Inspection on 19/10/06 for 85 Drove Road

This inspection was carried out on 19th October 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

85 Drove Road 16/03/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Drove Road (85) 85 Drove Road Swindon Wiltshire SN1 3AE Lead Inspector Stuart Barnes Unannounced Inspection 19 October 2006 10:00 th Drove Road (85) DS0000063428.V311155.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 Drove Road (85) DS0000063428.V311155.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. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drove Road (85) Address 85 Drove Road Swindon Wiltshire SN1 3AE 01793 635560 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) Community Access Network Mrs Tracey Lynne Parker Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager must work a minimum of 64 hours per 4 weeks in the home except when absent due to sickness, training or annual leave. 16th March 2006 Date of last inspection Brief Description of the Service: 85 Drove Road is a small sized care home for up to 3 people aged between 18 and 65 years of age who have a learning disability. A company called Community Access Network (C.A.N.) operates the home. C.A.N. have 3 other similar services in Swindon and North Wiltshire. The home opened at the end of 2005 after the company decided to sell an existing nearby home that at the time did not meet the relevant National Minimum Standards (NMS). Consequently all current service users and staff transferred to this house. Service users were actively involved in choosing the accommodation and deciding the decoration and furnishings. The house is a 3 bedroom, two-storey semi detached property and is located on a busy main road, within a 10 minute walk of Swindon town centre. It provides all service users with a spacious bedroom. Additionally there is a large L-shaped lounge/ dining room and a spacious kitchen that has been recently refurbished as well as two bathrooms. Parking is very limited. The service replicates principles of ordinary living and is typically staffed by one person on duty with an additional person at busy times. At night time there is no awake staff presence. Instead staff take in turns to sleep in on a rotational basis. Sleep in staff are expected to meet any night time needs as they arise. The main service aims are to provide high quality care within the community, where people are supported to take informed risks and to promote opportunity. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days, the first of which the inspector called without telling the home he was coming. As well as seeking information about the service the inspector spent time viewing the accommodation, examining in depth two service user case files, meeting all the service users and talking to them about living in the home, talking informally to four staff and interviewing 2 of them in private, spending time with the manager and contacting care managers and other people about their view of the service. The judgments contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Charges for care and accommodation at this home range from £924 per week to £960 and are subject to means testing. In total 27 out of 43 national minimum standards were inspected. What the service does well: What has improved since the last inspection? What they could do better: There needs to be one more big effort to complete the redecoration of the home and carry out some remedial repairs, including making good the lean to. Some parts of the home would benefit from a more thorough clean. Service users would benefit from access to job coaching or other solutions, which help them use their day time more usefully. Aspects of quality assurance need to be expanded so that performance can be measured and progressed more Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 6 effectively. Induction of new staff must comply with the relevant Sector Skills Councils guidance. 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. Drove Road (85) DS0000063428.V311155.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 Drove Road (85) DS0000063428.V311155.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. 2. 3. Information provided to the users of the service details all they need to know in a format suited to their needs. The service is very good at meeting assessed needs and is good at helping people to over come the difficulties they have. The quality rating in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The service user guide now provides improved formatting with the use of speech balloons and pictures to aid understanding. The service is very good at meeting service users needs. There is a strong person centred value base that runs right through the organisation and held dearly by the current manager. Assessments of both need and risk were found to be very detailed and person centred. This is underpinned by policies and procedures that support service users to develop their independence. Case documentation confirms that individuals have improved with their social skills and they verify that service users appear to be happy living at the home. Examination of case documentation confirms that each service user has a detailed person centred plan, which is closely monitored. It shows that service users are supported to access a wide range of specialist services that promote their well being. This includes well being for physical health as well as specialist support to manage some challenges. Current service users also report good levels of satisfaction. No service user made any adverse comment about the home. One service user Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 9 said that he, “likes living at Drove Road and that he enjoys the house.” Another said they; “like the staff and that it is also nice living at Drove Road”. Comments in case files from care managers report ongoing devolvement and progress for two service users. Where progress is not evident or there are setbacks it can be seen that staff work hard to maintain support the service user to overcome difficulties. All service users make use of star charts to incentivise expected behaviour or to promote better life skills, manage hygiene, or be a ‘politer person’. It is evident that service users are selected with care and the home only offers long term placements to those who it considers will benefit from the service. The manager works hard to ensure there is a managed approach to maintaining consistency. Drove Road (85) DS0000063428.V311155.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. 8. 9. Care planning is of a high standard and the service is being very successful at supporting service users to be active participants in care planning, decision making and in the running of the home. The management of risk is well managed. The quality rating in this outcome area is excellent. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: A strength of this service is the way it manages the planning of care and particularly how it supports service users to be active participants in the planning process. The format used is a highly person centred, integrated approach. It covers accommodation, communication, domestic living, family life, financial, health care, personal hygiene, personal support, social life, specialist support and work. Service user plans promote independence and life skills such as attending medical appointments using pubic transport, ensuring regular health checks like the dentist, ensuring healthy eating, dealing with sadness when family fail to contact and coping with medical appointments. It can be seen that the care plan is re-enforced by various strategies including the use of star charts. The staff team is expected to praise success and Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 11 peoples best endeavours and there are prompts and constant reminders for them to do so in the staff communication book and in team meeting minutes. Case documentation acknowledges how service users feel and report their moods, often described as “brilliant today”. However in one example a service user wrote that they were, “sad that his parent did not have more contact with him.” It was less clear that the sadness expressed was sufficiently acknowledged. Care needs to be taken that the focus on tasks and skills does not hinder acknowledgement emotional distress. The service is very good at supporting service users to engage in decision making that effect them. There is an integrated approach to how this is done. For example support staff and service users agree an action plan using specific template headings. Service users sign the plan, which is periodically reviewed; a processed observed during the inspection and evident in all case files. Star charts are used to progress key areas of challenge. Service users will be supported to write in their daily dairies and they have the option to conclude a weekly review on how well they have done. Key information is passed on to respective care managers or health care workers as appropriate. Case documentation is clear about any imposed restrictions such as not managing medication, restrictions on where to smoke or limits on going out without staff. Those needing support with handling money get this. Any monies held on behalf of service users are checked between shift handovers. Risk taking is also well managed with detail assessments in place for each person. They cover aspects such as fire safety, being alone in the house, medication, use of windows without restrictors, water temperatures, behaviours that challenge and wider access to the community. Drove Road (85) DS0000063428.V311155.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11. 12. 13. 14. 15. 16. 17. Overall the service meets all these standards very well. The weakest area is ensuring service users have sufficient opportunity to use their time usefully throughout the day and they can access paid employment. House meetings do not seem to be very effective at present. The quality rating in this outcome area is excellent. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Behavioural interventions illustrate a person centred approach. They provide clear guidance to staff and seek to maintain success through practice and praise. The services mission statement promotes meeting the needs of service users first and foremost. The manager reminding all staff in the communication book to work weekends fairly evidenced this. The mission statement promotes, “quality community integration through practice and business excellence” and “emphasises the importance of respect, dignity, valuing people, informed choice, equal pops, community integration, culture and diversity. These qualities are evident through out the service. Service users have the option to Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 13 go to church if they want. Even where a service user decides he does not want to go to church staff are reminded that this person should be supported to express any faith, should he change their mind. While it was observed that a support worker was trying to secure some paid work for one person, options to undertake useful and purposeful work for money is not well done. Only one service user has a programme that involves going out of the home five or more days a week to attend either supportive work placements or discrete clubs. The manager explained the lack of opportunities for getting paid work as a consequence of the national minimum wage means that one service user is unable to do a paper round. One service user said they were a bit bored sometimes – closer examination of this person circumstances and his lack of day activity is partly explained by deterioration in their health and the need to rest more. Another service user appears to spend time alone in her room. Examination of their case documentation shows that this person is more involved and active in the home than previously. However more job coaching may be needed to improve the take up of work and more purposeful social inclusion. Service users are supported to access the wider community, both independently of support workers staff and with them. Care Plans and risk assessments give attention to aspects of community safety including road safety. Service users confirm that they can access discrete clubs or drop-in centres for people with a learning disability as well as the very limited supported employment of a few hours each week for one service user and a 5 day placement for another (mornings only) or more often. One service user said he had stopped going to his work placement because he was not being paid enough – thus deciding for himself and illustrating that service users can make key decisions that effect them. Much better done is access to shops and social venues including speedway, pop concerts, football matches - all activities which service users report they undertake from time to time. Service users also confirm that support workers help them budget so they can afford to take a holiday to places of there own choice, including holidays abroad. Service users confirm they have the option of having a key to their bedroom and a key to the front door. It was observed that this is a service where staff engage meaningfully with service users, often re-enforcing to each other that it is the service users home not the staffs. Also observed was staff promoting service users where necessary and praising good endeavours. Staff are good at given discrete reminders to service users who need more encouragement to comply with or complete their programme. Service users confirm that staff do not enter their bedrooms without an invitation. As one put it rather forcefully, “No they are not allowed to [go into my bedroom] unless I say so.” Each person’s care programme supports fair sharing of routines and the promotion of life skills. For example each service user takes in turn to cook meals for all and to shop for food. People are also expected to share tasks such as household cleaning. According to 2 service users job allocations work well. It was observed that one service user went shopping for bread when stocks Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 14 were low and went shopping for more milk. Tasks like this are helping people to maintain a community presence. House meetings take place, but the minutes of these meetings show they not regular. The minutes indicate that the agenda is somewhat repetitive and lacks some dynamism – they could be better. Menus and meals reflect a good balance between people personal preferences healthy eating the level of skill each service user has prepare menus. Food stocks were checked and were found to be adequate, except bread is kept in the office and it was noted that some of it had mould. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 15 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. These standards are also areas where the service is doing well. There appears to be added confidence gained from the service being a well managed service and clear about what it is trying to achieve. The quality rating in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Service users get a lot of personal support that is both targeted and holistic. Service users confirm that staff are respectful to them for example by not entering their bedrooms, being able to lock the bathroom and managing all their own personal care. They also confirm that going to bed and getting up times varies. All service users choose what to wear, though case documentation shows that one service user is prompted when necessary about appropriate clothes for inclement weather. There is evidence of people being supported to understand and manage physical ill health. Care plans and the statement of purpose all promote continuity of care and consistency of approach. Case documentation shows that service users can and do access relevant medical staff and that they get the support to do so. There is also evidence Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 16 that staff share information openly with specialists about specific health challenges that may arise from time to time. The arrangements for managing medication were checked and found to be satisfactory, though there is scope to further improve the way it is being recorded. There is a written medication policy that aims to promote safety and well being. It outlines staff responsibilities for the storage, custody and administration of medication as well as recording. The policy also details what to do if there is an error made. In line with the service aims the procedure allows staff to support service users to purchase ‘over the counter remedies’ such as Beecham’s flu powder and headache pills for minor ailments. In practice only one service user is currently doing this and their GP is fully aware. Medication records were seen. They were double signed that is by two people and are routinely checked by staff. The number of tablets for one service user was counted and found to correspond with the record. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 17 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. Service users appear to be well protected from any potential harm, neglect or abuse. Although staff are provided with proper guidance and relevant training in these areas, it appears staff are not made aware of the General Social Care Councils code of conduct (G.S.C.C). The service is rarely complained about. The quality rating in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: This appears to be a service that is hardly complained about. That said there did not appear to be a record book to record any complaints, should they be made. Support staff confirm they have been given copies of the local ‘No Secrets’ booklet and spare copies were available in the office. There was no evidence to show that staff have copies of the General Social Care Councils code of conduct (G.S.C.C)– one staff member did not seem to know what this was. The current adult protecting policy needs updating to take account of the government policy titled, ‘Safeguarding Adults’. Examination of selected staff records show that staff have attended relevant training in preventing abuse and staff recruitment checks appear to be in order. Staff are also provided training and guidance on with dealing with aggression and have specialist ‘non violent crisis interventions’ as one method of managing difficult challenges. Examination of staff supervision records show that staff are getting appropriate support to manage some service challenges. Drove Road (85) DS0000063428.V311155.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. 30 The accommodation is adequate more than good, though current service users like it very much and it has improved greatly since the home was opened. There are some remedial areas that need further attention. The quality rating in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Service users praise the accommodation saying it is much, much better than the home it replaced. They like it for its location; being in a quieter road with easy access to the town and because it has bigger bedrooms, a better lounge and because there is a new kitchen. For health reasons smoking is not permitted indoors. It is noted that the company have not fully actioned all the recommendations of the local environmental health officer when they last visited i.e. the washing machine has not been located outside a food preparation area and there is no separate hand washing sink in the kitchen. While it is not a feature of the home to have badly soiled linen, nevertheless more consideration is a need to ensure prevention of cross infection when washing is taken through the kitchen area. There are plans to provide a new dining table in the kitchen to finish off Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 19 the recent kitchen refurbishment. There is an external lean to but it is in need of further upgrading. This is an area that could house the washing machine. It was noted that the door to the rear exit/garden area sticks. It needs some realignment. It was also noted that one of the dining room windows overlooking the garden has no blinds. The home benefits from 2 bathrooms. In one bathroom the shower tray has an appearance of mould around the shower tray. Overall the house was fairly clean but close examination shows there are some places that would benefit from a deep clean, e.g. skirting boards and radiator pipers in the bathroom. In the lounge /dining room the skirting boards that have been replaced need a topcoat of paint to match the existing. On the first floor there are three bedroom doors that would benefit from restaining or painting so as to improve the unfinished look. Service users were able to explain what to do if the fire alarm sounds. It was evident from these discussions that they practice the fire drill and fire safety is taken seriously. Fire records where found to be in good order. There was a fire risk assessment in place though this did not include the date of next review. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 20 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): 32. 33. 