Inspection on 27/09/06 for 7 Hyde Road

This inspection was carried out on 27th September 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7 Hyde Road 19/06/07

7 Hyde Road 29/11/05

7 Hyde Road 18/08/05

7 Hyde Road 22/02/05

7 Hyde Road 25/06/04

Similar services:

The Vicarage

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

Bethesda

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

CARE HOME ADULTS 18-65 Hyde Road (7) Gillingham Dorset SP8 4BX Lead Inspector Veronica Crowley Unannounced Inspection 27th September 2006 10:00 Hyde Road (7) DS0000026754.V313747.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 Hyde Road (7) DS0000026754.V313747.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. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Road (7) Address Gillingham Dorset SP8 4BX 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) 01747 825104 01747 mulberry.court@scope.org.uk SCOPE Care Home 2 Category(ies) of Physical disability (2) registration, with number of places Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: 7 Hyde Road is the home of two service users who have been married for a number of years. Their home is a 2 bedroom bungalow in a residential part of Gillingham, approximately 1 mile from the centre of the town. The service users live independently for the most part, receiving around 40 hours staff support during the week, plus periodic visits to monitor their health and welfare. The bungalow is owned by a local housing association, and the service is operated by SCOPE, a not-for-profit organisation providing services to people who have physical disabilities. Management and staffing of the home is undertaken from Mulberry Court, which is the administrative centre for the group of related services operated by SCOPE in Gillingham. Service users have copies of Commission for Social Care Inspection reports in their home. Fees for the service, as of July 2006 range between £20,141.60 and £34,804.31 per annum. Variable additional charges are payable for holidays, hairdressing, toiletries, activities, trips, magazines/papers and public transport. The Office of Fair Trading fees and fair terms of contracts can be accessed via the following web link: www.oft.gov.uk. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken as part of the statutory inspection process in accordance with the Care Standards Act, 2000. All key standards were assessed according to the Care Home for Adults (18-65) National Minimum Standards. It took place over a two-day period in addition to four hours preparation. 2 service users were being accommodated at the time of this inspection. This report will refer to those resident as service users as this is their preferred means of reference The inspection involved time spent at Mulberry Court, which is the administrative and staff base for Hyde Road, where the Interim Manager and staff were spoken with and records and documents examined. One service user case file was also examined in the home. The Commission also received comment cards back from the two service users, one GP, one Care Manager and one relative. All responses received were positive. Where concerns had been raised by one of the service users these issues were discussed thoroughly with the service user and the Interim Manager to ensure action was being taken to address satisfactorily. The content of the all other responses were also discussed fully at the inspection and pertinent comments incorporated within the report. An unannounced inspection had taken place on 29th November, 2005 establishing that service users continued to enjoy a high degree of satisfaction with the support and care provided, underpinned by a strong emphasis on equality, independence and human rights All key standards were assessed at this inspection. What the service does well: The service users at Hyde Road enjoy excellent outcomes. The home has an effective and thorough assessment and care planning process which involves the service user fully. Service users’ rights are respected with service users making their own decisions and choices. Staff are proactive in ensuring that service users can be as independent as possible, offering minimal support where necessary. Service users participate fully in the running of the home, including decisions about meals, housework, trips, meaningful employment and education opportunities. Care plans detail the assessed health needs of service users and records seen also demonstrated evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 6 with clear, comprehensive arrangements in place to ensure service users’ medication needs are met. The home excels in ensuring good relationships inside and outside the home are maintained. They also enjoy good links with the community, which supports and enhances the service users’ social and educational opportunities. Hyde Road offers a good standard of accommodation, which is domesticated comfortable and homely. The Interim Manager and his staff team are competent and confident in their jobs and enjoy good relationships with the service users. Comments received from relatives, a Care Manager, GP and both service users were mostly very positive. Staff have a wealth of experience, with the majority suitably qualified and/or undertaking appropriate training. Staff also enjoy a high level of support which includes regular one to one supervision, group supervision attained in staff meetings, training opportunities, appraisal and development. The Interim Manager oversees and monitors the service well. Despite the service being without a Registered Manager for some months the Interim Manager is congratulated on his continued commitment ensuring continuity of care for the service users. Both service users and staff spoke highly of his efforts. What has