Inspection on 19/06/08 for 9 Victoria Square

This inspection was carried out on 19th June 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

9 Victoria Square 04/07/06

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 9 Victoria Square 9 Victoria Square Lee on Solent Hampshire PO13 9NE Lead Inspector Jan Everitt Unannounced Inspection 19th June 2008 13:00 9 Victoria Square DS0000067404.V366992.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 9 Victoria Square DS0000067404.V366992.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. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 9 Victoria Square Address 9 Victoria Square Lee on Solent Hampshire PO13 9NE 02392 552772 02392 551887 Lesley.senior@sanctuary-housing.co.uk 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) Sanctuary Care Ltd Mrs Lesley Joy Senior Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: 9 Victoria Square is a three storey detached property, which is situated in a quiet residential area of Lee on Solent. The home is registered with the Commission for Social Care Inspection (CSCI) to provide care and support to 6 service users between the ages of 18 - 65 who are in the learning disability category. The home is situated a short distance from the seafront at Lee-onSolent and is close to local shops and amenities. A frequent local bus service operates into the nearby town centres of Gosport and Fareham. The current fees are £590:61. This includes the client’s contribution to their fees. These fees do not include chiropody, hairdressing, personal items, holidays and outings. 9 Victoria Square DS0000067404.V366992.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 2 star. This means that people who use this service experience GOOD quality outcomes. The site inspection visit to 9 Victoria Square was unannounced and took place over a one-day period on the 19th June 2008. The manager, Mrs. Lesley Senior assisted the inspector throughout the visit. The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The home sent us their Annual Quality Assurance Assessment (AQAA) back on time, which had detailed information and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI. Documents and records were examined and staff working practices were observed where this was possible without being intrusive. The inspector visited all areas of the home and spoke to a three of the six residents who were at home that day. Three residents were out attending day centres and other community activities. Those spoken to expressed satisfaction about their home and were very happy and complimentary about the lives they live. Surveys had been distributed to service users, relatives, staff, care managers, GP and other visiting professionals. Five service user survey, fifteen staff surveys were returned to the CSCI. The outcome of the surveys indicated that there was a high level of satisfaction with the service and that generally residents were very satisfied with the care and other services the home provides. The surveys returned from staff also indicated that they have good training opportunities, are listened to and feel very supported by the management. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 6 What the service does well: The home has effective systems for assessing residents’ needs and for planning ongoing care and support with their involvement. All information about the service and care plans are produced in a pictorial format and residents are able to participate fully in all monthly and annual reviews. Residents have opportunities to exercise choice and to take part in the daily routines of the home. Independence in all areas of their lives is risk assessed and managed accordingly to enable residents to reach their anticipated goals. Residents are supported to access the local community, maintain relationships, undertake activities of their choice and attend the local day service. The home ensures that service users’ have access to specialist healthcare support as required. The home offers a good standard of accommodation for residents and the house has an ongoing maintenance programme in place. Staff recruitment procedures, induction, training and supervision are in place to protect and support service users and the home encourages and supports all staff to undertake care related qualifications. The home listens to residents’ views and concerns and action taken. The home has reviewed policies and procedures in place to ensure safe working practices for residents and staff. The questionnaire surveys returned by five of the six residents and those spoken with at the time of this visit said they were very happy with their home and they were able to make decisions and choices and live their lives as they wished. Residents said they knew how to complain and who to, and the complaints procedure was in pictorial format for them to understand. Staff surveys returned said: ‘We are well supported with training and by the manager’. ‘I feel we have the right support and knowledge to meet the needs of the people who live in this service. ‘Care plans are updated regularly ‘We have regular training which is helpful’. ‘The residents live individual life styles and are appropriately occupied’. ‘Residents mix well in the community and all service users are offered outings and a holiday’. ‘We put residents first and give them choices and control over their own lives’. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. 9 Victoria Square DS0000067404.V366992.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 9 Victoria Square DS0000067404.V366992.