35 The home is adequately staffed though a recent vacancy has meant that the home has had to rely on agency staff to ensure sufficient cover. Staff are encouraged and supported to undertake relevant training including National Vocational Qualification. Induction of new staff could be better done. All but one staff member has meet at least 6 times a year with their supervisors; staff appear to value the supervision they receive. Recruitment systems appear to be satisfactory. The quality rating in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Rotas and staff records show that the home is adequately staffed but due to a staff vacancy the service has had to rely on agency staff to supplement the permanent staff. The manager and other staff praised the agency staff for the contribution they make and reported that the staff sent by the agency get on well with the users of the service. Examination of the rotas show there is always one person on duty, typically with a second person undertaking a bridging shift so that service users can be supported at busy times. This level of staffing appears to strike a balance between staff being available when needed and not having so many staff on duty that service users are disabled Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 21 by their interventions. However it should not be reduced while the current service users are placed in the home. All established staff have successfully completed a relevant National Vocational Qualification – certificates for 2 staff were seen. Some staff are being supported to undertake National Vocational Qualification level 3 awards. The recruitment records of a newly appointed support worker was checked and found to be in order. This person’s personal and professional development portfolio was examined. It showed that they had been supported with their first day and first week induction schedule. Their portfolio included details of the company’s mission statement and how to complain, a training agreement and confidentiality policy. Insufficient attention is given to explaining national minimum standards (NMS) or the G.S.C.C code of practice. However this method of induction does not meet the relevant skills council specification. Staff praise the company for the amount of training provided. The company supports care workers to undertake a range of relevant training to supplement the National Vocational Qualification training people undertake. Other training provided includes training in fire safety, adult protection, non-crisis interventions, food hygiene, managing medication and infection control. Examination of the training records confirm that relevant training is being provided, though one person is awaiting training in fire safety. Staff also report that they meet with the manager for the purpose of supervision. Three records were checked. In two cases the staff had met with their supervisor at least 6 times in the previous 12 months. In another case there were only 4 such meetings in the same timescale, so this shows a slight slippage from the expected. A feature of the management style is the way the manager engages staff in improving their performance. In one supervision session the need to support service users with positive re-enforcement was discussed openly along with difficulties arising from behavioural challenges. There is a good and effective appraisal system in place with staff having had an appraisal in the past year. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 22 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. The evidence is strong that service users benefit from a well-managed service, that is user focussed and safe. There is scope to further develop quality assurance and annual improvement plans so progress can be measured over time. The quality rating in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: There is evidence of periodic updating of policy – but there is scope to further improve the way policies are documented as old policies, updated policies and existing policies are kept in the same folders. Some key policies such as safeguarding adults, managing medication need to be updated to reflect new guidance. The current Investors in People award is valid and the company is in the process of surveying care managers and others to get their viewpoint. The Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 23 company has a drawn up an annual quality action plan but this has yet to be fully actioned and lacks breadth. While it is a feature of this service that staff constantly seek feedback from service users about the experience in the service; this does not fully equate to an adequate quality assurance initiative. There is scope to improve this aspect of managing the service. Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 24 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 3 2 4 3 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 4 X LIFESTYLES Standard No Score 11 4 12 3 13 2 14 4 15 3 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 3 2 X X 3 X Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA24 Regulation 22(3)(b) Requirement So as to further improve the accommodation and complete the decoration programme already started the following work must be carried out. 1. Ensure all replaced or repaired skirting boards are painted with gloss paint. 2. Paint or varnish or stain all bedroom doors. 3. Investigate and eliminate where possible the cause of the mould growth around the shower tray. 4. Provide curtains or blinds in the dining room casement window. So as to further improve the standards of cleanliness and hygiene the following work must be carried out;1. Clean hidden areas such a pipe work from radiators, behind toilets and skirting boards 2. Further assess any possible risk of cross contamination and DS0000063428.V311155.R01.S.doc Timescale for action 01/12/06 2. YA30 22(3)(d) 01/12/06 Drove Road (85) Version 5.2 Page 26 3 YA24 22(3)(b) 4 YA35 18(1)(c) 5 YA31 18(4) infection control measures that may be needed to eliminate cross infection when undertaking laundry tasks and ensure that support workers are issued with relevant guidance and know the procedure they must follow to reduce any potential risks. To ensure safety and to 01/06/07 complete the upgrading of the home, make good the existing lean to leading from the kitchen. So as to further improve the 20/10/06 induction of newly appointed staff the company must ensure that any staff member appointed after October 1st 2006 has an induction which meets the specification of the Skills for Care council All staff must be provided with a 01/12/06 copy of the General Social Care Councils code of conduct, if they do not have one Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 27 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 YA17 YA13 Good Practice Recommendations It is recommended that arrangements be made to store bread in the kitchen area. It is recommended that serious consideration is given to supporting service users to access or be provided with, job coaches, so they can be better supported to participate in more meaningful activities and routines outside the home. It would be a good idea if at least annually the home arranges for a cleaning company or the support staff to carry out a thorough clean of those areas that services users do not routinely clean. It is recommended that policies concerning the protection of vulnerable adults take account of the newly published local ‘safeguarding adults’ protocols and procedures. 3 YA30 4 YA40 Drove Road (85) DS0000063428.V311155.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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