improved since the last inspection? Key-workers have used results from recent resident surveys to formulate action plans for individuals in order to continually improve the service provided. One service user is being supported towards self medicating following the most recent review. SCOPE are proactive in keeping up with all relevant guidance and legislation. Training on race equality and anti-racism has taken place following a recommendation made at the last key inspection in August 2005. This topic remains on the rolling training schedule. Service users have acquired a new bed and sofa. Through positive recruitment campaigns, for workers with a disability, SCOPE in Gillingham has been able to improve their ratio of workers with a disability to 32 . The Manager and staff at the home are continually looking at ways to improve the service. Surveys, reviews, staff meetings and house meetings are used as a means of identifying where improvements can be made and included within the Development Plan. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 7 SCOPE are proactive in keeping up with all relevant guidance and legislation. 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. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in the outcome area is good. This judgement has been made using evidence including a visit to this service. No new service users had been admitted within the last year so this standard was difficult to assess, however by examining care files it was clear that full assessments had been undertaken ensuring the service could meet the identified needs of individuals. EVIDENCE: SCOPE has a comprehensive admission and placement policy, including a preadmission assessment. From records seen, the home had obtained a Care Management Assessment in addition to completing an in-house assessment prior to admission. This assessment identified the care hours needed to meet the service users’ needs. The home had also obtained information and assessments from the service users previous placement. The pre-admission assessment identified the care hours needed to the meet the service users’ needs, and detailed any known risks or restrictions needed on freedom of choice. There was evidence that the service users were involved in the assessment, they had signed the documents and the plans were written in their words. The working records also evidenced that the views of the families are taken into account, and that staff liaise with families where appropriate. Hyde Road (7) DS0000026754.V313747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in the outcome area is excellent. This judgement has been made using evidence including a visit to this service. The care plans are comprehensive, up to date and cross-reference to action plans, demonstrating that staff are conversant with the service users changing needs and personal goals and able to support them appropriately. The systems for service user consultation in this home are good with a variety of evidence that indicates that service users’ views are sought and acted upon. The home has appropriate policies and procedures in place for assessing and managing risks, which are based on enabling service users to take responsible risks rather than preventing them from doing so. EVIDENCE: One care file was examined in detail. The care file included an up to date Care Plan and Assessment. Through discussions with service users and staff it was clear that care plans are updated every six months with full participation of service users. The care plan seen was accurate, thorough and covered all Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 11 areas of personal and social support, associated health needs and a ‘working’ Action Plan. The care plan also included where specialist input is needed and how staff the support service user in accessing these services. The care plan was written in the first person and set out both short term and long term goals based on the wishes and aspirations of the service users. Evidence was seen where staff have supported and are continuing to proactively support the service user to reach their goals. Following discussions with service users they confirmed that there were no restrictions of choice or freedom in place. Where extra supervision by staff is needed for a particular activity (i.e. using public transport, cooking) this followed a risk assessment, and was recorded in the service users care plan. The Interim Manager and staff are proactive in promoting the rights of service users to make decisions and control their lives. This was evidenced by talking with the service users, staff and by examining the daily records. Staff provide service users with information and assistance in order to support the service users making their own decisions and choices. Examples include providing information on day opportunities, holidays, clubs, advocacy, health services and personal relationship guidance. Service users have been supported to manage their own finances, go shopping independently and in deciding the level of support they need. There were no significant limitations placed on service users in relation to their choices or human rights. There are monthly service user house meetings, (joint with the other SCOPE homes in Gillingham), where service users are able to discuss the running of the home and issues they may have with the organisation. Both attend regularly with one service user chairing and taking minutes for the meeting. It is identified that one service user needs extra supervision at certain times of the day, for particular activities and has a detailed multi-disciplinary risk assessment, reviewed six monthly ensuring that the extra supervision is appropriate and meets the service users human rights. Although this service user