on-Trent Staffordshire ST2 9PS 01782 201766 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Choices Housing Association Limited Mrs Terri Byczkowski Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (6), of places Physical disability over 65 years of age (6) 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with either Learning Disability (LD or LD(E) category may also have a Physical Disability (PD or PD(E) 10 January 2006 Date of last inspection Brief Description of the Service: Hoveringham Drive is located on a large private housing estate in the Bucknall area of Stoke-on-Trent. It has access to a small but adequate shopping centre and, via a local bus route, has relatively easy access to the main shopping centres of Hanley and Longton. The bungalow is a purpose built unit that is run by The Choices organisation, who have a number of similar homes throughout the Potteries area. This home is registered to provide care for six [currently female] residents with varying degrees of Learning Disability. Two current residents have physical incapacity. The design of the home is based on the domestic model, with six bedrooms, a domestic kitchen/diner, laundry, and a communal lounge. Bathrooms and toilets have been specially adapted to assist those residents with a physical disability. Doorways and corridors are wide to facilitate wheelchair use and have been fitted with grab rails. The open plan layout established by creating an archway between the kitchen and the lounge has achieved its objective of encouraging residents to make more use of the lounge facilities. The property has a small but well kept garden at the rear with adequate seating for use in fine weather. There is a sloping Tarmac covered area at the front for car parking The exterior and interior are in a good structural state of repair. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over the late morning and afternoon of Tuesday the 12th of December 2006. The registered care manager was in attendance as were two members of the support staff, a third member being out with the resident at a session of Armchair Aerobics, at the nearby Berryhill Care Complex. The home had been decorated for Christmas, and plans were a foot for residents to visit friends and family, or to receive visits from them at this festive time. The home was clean, warm, tidy, and well maintained throughout, and staff were observed giving positive regard to residents during their interaction, and in discussion, to be knowledgeable about their needs and choices. Those care plans examined demonstrated a sympathetic understanding of the social, physical, and psychological needs of the individual residents of the home, together with appropriate planned intervention to assist them in maintaining their well-being and lifestyle. The current scale of charges for accommodation in this home was quoted by the care manager has been between £370 and £450 per week. What the service does well: What has improved since the last inspection? Much work has been undertaken to comply with the most recent advice and requirements of the fire service. The Statement of Purpose has been re-issued in updated form with colour photo. A new bath aid has been obtained for one resident to allow her to have a proper lie down and a soak in the bath, with neck, lumber, and legs appropriately and safely supported. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 6 A new security light has been fitted to illuminate the alternative evacuation route from home. All staff have received refresher training on protecting residents from abuse. A new washing machine has been purchased for the laundry, and this is fitted with a sluicing facility. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome for this group of residents in this area was good. This judgment was made using all available evidence including a visit to the service. The homes Statement of Purpose and Service Users Guide was good, providing prospective residents and their supporters with details about the service the home provided, thus enabling them to make an informed decision about admission to the home. EVIDENCE: The newly updated Statement of Purpose was examined, and this was found to have been reissued with colour photographs to enhance the quality of the information contained therein. It was found that it clearly set out the aims and objectives of the home, and what needs and choices the home would be able to meet. The care records of one resident recently admitted were examined in depth to ensure that there had been a full assessment of their needs and personal choices prior to a place being offered to her in the home. It was clearly shown that her placement had been handled by a social worker under the National Health Service and Community Care Act 1990 Care Management provisions, 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 9 and that information had been gathered from a range of sources as well as from the resident herself. This showed the things that she liked, the things that she disliked, those things with which she needed help, and those things that she was able to do herself. Spiritual, physical, social, and psychological aspects of her had been included in this assessment, and the daily record and subsequent care plans used since her admission demonstrated that these were being met adequately. The resident herself was questioned, and though not able to engage in a prolonged verbal exchange, indicated that her needs were met, and that she was happy at the home. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. The quality outcome for this group of residents was good. This judgment was made using all the available evidence, including a visit to the service. It was based upon comprehensive personal care plans, and finding that residents had been assisted to make what decisions they were able to, and to take any risks that were appropriate for them. EVIDENCE: The care plans of one resident were examined in detail, and of others less minutely. These were taken as a sample chosen at random, and verified by discussion with members of staff on duty and the care manager, and to the extent that she was able, the primary resident herself. It was seen that these recorded their individual assessed and changing needs and personal choices, and that they were used as a basis for the work done with them to assist them in their home in their daily activities. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 11 It was seen that wherever possible they were included in any choices that were made relative to how they were cared for, and that they were supported to maximise their independence and to minimise their dependence on other people in their daily lives. There were at risk assessments covering a wide variety of needs, and there was one looking at various alternatives for meeting the problem of one resident who was more unstable when she got out of bed during the night, than she was than during the daytime. An arrangement had been made for a monitor in her room, and she had agreed to this being the least imposition on her liberty to help ensure her safety. This alerted members of night staff if she left her bed, and they would then quickly go on to assist her to use the toilet, or carry out what other task it was she wanted to do. The use of the Every Day Living Skills Assessments tool appeared a very positive step in care planning, as it focused the mind on strengths and needs, and helped channel thinking into an enabling mode, rather than a disabling one. All residents in this home are cared for under the personal carer (Key Work) system. The inclusion of a section in the monthly review documenting to discuss whether they wished to stay with that nominated carer, or to change their personal carer, was deemed to be a further example of good practice. In the folder of the lady chosen as an example for Case Tracking , a further example of her being enabled to make decisions was the indication that she should remain up at night until she indicated that she was no longer comfortable with doing this. Those risk assessments reviewed during this inspection demonstrated the least restrictive practice being followed to enable a resident, but did not shy away from confronting somebody with the consequences of the actions that they wished to take. Thus discussion and specific reference to the care plan of one lady was made in the light of the enormous amount of diversion or work that had to be done with her to prevent the retiring to bed at all and any time during the day. It was shown in the health-care plan that this posed a serious risk to her on account of decreasing mobility and increasing body mass, and various health professionals including the dietician and the consultant in Learning Disability, had been involved in recommending this course of action. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. The quality outcome for this group of residents was good. This judgment was made taking into account all available evidence including a visit to the service, and because they were seen to be an able to have a community presence, to be occupied or stimulated, to maintain friendship and family links, and to eat healthily and enjoyably. EVIDENCE: None of the current residents of this home are able to attend either college, or undertake paid employment. They do however have a number of community and social links, and are fortunate in being located near to a large care complex (Berryhill) where the ladies can go for fellowship and activities, and when the inspector arrived in the home, one resident had been taken there by her personal carer for a session of Armchair Aerobics. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 13 Discussion and reference to care plans showed that a wide variety of friendships and relationships were maintained, including with residents in other homes, many of whom shared a common history of living in large National Health Service Learning Disability institutions. Interhome visiting was a feature of these relationships, both on an individual and a group level, as was letters and phone calls to and from family members. The particular resident whose care plans were being examined in depth had been on a five-day holiday to Blackpool with a friend, supported by two members of staff. Whilst there they had enjoyed shopping trips to Fleetwood and the nightly entertainment provided by the hotel. In response to questioning the inspector was told that whilst the ladies are assisted with grooming in the home, they all go to hairdressing salons locally, and do not all choose to go to the same one. The residents of this home helped with the routine tasks around the home in line with their given ability, and from casual observation appeared to gain benefit from the status this afforded. The input of the dietician has already been referred to previously in this report, and her input was noted in care plans both to advise in cases of weight gain, and of weight loss. Records show that as well as eating in the home, residents regularly access the community for pub lunches, and this is usually done on a one-to-one with their personal carer, rather than in an easily identifiable [and therefore stigmatised] institutional group. During the late afternoon staff were preparing the evening meal and were exercising themselves with the question of how to make this most attractive. Menus and records of meals actually served demonstrated a good variety including seasonal and local choices, and the likes and dislikes of residents in relation to food had been recorded in their care plans. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, and 21. The quality outcome for this group of residents in this area was good. This judgment was arrived at using all the evidence available, including a visit to the service. It was formed because residents were seen to receive comprehensive Social and Healthcare support in line with their assessed needs and choices, and because programs had been reviewed regularly, as demonstrated by the record in their personal care profiles. EVIDENCE: All current staff working in this home are female, as are all current residents, so there was no conflict over having a choice of staff from the same gender to work with them, and similarly they all had the same ethnic background. It has been mentioned before the technical aids have been provided to improve the safety of one resident when getting up out of sleep at night, and another so that she could enjoy the process of having a bath, and be appropriately supported to relax and soak up the benefit of warm water to painful body parts. During the course of the day staff were observed to work sensitively to maintain the dignity of these ladies in terms of personal hygiene, and to assist them with any intimate care tasks in privacy. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 15 The healthcare modules of those care plans examined demonstrated the extent to which staff worked to try and maintain the well-being of the residents of the home. All staff had undertaken a three-day training course in the Management of Actual and Potential aggression, and where this knowledge had been put to use in agreeing restrictions on one resident, the record showed a welcome and significant decline in incidence of aggression. Additionally there was a whole range of entries relating to maintaining general and psychiatric health, reflecting the regular checks had been initiated by the provider on the basis of good practice recommended in the British Institute for Learning Disability key values 24-hour support plans behavioural risk assessments and appropriate and regular reviews of the status of the individuals health including tissue viability, blood pressure monitoring, and nutritional screening, and regular individual reviews of medication. Appointments being made with individual healthcare clinicians including Hospital Consultants, GPs, and district and specialist nurses, and at clinics and Health Centres with appropriate support to transport them to these appointments. The tertiary healthcare practitioners of dentistry, chiropody, ophthalmology and audio clinicians had also been visited at regular intervals, or when and as necessary. The local GPs surgery had been involved in Well Woman annual health checks. Whilst reviewing the newly updated draft policy on death and dying, the inspector felt that the moves to make this more user friendly had perhaps been at the expense of some old fashioned basic procedural directions to staff about what to do when somebody dies. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The quality outcomes for this group of residents in this area was good. This judgment was made using all the available evidence including a visit to the service. It was founded upon the staff being seen to be well-trained, and because sound policies and procedures were in place to protect the vulnerable adults in their care. EVIDENCE: During an initial discussion with care manager it was established that all staff receive refresher training on the protection of vulnerable adults every two years. Protection of vulnerable adult policies are really read with a proportion of the staff once every two months, so that each year everybody will have signed to say that they have really read and understood these policies. The Commission for Social Care Inspection has not received any complaints concerning this home during the last 12 month inspection period. The care manager has reported that no complaints have been received by the home in this period either. During the afternoon a formal interview was undertaken with a member of staff during which the subject of the abuse of vulnerable adults, and how to ensure that they could be assisted to make a complaint if they need to was discussed. This member of staff commented quite bluntly: I would hope that everyone I work with contributes towards reducing the vulnerability of the people here. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 17 She went on to correctly identify that due to the capacity of the residents anybody could abuse them, be they a fellow resident, friends, family, or any professional in a position of trust who came into contact with them, including members of staff of the home itself. She was able to enumerate a list of activities that would constitute abuse of a vulnerable adult including them not being looked after properly in such ways as: Not having a drink as often as they want one, not having a bath as often as they want, being shouted at, or just the tone of voice used when speaking to them, being overregulated, and not speaking up if you felt they were not being adequately protected (turning a blind eye). She went on to correctly identify the procedure required by the policy produced between all agencies for the protection of the adults should anybody suspect them of being abused. She felt she spoke for all her colleagues in reassuring the inspector to the ladies living in this home were protected from abuse by the ethos and actions of those people employed to care for them. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, and 30. The quality outcome for this group of residents was Excellent. This judgment was reached using all the evidence available including a visit to the service. It was made because residents were seen to be living in a homely, comfortable, and safe environment, with personal and, communal space that met their needs and lifestyle, and helped to promote their independence in an environment that was well maintained, clean, and hygienic. EVIDENCE: A cursory visual examination of the exterior of the building was made upon arrival, and this showed it to be in a good state of decoration, and maintenance. The grounds were well-kept, and the tarred parking space leading up to the front door was in a similar good order and appeared to be regularly swept bearing signs of neither leaf accumulation or algae. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 19 Choices maintenance team were on-site improving the route away from the rear fire exit, by enhancing the path, and installing a security light to make the area safer to use after dark. The building itself is all on one level and constructed in similar brick to the rest of the estate on which it stands, and is not stigmatised in any way as being a care institution. There is a bus service passing through this estate, but it would not be helpful to several of the residents, and they are assisted to access the community, their friends, and any appointments that they need to keep, through a mixture of taxis and appropriate transport belonging to the provider. There is a large care complex at the other end of the estate, and this has proved to be very beneficial to the residents of this home both in terms of individual activities provided there, and also of the facilities such as the cafe/meeting area that has been the venue for some residents to make new friendships. There is also an esplanade of shops on the estate and a public house. Furniture and fittings are of good quality, and the construction of the home provided for wide enough corridors and doorways to allow wheelchair access to all areas of the home needed by the residents. In a tour of the interior environment several bedrooms were visited, and these were found to be of adequate size to accommodate any aids or adaptations that might be necessary for the resident, or for them to engage in any pastime or hobby, or entertained family or friends. All bedrooms were fitted with variable height wash basins, though none have the benefit of ensuite toilet facilities. Toilets and bath and shower facilities are located close to the bedrooms, and there are also toilet facilities close to the communal rooms. The assisted bath room in this home is always worth mentioning, as a great deal of thought and care has gone in to making it the excellent facility that it is. In addition to homely decoration of the walls, much sensory equipment has been installed so that the area serves a triple function of meeting hygiene needs, being an enjoyable place in which to be immersed in warm and soothing liquid, and being an acceptable and safe area to alleviate tension and agitation, without the use of chemicals or restraint. A reassessment of the communal space some years ago in the light of experience gained from meeting the needs of the resident care group resulted in knocking through an archway between the dining room and the lounge, and the latter area now sees much greater used by the residents than it did previously. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 20 The home is fitted with hand rails in the corridors, and appropriate mobility devices in each of the toilets. Wheelchairs, Zimmer frames, bath seats, and fixed and mobile hoists were also observed, and the documents relating to their servicing were checked and found to be appropriate, in date, and relating to see relevant timescales. Of particular note on this visit was a new bath aid that had been purchased so that one residents would be better supported and more comfortable whilst in the bath. This supports her neck, legs, and lumba region allowing her to enjoy total body immersion. The premises were clean, hygienic, and free from offensive odour throughout, and systems were seen to be in place to control the spread of infection in accordance with relevant legislation. There was a new washing machine with appropriate sluice facility in the laundry, where the walls are tiled, and the floor is of an impervious covering which is easy to keep clean. The boiler which is situated in this room was guarded with a mesh cover. The radiator, like all other radiators in this home, was covered to ensure that residents would not burn if the fell against it. The Containment of Substances Hazardous to Health cupboard was situated in this room, and was appropriately locked with relevant safety notices for the protection of anybody using it. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. The quality outcome in this area for this group of residents was good. This judgment was made using all evidence available, including a visit to the service. It reflects an adequate staff to resident ratio, and there been sufficient and appropriate training of, and employment of, experienced and qualified staff. EVIDENCE: During the afternoon of formal interview was undertaken with a member of staff who confirmed that the employing organisation was exceedingly proactive in offering training to its staff together with supervision and support. The Pre-inspection Questionnaire returned by the care manager showed that all mandatory and specialist training needed to assure the care needs and personal choices of residents in this home were met, had been undertaken at the time intervals specified. 100 of the care stuff in this home are current holders of the emergency first aid certificate, and 91.5 hold NVQ level 2 or above. All staff are responsible for the administration of medication and receive adequate training for that. Mandatory fire safety training is carried out once every two years, as is training in moving and handling and first aid. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 22 Food hygiene, abuse, sexuality, and the origins and management of behaviours are refreshed every three years, and staff have recently undertaken a three-day course in the management of actual and potential aggression. This is complemented by a one-day course in personal safety training and the in-house provision of three monthly fire drills Containment of Substances Hazardous to Health training medication training infection control training and manual handling training. New starters undertake a full induction course that also covers finances, and, What is a Learning Disability? A recent introduction has been provision for members of staff of sessions on stress management. A member of staff being interviewed assured the inspector that the registered manager and the organisation had behaved in a proper manner during her recruitment process, and in her view this had been based on the best practices of equal opportunity and diversity recognition. She gave permission for her records to be examined and these confirmed that she had had to provide two written references, as well as a satisfactory C. R. B. check, and that she had never been subject to disciplinary action, or placed on a P. O. V. A. register. She confirmed that she had a statement of her terms and conditions, and that staff were regularly paid by automatic bank transfer. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Equality outcome for this group of residents in this area was Adequate. The judgment was made using all available evidence including a visit to the service. It recognises the good reputation of the current manager, and the steps taken to review quality and embed the views of significant people into the running of the home, but because there still remains an issue with the fire officer, namely the length of time taken to evacuate the building at night when there is only one member of staff on duty, reduces quality in this area from the previous good level. EVIDENCE: The manager of this home holds all the necessary qualifications to fit her for her post, and has copious experience of running a care home for people with 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 24 Learning Disabilities. She is a first level nurse who also holds the Registered Managers Award. She has a clear understanding of how responsibilities and has been said by her staff to always be ready to support people in their jobs, and to be open and fair in the way she manages to home. A selection of questionnaires that had been sent out to relatives were reviewed and found to contain nothing but positive comments. In the cards returned to the commission prior to this inspection, two people had commented that when there were only two members of staff on duty there did not seem enough time for one-to-one interaction, but the assessment of dependency levels and the number of people in the home did not indicate the need for further staffing at all times, only when an extra activity was taking place. On the day of the inspection there were two staff on duty at all times in addition to the care manager, and an extra member of staff was brought in to take one resident to the armchair aerobics session at Berryhill care complex. The commission received regular quality audits from the provider to us under the arrangements for reporting monthly visits under regulation 26. Those records that the home is required to keep to show that equipment has been regularly and safely serviced, and was in a fit condition to use when examined, and were felt to be satisfactory. All staff had undertaken fire drills in August and then again in October/November, emergency lighting had last been tested on the 30th of October, fire equipment maintenance had taken place on the first of December and alarms had been tested every week. Fire checks had been carried out every evening when the residents went to bed, and these covered examining all extinguishers and fire blankets to ensure that they were in place, emptying the ashtrays, ensuring that furniture had not been moved in such a way as to create a fire hazard, ensuring that electrical equipment had never been left near soft furnishing or curtains, ensuring that all fire guards were in place, checking the alarm control box for fault indicators, ensuring that all newspapers and magazines had been cleared away safely, and that all fire doors had been closed. The home is fitted with three heat and 13 smoke detectors, and the last full evacuation took place on the sixth of November at twenty to nine in the morning. Unfortunately it has been stated by the fire officer that the time taken to achieve this evacuation was unsatisfactory, and he has had discussions with the management about further adaptation being made to the home which could reduce it to a more acceptable level. At the current time the providers have not been able to confirm with the Commission for Social Care Inspection how they will meet these requirements, and therefore it has to be a requirement of this inspection report, that the registered person ensures the safety of residents and staff of the home in respect of any outbreak of fire at any time during the day or night, and that this is confirmed by the fire officer as being satisfactory and sufficient. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 4 27 4 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 23 [4] b & C (iii) Requirement The registered person shall undertake appropriate action to ensure that a satisfactory and sufficient evacuation of the home can be undertaken in case of fire at any time of the day or night. Timescale for action 12/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA21 Good Practice Recommendations The registered person is recommended to ensure that during the review of the policy on death and dying, the important practical instructions to staff about what to do when they discover a death should not be omitted. 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 63 Hoveringham Drive DS0000008319.V321976.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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