Inspection on 17/07/08 for 8 St Winifred`s Road

This inspection was carried out on 17th July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 St Winifred`s Road 16/01/07

8 St Winifred`s Road 26/01/06

8 St Winifred`s Road 15/09/05

8 St Winifred`s Road 21/10/04

8 St Winifred`s Road 16/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 8 St Winifred`s Road Shirley Southampton Hampshire SO16 6HP Lead Inspector Mark Sims Unannounced Inspection 17th July 2008 10:00 8 St Winifred`s Road DS0000011806.V366978.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 8 St Winifred`s Road DS0000011806.V366978.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. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 8 St Winifred`s Road Address Shirley Southampton Hampshire SO16 6HP 023 8070 5506 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) H4012@mencap.org.uk www.mencap.org.uk Royal Mencap Society Vacant Care Home 8 Category(ies) of Learning disability (0) registration, with number of places 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) The maximum number of service users to be accommodated is 8. Date of last inspection 16th January 2007 Brief Description of the Service: 8 St Winifred’s Road is a large detached family home situated in a quiet cul-desac close to Shirley High Street and local amenities. The home is registered to accommodate 8 residents with learning disabilities between the ages of 18 65. The current residents are all over the age of 30. The home comprises eight single bedrooms, which are spacious and suitably furnished. There is a lounge, lounge/dining room and large kitchen and the home has a rear garden for recreational use. Hyde Housing Association owns the property and the Royal Mencap Society are the registered providers. At the time of this inspection the home was being managed by an experienced acting manager. Fees: weekly fees are from £610.00 basic plus additional to cover assessed needs not included in the basic fee. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures services against core National Minimum Standards. The fieldwork visit to the site of the service was conducted over 5.5 hours, where in addition to any paperwork that required reviewing we (the Commission for Social Care Inspection) met service users, staff and management. The inspection process involved pre fieldwork activity, gathering information from a variety of sources, surveys, the Commission’s database and the Annual Quality Assurance Assessment information provided by the service provider/manager. The response to the Commissions survey was good, with five surveys returned by people involved with the home. What the service does well: What has improved since the last inspection? 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 6 The environment is in the midst of being refurbished, the main corridors and stairwell having been redecorated, the shower room revamped and bathrooms renewed. Records within the home have also been updated with new health and financial profiles established for each service user, person centred plans introduced and a continuous improvement plan developed. 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. 8 St Winifred`s Road DS0000011806.V366978.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 8 St Winifred`s Road DS0000011806.V366978.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): Standard 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have access to information when choosing a home that will meet their needs, although this is not always presented in the most appropriate format. EVIDENCE: The dataset, which forms part of the AQAA documentation, establishes that no new clients have been admitted to the home since the last inspection report was produced. A statement that was confirmed with the acting manager during the fieldwork visit, the actual visit to the home. During the visit the manager provided copies of the home’s ‘statement of purpose and service users guide’, both documents are only available in a written format, which reduces their value, as some service users are unable to understand information produced in this format. The service has produced a pictorial brochure, which combines written descriptions and images; however, this document needs of updating as the 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 9 information contained within it relates to staff and management personnel who no longer worked at the home. Information provided by the service users indicate that they feel they were involved in the decision making process, when choosing whether or not to move to the home, four people ticking ‘yes’, in reply to the question: were you asked if you wanted to move into this home’. Whilst no new service users have moved into the home, since the last inspection, one person has decided to move out of the home. The acting manager was able to discuss the process involved in supporting the service user in making this decision and on ensuring the home they moved to would meet their needs. This process has involved enabling the service user to visit the new home and to remain for meals and overnight stays. An information pack has been put together for the new home, which contains basic details about the service user and summaries their personal care/support requirements. During the visit the staff and management were overheard and/or observed assisting the service user in making arrangements to move, organising boxes for packing, liaising with the staff at the new home, confirming removal van times, etc. Whilst this not evidence of how the home manages admissions, the principles of support, etc, are similar with the management and staff demonstrating how they support people with change and ensure that all choices are made by the person. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in making decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The service tells us via their AQAA that: ‘Service users have individual care/support plans. These evidence and monitor all support needs and wishes. An assessment of service users needs is reviewed on an annual basis, then reviewed monthly by keyworkers, Social Services are involved in this process. Choices and wishes are recorded on the service users person-centred-plans and objectives are identified for the forthcoming year. Service users are consulted as much as possible in all aspects of the running of their home. Their views and wishes are discussed and recorded via house 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 11 meetings, keyworker meetings, reviews, quality visits, meetings with house officers, etc. All service users are encouraged to participate in their ‘Managing Risks with Individuals’ and these are maintained in their files. All service users have a keyworker. We are currently working with the health team in supporting two of our service users living at the house to receive the specialised support they need. We liaise with day services to support the service users to obtain a programme of their choice and keep abreast of service user progress’. During the fieldwork visit we (the Commission), found evidence to support the above statements the service having introduced person-centred-plans and support plans, documents that place the person at the centre of the planning process and set out how they like or wish their care to be delivered and how they would like to live their lives through the attainment of goals. The support plans, which are separate from the person-centred-plans, were well completed documents, which contained detailed information about both the service users actual support needs and how the staff should assist the service user in managing these needs. The person-centred-plans are also useful documents, which capture and relay the service users aspirations and how they might be supported in achieving their aims or aspirations. The only shortfall in these documents is the format used to convey the information, as again it is only in a written format and therefore not fully owned by the service users, who might prefer other methods or options to communicate what they would like to achieve. The language used to complete the documents, also suggests that the service user do not truly own their person-centred-plan, as everything is written in the third party and not the first, i.e. ‘person one likes’ instead of ‘I like’ or ‘I would like’, etc. Risks to the service users are managed well within the home, with the ‘Managing Risks with Individuals’ process ensuring that all aspects of the persons life/activities, which might potentially result in harm, having been identified and a plan to reduce the risk produced. During the fieldwork visit two ‘Managing Risks with Individuals’ files were reviewed. These were informative documents, which were kept under regular review and updated were and when necessary. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 12 Whilst in the office talking with the manager one service user came to inform the staff that they were going out into the town, this was an unaccompanied trip and as per the risk management plan the person was informing the staff that they were going out, where they would be and what time they would be returning. In discussion with the manager it was established that this is a regular or routine occurrence and that the person is being support to achieve independent living, this is also documented in their support plan. The views of the service users are quiet clear with four of the five people returning surveys ticking ‘always’ in response to the question: ‘do you make decisions about what you do each day’ and ‘yes’ in reply to the questions: ‘can you do what you want to do during the day, evening and the weekend’. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle, and receive support to develop their life skills. Opportunities for social, educational, cultural and recreational activities can be affected by the instabilities in the staff team. EVIDENCE: The feedback from the service users, as evidenced above, indicates that they feel they are provided with choice over their day-to-day activities a belief that is supported by the evidence contained within the support and person-centredplans. Observations also indicate that people are supported to live the lifestyle they require, with one service user, as mentioned taking themselves out to the 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 14 town, whilst two other people were escorted on trips into the local shopping centre. However, a third person, opted not to go out with staff on several occasions, which seemed to be because the relationship between the service user and staff member was not well established, the result of the service only having four permanent staff, one of which is the acting manager. Whilst the Commission appreciates that the manager is making efforts to consistently book relief and/or agency staff the fact remains that these people are not permanent staff members and are transient by the nature of the job they undertake and this can be both unsettling and troubling for the people living at the home. The lack of permanent staff can also have knock on effects with people’s holiday plans, etc, the manager saying during a conversation that people might not be able to go away this year, as she only has three staff and herself to cover the holiday requests of six people. If this was to happen and the service users were unable to have the holidays they requested, as evidenced via the minutes of the house meetings, it would be as a result of the provider organisations failure to properly staff the home and not through any lack of commitment on the part of the staff employed at the home, who are already covering additional shifts to support the service users, as evidenced via the duty rosters. Presently the lack of staff does not seem to be impacting upon people’s attendance of day services, etc, with relief/agency staff and keyworkers able to provide the support required by people when attending such events. People’s support files providing good evidence and/or contain information of the persons’ weekly schedule. The service states via the AQAA that: ‘ We support service users to access appropriate college and day service programmes/ course of their choice. One service user belongs to the Special Olympics Team and has won Gold and Silver medals for running and long jumping. All service users attend a range of social activities including club, chill out club, Gate way club, bowling, cinemas and shows, football matches, swimming, church services and events, outings, meals out, trips to local pubs, holidays and day trips of service users choice. All service users are encouraged and supported to participate in home activities, including domestic tasks, menu planning, cooking, choosing furnishings, etc. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 15 Service users are encouraged to maintain contact with their family and friends and invite them home. All service users have their own front door key and bedroom key and can come and go as they please, unless their risk assessment says they need staff support when out in the community’. During the visit it was established that service users are involved in domestic duties/tasks, which are planned and equally shared out amongst the client group, a schedule in the kitchen setting out people’s responsibilities, which are largely focussed around setting tables, clearing tables and loading the dishwasher, etc. The home can also evidence that the service users are involved in setting the weekly menu’s, as the staff hold a weekly menu meeting, during which people’s meal preferences are planned into the weeks’ menu. In discussion with the staff member who co-ordinates the menu meetings, it was established that where people’s choices differ it is the majority view that takes president, which is accepted by the client group. The services statement about service users being encouraged to maintain contact with their families and friends was clearly demonstrated during the fieldwork visit, with one service user supported to ring two members of their immediate family for a chat. In discussion with the manager, it was established that this was a common event and that it had been agreed with the service user and their relatives that they could ring at anytime and especially to allay anxiety, which the service user can experience. The support plans contain details of people’s next-of-kin and the service users have flies, which contain photographs of people who are significant to them, one person showing us (the Commission) their file, which contained photo’s of their parents and immediate family. The layout of the kitchen indicates that mealtimes are a social event, with service users able to eat either in the lounge/diner or kitchen/diner, depending on their preference. People are able to make snacks and drinks for themselves, although it depends on their risk assessment, as to whether or not this is supervised. During the visit a client was kind enough to offer and make a drink for me (the inspector), which was greatly appreciated. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 16 As our (the Commission’s) arrival in the home caused some disruption to the home’s daily routine, the manager asked the service users if they would prefer fish and chips for lunch, which was a keenly received suggestion. In discussion with the manager it was established that take-away meals or eating out are options preferred by the service users and that the service users often accompany the staff to collect the meals ordered/required. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The service users are provided with person-centred-plans, which as discussed earlier within the report require the service user to provide input, where possible. The two person-centred-plans seen during the fieldwork visit provided staff with good levels of information, which did indeed include details of how the service user wished to be supported with their care and the attainment of the goals or aspirations. Each service user is allocated a keyworker and it is understood from discussions with the manager that it is the keyworker’s responsibility to ensure the plans are reviewed and updated; and that the service user has been 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 18 consulted as part of the process, the plans reviewed did contained entries verifying that the plans had been reviewed. People’s health care needs are well catered for at the home, with each plan containing written details of the persons’ health care needs and evidence both in the running records and via copies of correspondence maintained on the persons’ file, of their involvement wit health and social care professionals. Each service user also has a ‘health action plan’, which identifies how and where the service user likes to receive support when involved with health care services, dentist, opticians, general practice, etc. The support plans were also noticed to contain documents referred to as ‘grab sheets’, which are designed to accompany the service user into hospital and provide basic but essential details of the person’s health care needs, current medications, medical history, etc. The storage of the service users day-to-day medication was reviewed during the fieldwork visit and found to be safe and secure, whilst the records appertaining to the handling and administration of the residents’ medicines accurate and up to date. The home’s storage of controlled medications is in need of review, as the current storage arrangements do not comply with the ‘Medicine Act’, ‘safe custody’ regulations, which were updated in October 2007. Lloyds Pharmacy provide medications to the home on a 28 day cycle, all medicine arriving at the home are signed as received into the home on the medication administration record by the staff. Staff training records, seen during the fieldwork visit, establish that all permanent staff members have received medication administration training and that this is updated on a regular basis. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The dataset, which forms part of the AQAA documentation, establishes the existence of the home’s complaints and concerns procedure and that this was last reviewed in the October of 2007. The dataset also contains information about the home’s complaints activity over the last twelve months: No of complaints: 5. No of complaints upheld 0. Percentage of complaints responded to within 28 days: 100 . No of complaints pending an outcome: 0. The evidence indicates that people’s complaints are being appropriately handled, with a complaints logging system documenting all activities associated with a complaint. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 20 During the fieldwork visit we (the Commission) saw documented evidence that complaints are also reviewed during ‘Regulation 26’ visits (Quality Visits), the reports from the monthly visits reviewed. In discussion with the acting manager it was stated that the service users rights to make complains are reinforced at each service user meeting, the minutes of the last two meetings providing evidence to support this statement. Details of the persons’ complaints or concerns are also documented in their support plan. During the visit the acting manager provide us with sight of the homes/staffs training files, which indicates that staff have completed ‘protection of vulnerable adults’ training, this corroborated the information contained within the AQAA, which states that staff have undertaken ‘adult protection training’. The home tells us, via their AQAA and dataset, that policies on the protection of service users are in place, ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’, the policies updated/reviewed in the October and November of 2007. The dataset also establishes that over the last twelve months one safeguarding referrals have been made to the Local Authority, a statement support by a review of our database, which established that one alert has been brought to the Commission’s attention during this period. During the fieldwork visit the manager produced the minutes of a recent meeting with the Local Authority, which indicated that the protection concerns had now been resolved. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour of the premises was undertaken in the company of the acting manager. The home was noted to be in clean and tidy throughout and the general decorative state of the home good. The acting manager had indicated via the AQAA that over the last twelve months the environment had benefited from the following improvements, the main corridors and stairwell having been redecorated, the shower room revamped, bathrooms renewed and new garden furniture provided. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 22 The manager also provide us (the Commission) with sight of the home’s development plan, which establishes that the main lounge is to be decorated and new furnishing provided. Whilst undertaking the tour of the premises, it was noticed that scaffolding was ready for collection in rear garden, when asked the manager explained that there had been a leak in the roof and the Housing Association who own the property had responded quickly to repair the damage. The manager explained that all remedial works and maintenance of domestic services, etc, is undertaken by the Housing Association, as the landlords and that she (the acting manager) is provided with a list of contact numbers’ in order to report and arrange for repairs to be completed. Evidence of how the system operates was shown to us (the Commission) by the manager, who produced the paperwork for the recent leaking roof, which included details of the initial report and a repairs notice that confirmed the date for the work to be commenced, 18 July 2008. Feedback from the service users indicate that they find the home to be clean and tidy, with four of the five people ticking ‘always’ in response to the question: ‘is the home fresh and clean’. The service does not employ any domestic staff and the upkeep and cleanliness of the home is ensured by the staff and the service users, who undertake some domestic duties/tasks, as mentioned previously. During the tour of the home the premise was found to be clean, tidy and free from any unpleasant odours, which given the shortages within the staff team is a testament to their dedication to the service and the service users. Communal facilities (bathrooms and toilets) were clean and fresh, however, none contained liquid soaps or paper-towels during the visit, which was brought to the acting manager’s attention, as an infection control concern. The acting manager stated that this was unusual as paper-towels and bottled liquid soaps are purchased and left in the communal areas normally, she (the acting manager) undertook to remedy the situation. The laundry, which is located within the main building but away from areas of the home used by the service users, is the responsible of the staff who launder service users clothing and returning this to the client room. The laundry has recently been refurbished and houses not only the homes’ domestic washing machine and dryer but also the home’s ‘COSHH’ (Control Of Substances Hazardous to Health) cupboard, which is a lockable facility. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff receive access to training and skills development courses but are not provided in sufficient numbers to appropriately support the people who use the service. EVIDENCE: The dataset, which forms part of the AQAA documentation, indicates that the home employs six permanent staff, however, during the fieldwork visit the duty roster establishes that only four permanent staff remain at the home, with two staff, including the manager, having resigned. The provider organisation failed to notify us (the Commission) of the manager’s absence or resignation from the home in accordance with the regulations, which will be addressed in section of report immediately after this section. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 24 During the fieldwork visit three permanent staff, including the acting manager were seen on duty. These staff were then supported by three relief or agency staff, who were also seen around the home during the visit. The over reliance on agency or relief staff has already been discussed in this report, as has the potential impact on the service users, with the possible loss of their holidays and anxieties caused by being supported by unfamiliar people. The minutes of the safeguarding meeting, referred to earlier in the report, indicate that the provider organisation are intentionally delaying the recruitment of new care staff, as they have concerns over the financial viability of the home. This has not been discussed with us (the Commission), as the regulatory body for the service, as evidenced by a review of our database prior to undertaking the visit to the home. The provider organisation should consider the impact this decision might be having on the service users and seek to resolve the problem as soon as possible, so as to limit the affect upon the people living at the home. Since the last inspection on the 16th January 2007 no new staff have been employed at the home. As the previous recruitment and selection process was considered to be robust and thorough we (the Commission) did not re-review any of the existing staffs files. During the fieldwork visit the acting manager provided us (the Commission) with sight of the training files maintained by the staff, which provide a good indicator as to the recent courses attend by the staff. In addition to copies of certificates (if appropriate), each file contains a training matrix, which identifies the courses completed and the dates by which updates are to be attended. In conversation with one keyworker it was established that they had recently completed their National Vocational Qualification (NVQ) at level two and was hoping to commence level 3 shortly. The keyworker also stated that she had recently attended a safeguarding adults course and was due to attend a three-day diabetes course and a course on the management of challenging behaviour. The provider organisation, produce an annual training plan, which is available via their intranet, the manager producing a copy for us (the Commission) to review during the visit. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 25 Information taken from the dataset and adapted during conversations with the manager; indicates that three care staff are employed at the home. All three staff have completed a National Vocational Qualification (NVQ) at level 2 or above and this gives the home a percentage rate of 100 of its care staff possessing an NVQ at level 2 or above. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home may be based on openness and respect but the stability of the home’s management structure is a concern. EVIDENCE: The service has no Registered Manager and whilst an acting manager is in post, an application for Registration with the Commission for Social Care Inspection had not been received prior to undertaking the fieldwork visit and no notification had been received from the provider organisation informing us of the manager’s absence and/or resignation. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 27 A review of our (the Commission’s) database established that this is not the first time the service has been without a manager, the Commission having to remind the provider of the need to Register a Manager previously. This matter has been brought to the attention of the Link Inspector for the service, a role within the Commission, who is to contact the provider organisation. To ensure the satisfactory operation of the home the acting manager has overseen the introduction of a number of systems, including the development plan, the new person-centred-plans and new financial management plans. The acting manager was able to demonstrate through the fieldwork visit that she has developed a good rapport with the service users and a sound working relationship with her staff team. People spoken with praising the acting manager for her performance, attitude and dedication to the role. She (the acting manager) is well supported by the provider organisation; who undertake regular visits to the home in order to complete ‘Quality Visits’ (Regulation 26 visits) and copies of the reports produced following these visits were seen during the fieldwork visit. At a previous inspection we (the Commission) required the person undertaking the visits to provide and/or include greater evidence of the views of the service users. However, the reports seen during the visit are still largely devoid of any service user input, with only one service user spoken with during the last two visits, or only one persons’ comments included in the report. Within the home the views of the service users are more regularly sought, with regular service user or house meetings taking place, minutes of these meetings are maintained and menu meetings, as discussed earlier in the report. Service reviews are also regular occurrences and the documented evidence is that professional social care representative, the service user and keyworkers attend these meetings. The keyworkers also ensure the support plans and person-centred-plans are kept under review and are updated in accordance with the changing needs and wishes of the service users. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 28 The service tells us, via the AQAA and dataset that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. The AQAA is also used to inform us that: ‘Personal protective clothing (aprons and gloves), are provided to staff and that COSHH materials are appropriately stored’, both comments were substantiated during the visit. Health and safety training is being made available to staff, with the training matrix and plan providing evidence of the courses attended and those to be attended by staff, including: health and safety, infection control and moving and handling, etc. The tour of the premise identified no immediate health and safety issues, and the risk assessments documentation does consider both potential areas of harm and how these can be managed. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 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 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 3 X X 3 X 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes 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 YA12 Regulation Requirement Timescale for action 27/09/08 2. YA20 3. YA32 4. YA37 Regulation The provider organisation must 12 ensure sufficient permanent staff are employed at the home to appropriately support the service user live the life they require. Regulation The provider organisation must 27/09/08 13 ensure all medications are appropriately stored and secured. Regulation The provider organisation must 27/09/08 18 review its staffing complement to ensure sufficient skilled and competent staff are employed at the home at all times. Regulation The provider organisation must 27/09/08 8 take steps to recruit a permanent manager who must apply for registration. Regulation The provider organisation, when 26 supporting the management of the home via ‘Quality Visits’, must ensure the views of the service users are considered and reflected. 27/08/08 5. YA37 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 31 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 YA2 Good Practice Recommendations The provider organisation should ensure its service user documentation is updated and made accessible to people in appropriate formats. 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 8 St Winifred`s Road DS0000011806.V366978.R01.S.doc Version 5.2 Page 33 - 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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