wishes for more autonomy regarding self medicating this was being partially supported following a recent review and risk assessment. Both service users reported that they were generally happy with the level of independence and decision-making they have within the home. A comprehensive, user-focussed risk assessment policy and procedure is in place. Risks are well documented and focus on enabling service users to continue to take responsible risks and maximise independence. Where, from the case file examined, risks had been identified following a needs assessment these had been duly recorded. Examples of these included using the kitchen, managing own finances and specific health problems. As with care plans, risk assessments are updated every six months. Service users also receive support and training where necessary – such as Health and Safety training, road safety and personal safety when out and about in the local and wider community. A member of the probation service had recently visited Mulberry Court to instruct Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 12 on personal safety issues, which the service users had attended and reported as very useful. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in the outcome area is excellent. This judgement has been made using evidence including a visit to this service. Service users are well supported to take part in meaningful, appropriate jobs and education or training opportunities in order to achieve their full potential. Links with the community are excellent which support and enhance service users’ social and educational opportunities. The service users enjoy excellent relationships inside and outside the home and maintain good family links, which enrich their lives. The daily routines promote independence and individual choice facilitating and supporting service users to achieve their individual goals. The meals in the home are good offering both choice and variety and cater for special dietary needs. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 14 EVIDENCE: The service users at Hyde Road work on certain days at the nearby Thorngrove Garden Centre on a voluntary basis. The Garden Centre is an established local business and provides a real working environment as well as the opportunity to gain a range of social and work related skills. Service users can choose how many days they work in the Garden Centre. One of the service users works full time at the Garden Centre and the other is involved in working part time in the shop on the till and working in the café in addition to spending two mornings at a local supermarket. The staff confirmed that service users are provided with information about Adult Education classes and any other employment or educational opportunities that may arise. The service users spoken with were fully aware of the local activities and support offered by specialist organisations and confirmed that staff assist them with gaining this information (for example PHAB club, DAB club, Riding for the Disabled, NorDis, Lifestyles and Stepping Stones). The care plans examined demonstrated that service users participate fully in the community, that they regularly go shopping, out for day trips, to the cinema, pub, skittles and swimming. The service users can join in the planned activities arranged by Mulberry Court (a larger SCOPE home near by) should they so wish. The service users spoken with were fully aware of the local activities and support offered by specialist organisations and confirmed that staff assist them with gaining this information (for example PHAB club, DAB club, Riding for the Disabled, Local Disability Action Group, NorDis, Lifestyles and Stepping Stones). The care plans examined demonstrated that service users participate fully in the community, that they regularly go shopping, out for day trips, to the cinema, pub and skittles. The service users also reported that they enjoy good relationships with their neighbours and local shop keepers and entertain friends on a regular basis. Staff support within the home is limited to certain times of the day. If a specific request is made for staff support at any other time the Interim Manager confirmed that this can be provided. The two service users at Hyde Road are fully independent with their mobility. The needs of the service users in relation to social and well-being are very well documented. Staff remain committed to supporting family links and friendships, but are also careful to ensure that service users determine who they see and when. Both service users have contact and friendships with disabled and non-disabled people. Support plans detail information about social contacts and significant people in the lives of the service user, and daily care records include entries relating to contact with families, friends and acquaintances. They are also encouraged to have friends and family to visit including for dinner and/or parties/celebrations. This standard is exceeded. Staff are unable to fully support service users in intimate or personal relationships because SCOPE have yet to finalise/ratify their policy on Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 15 ‘sexuality and personal relationships’. Although the previous Manager had reported at the last key inspection in August 2005 that he and a number of service users had been involved in a working group to develop appropriate policies on sexuality and personal relationships, this after some 18 months is still unavailable to staff and Service Users. A recommendation is therefore made for the second year running for this policy and any appropriate training to be available in order for staff to guide and support Service Users appropriately. Hyde Road is set up as the private home for two service users who have been married a few years. They are very much autonomous, free to make most of their own decisions with minimal support and guidance from staff. Staff enter the home with permission only, and it is only the service users who have a key to the home. The service users have personalised the whole home to their taste and are responsible for the security of the premises. The service is flexibly delivered and shaped by the service users needs and wishes, who do their own shopping, cleaning and the majority of the cooking. The service users reported that they have some support when deciding upon a weekly menu, shopping and cooking, but in general are fairly independent with these tasks. The staff support offered is guidance and supervision rather than staff members actually undertaking the tasks themselves. The service users felt the level of support was appropriate. The inspector did not observe a mealtime, but copies of menus were seen on the notice board in the kitchen and demonstrated that the service users are generally maintaining a healthy lifestyle. There was also clear evidence in the care files and by talking with staff that service users nutritional needs are assessed, regularly reviewed, and that referrals are made to specialist health professionals when appropriate. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in the outcome area is excellent. This judgement has been made using evidence including a visit to this service. Although service users require minimal personal support staff ensure consistency and continuity of support for them through the allocation of designated key-workers, concise individual working records and partnerships with advocates, family, friends and relevant professionals. The health needs of the service users are assessed and well met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear, comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: The service users living at Hyde Road require minimal staff support with personal care. They have detailed care plans and assessments which outline the exact support they require and prefer. If they do require some support this is in agreement with the service user and any other professionals / family where appropriate. The care records evidenced that staff adhere to the home’s Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 17 procedures for maintaining privacy and dignity, as evidenced in the care plan for bathing, that staff supervision should be non-intrusive and minimal. The service users each have independent routines and can get up and go to bed when they choose. Each service user has an independent key worker and they commented that this relationship is useful and beneficial. The care files and daily records evidenced that the healthcare needs of service users are assessed and met within the home. The care plans set out the support needed to meet their needs. The service users are semi-independent in accessing the doctor/dentist/opticians. Staff support is arranged with the focus of enabling the service user to be as independent as possible, therefore ranges from prompting service users to attend appointments to supervising the service user with attending and sitting in on appointments. Care files demonstrated that staff have made referrals on behalf of service users to specialist services, i.e. chiropody and the diabetic nurse. Service users have a choice of GP, although they both attend the local village surgery. One care file evidenced that the service user has been given the support and opportunity to manage their own medical condition as much as is feasible within a risk management framework. Staff have been provided with detailed and thorough information in relation to one of the service users health needs/ condition. There is a clear action plan to be followed and daily checks to be made. The records evidenced that the service users’ health is monitored closely and problems dealt with at an early stage. Staff have received training in managing specific needs such as epilepsy. The home has a robust medication policy, which had recently been reviewed and updated. All staff complete an induction in administering medication. This is an informal training session as part of SCOPE’s induction for new workers. A number of staff had completed a ‘Safe Handling in Medicines’ course and in addition the local Pharmacist provides specific training on medicines used in the home. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in the outcome area is excellent. This judgement has been made using evidence including a visit to this service. The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Robust systems and effective adult protection training ensures that service users are protected from abuse and that their welfare is being promoted. EVIDENCE: The service users spoken with knew who they could complain to, and stated that they were confident any complaints would be addressed fairly. Further evidence of this was found in the minutes of house meetings and in the individual working records, where it was noted that staff give service users the opportunity to complain or raise concerns, and listen to any worries the service users may have. Information on how to complain is detailed in the home’s Statement of Purpose, in the Service User Guide and in a leaflet given to service users titled ‘Complaining isn’t wrong – it’s a Right’. SCOPE have a designated complaints officer to deal with service users formal complaints. The Interim Manager reported that the service had received two complaints, which had been addressed satisfactorily, since the last inspection. Refresher training on ‘dealing with complaints’ had taken place in September 2005 and another session is booked for early 2007. The comment cards received from relatives and health professionals confirmed no complaints had been made against the home. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 19 SCOPE has robust policies and procedures in place and staff undertake regular training in relation to the protection of vulnerable adults. There is an identified adult protection officer at the Mulberry Court and an Adult Protection Team based at SCOPE’s Head Quarters. The Adult Protection Officer attends regional conferences on best practice and key issues relating to Adult Protection. A copy of the Local Interagency ‘No Secrets’ guidance was seen at Mulberry Court. The Interim Manager reported that there had been two local level investigations on adult protection within the service but no interagency Adult Protection referrals since the last inspection. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in the outcome area is good. This judgement has been made using evidence including a visit to this service. The standard of the environment within this home is good providing service users with a clean, bright and homely place to live. EVIDENCE: 7 Hyde Road is a 2 bedroom bungalow in a residential area of Gillingham, Dorset. Although the bungalow has some adaptations to meet the current service users’ needs, it would not be suitable for accommodating people who used a wheelchair. The property has two bedrooms; one is used by the service users themselves, and the second is used by them as an office. There is a kitchen and a lounge. There is a bathroom (with overhead shower) and a toilet. There is a small garden to the rear of the property. This has a patio area and some plants. On the day of inspection the bungalow presented as a homely, clean and bright place to live. The service users were pleased with their new bed, recently purchased. The building is owned and maintained by a local housing association. The external fabric of the building is in good repair. Hyde Road (7) DS0000026754.V313747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in the outcome area is excellent. This judgement has been made using evidence including a visit to this service. Staff have accurate job descriptions in order to ensure that the principles and ethos of the home are met. The majority of the staff team are well qualified, have suitable experience and are sufficient in number and competence to meet the needs of the individual service users. Robust systems for vetting and recruiting staff are in place allowing the most suitable, dedicated staff team to be recruited. Staff receive regular supervision, appraisal and development underpinned by a good training programme in order for them to deliver the best possible care to the service users. EVIDENCE: Staff files seen previously included an accurate job description clearly linked to achieving service users’ individual goals as set out in the Service User Plans. Staff spoken with demonstrated an awareness of their roles and responsibilities, including where it may be necessary to appropriately involve other agencies with more expertise. The service users spoken with confirmed that they generally enjoyed positive relationships with the staff that support them and feel they are treated fairly and with respect. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 22 At the time of this inspection the majority of the care staff employed either have an NVQ2 or NVQ3 with the remainder working towards the awards. Two members of the staff team also hold the A1 Assessors Award. The service users spoken with confirmed that the staff are approachable and support and empower them to live as independently as possible. Through discussions with staff and by reading various documentation staff have an awareness and understanding of the disabilities and specific conditions of the service users. One staff personnel file was examined. This file demonstrated that a robust recruitment and selection procedure had been followed. A Criminal Record Bureau certificate had been obtained and two written references received. The staff member, had completed a detailed application form and listed their previous experience, work placements, qualifications and personal details. Notes of the interview are kept. Service users are involved in the selection and interview of new staff, and evidence of their participation was found in the personnel files examined. Proof of identity (including birth certificate and driving license) had been copied and kept on their file. All applicants also have to complete a health declaration and give a medical history summary. Copies of the staff member’s contracts (terms and conditions of employment) and job descriptions are also held on file, and the newly appointed staff member spoken with was aware of these documents and stated that they had agreed and understood them. There is a six-month probationary period. SCOPE has developed an Induction and Foundation training pack for all new staff, which meet the ‘Skills for Care’ standards (previously TOPSS). The staff team not only work at Mulberry Court but also at three other community homes run by the organisation in Gillingham. SCOPE provide regular training for staff in all key areas (for example first aid, manual handling, food hygiene, adult protection, risk assessments). A training events calendar is produced annually and staff are also encouraged to undertake training courses external to this. The Interim Manager confirmed that staff are all up to date with mandatory training and random checks on the records of three members of staff further evidenced this. The training is linked to the home’s service aims and to service users needs. For instance staff have received training in epilepsy, diabetes, disability equality and autism. Following a recommendation made at the last key inspection in August 2005 SCOPE have also run race equality training, an issue which is now part of their rolling programme of training. In addition well over 50 of the staff team hold their NVQ Level 2 award. The organisation is also funding a number of staff to undertake the NVQ level 3 award. Staffing for Hyde Road is provided from Mulberry Court. Currently 32 of staff at Mulberry Court, covering all four services, has a disability; clearly demonstrating SCOPE’s commitment Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 23 both to issues of equality and to reinforcing positive role modelling for the service users. Each member of staff has a training needs assessment completed annually. Staff also confirmed and records seen further evidenced that staff receive regular supervision in order to enhance their skills and receive support and professional guidance. SCOPE has a detailed policy and procedures relating to formal supervision and appraisal of staff. The Interim Manager confirmed that he receives formal supervision from the regional SCOPE Operations Manager. The written records of supervision discussions confirmed that the sessions include the monitoring of the staff members work with individual service users, support and professional guidance, identification of training needs and discussions around the aims and objectives of the home. Staff meetings also provide group support and supervision. The Interim Manager and Team Leaders have daily contact with staff. Staff spoken with confirmed that they receive a good level of support from their line managers and that supervision sessions are thorough. The Interim Manager and Team Leaders have received training in supervisory management. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in the outcome area is good. This judgement has been made using evidence including a visit to this service. The Interim Manager effectively runs and monitors the service ensuring the Statement of Purpose is fulfilled in practice. The open culture of his management style allows for positive direction and leadership. There are robust systems in place for monitoring the performance of the home against its’ Statement of Purpose and The Care Homes Regulations to ensure service users achieve good outcomes. The health, safety and welfare of the service users is promoted and protected by a huge variety of excellent risk assessments, good monitoring and recording systems and a trained staff team. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Interim Manager is currently applying to the Commission for Social Care Inspection (CSCI) for formal registration. Having been ‘Acting Up’ in the Managers role since April 2006 he has gained great respect from both staff and Service Users. All those concerned are aware that his post is temporary and that another Manager from another service, currently seconded, will be taking the helm early in 2007. In the mean time the Interim Manager is about to undertake his Registered Manager’s Award showing great commitment to both the overall philosophy of the service and the service users. A requirement is made to ensure the Interim Manager’s application is received by the CSCI. There was evidence of continuous self-monitoring, involving service users. Yearly reviews are carried out with the service users and their family/ representatives / friends. This review monitors how the service users’ goals and care plans have been achieved. In addition service users are formally asked their views about the service provided to them. The results from this years’ overall survey demonstrated that the service was performing at 3.3; 3 equalling good and 4 equalling excellent. This was slightly lower than last year and plans are to be formulated in order to address issues brought up for improvement. Regulation 26 visits are carried out monthly and copies of reports sent both to the home and to the Commission. A copy of the Annual Development Plan was also seen on the service users notice board at Mulberry Court. SCOPE are proactive in keeping up with all relevant guidance and legislation. Examination of maintenance and safety records indicated that all checks, testing and servicing of equipment and systems were being undertaken at the recommended intervals. There is a designated staff member responsible for health and safety, fire precautions and first aid. Service users have also had training in personal safety, manual handling and food hygiene. Appropriate policies and staff guidance were in place and all staff receive training in first aid, manual handling, health and safety (including COSHH and Infection Control) and food hygiene. Risk assessments examined were being used to support safe working practices. Accidents and Incidents had been recorded accurately and appropriately and where necessary notified to the relevant agencies. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 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 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The application for the Interim Manager to be registered with the Commission for Social Care Inspection must be completed within the stated timescale. Timescale for action 31/10/06 1. YA37YA37 9.2 (1) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6YA6 YA15YA15 Good Practice Recommendations All individual ‘Action Plans’ should be completed in order to demonstrate work carried out. Policies, which have been in draft for some 18 months, on sexuality and personal relationships should be verified and made available to staff in order for them to guide and support Service Users appropriately. Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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 Hyde Road (7) DS0000026754.V313747.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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