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that service users’ aspirations and needs are assessed before they move into the home EVIDENCE: Pre-admission assessments are achieved in consultation with the prospective resident, care managers and relatives to ensure the home can meet that person’s needs and aspirations for the future. The manager reports that there is a large family and parental involvement in the home and most residents are supported by their family, who are involved with all reviews of the resident’s needs and care plans. The manager described how one of the residents, before she moved into the home, visited the home with her parents and gradually increased the time she spent in the home and away from her parents. This allowed her time to become familiar with the home and gradually ease into a more independent life style. Following this period discussion takes place with the existing residents and prospective service user and family and a trial period is decided on. It is after this trial period that a review takes place and includes all the people involved in the placement, and at which time the viability of the placement is discussed a decision is reached and the resident is issued with a 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 10 contract. Following the initial assessment, a further assessment is undertaken one month from the resident moving into the home and there after six monthly reviews take place. All except one of the surveys returned to CSCI said that they had been consulted about living in the home before they moved in. Service users spoken with at the time of this visit expressed happiness about living in this house and knew the home before they moved in permanently. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear and effective care planning and risk assessment systems in place to promote service users’ independence and provide staff with the information they need to meet service users’ needs. Service users are enabled to make decisions and the staff provide them with support. EVIDENCE: The AQAA stated that the home continues to involve service users in their care planning and that they have made improvements by giving the residents more ownership of their care planning by holding their own plans with more pictorial content and have become more involved in care review meetings. This was evidenced in the care plans viewed. Care plans were comprehensive and contained information and guidance for meeting each resident’s individual needs and goals. The care plans contain risk assessments and care plans to 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 12 manage risk, which run alongside daily care plans and are working documents for staff to follow. The organisation, that own the home, are currently piloting a new care planning system which is more person centred and consists of a personal planning book for residents to go through with their key worker. The book is in a pictorial format and identifies all aspects of the resident’s life and their perception of how they wish to live their lives and records their dreams and aspirations. There was evidence in the care plans that care plans are reviewed monthly, six monthly and annually. The yearly review reports include a summary of notable events over the past year, significant progress and areas for development. Service users’ relatives are invited to attend the six-monthly and annual reviews. Residents are encouraged to participate in their plans and to discuss any of their changing needs with their key worker, who they meet with monthly for a discussion and review of their care plans. Residents spoken to were very aware of what was in their care plans and talked about their key worker in a friendly way. The home provides appropriate assistance to service users with managing their finances and this is well documented. There was information on each specific identified risk, action needed to manage the risk and the people responsible for this. Risk assessments included, for example, activities such as making hot drinks and accessing the community and were clearly linked to promoting service user’s independence, participation and choice. Staff comments on surveys returned to CSCI say that ‘Care plans are updated regularly’. ‘We look after residents in a person centred way all the time’ ‘We staff promote the resident’s independence’. ‘We put residents first and give them choices and support them to have control over their own lives’. Those service users spoken told us that they make decisions about their lives and make choices and are able to live their lives as they wish. Records that documented the service user’s daily activities were seen and evidenced that residents have a varied and daily choice of activities and are supported and encouraged to make their own decisions and choices. 9 Victoria Square DS0000067404.V366992.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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit through opportunities to take part in appropriate activities, access the community, maintain relationships and participate in the planning of meals. Service users’ rights and responsibilities are recognised in the daily routines of the home. EVIDENCE: The care plans viewed, evidenced that the residents have excellent social and educational programmes in place. Service users at home on the day of this visit confirmed that they enjoy going to the local shops, shopping, pubs for lunch, cafes, and college to undertake courses in swimming, computer skills and cooking. Outings are arranged on an individual basis with the key worker or as a group. A resident spoken to said that she enjoyed going to college and that next year she wanted to attend for extra tuition. Two service users were at a day centre for the day and the manager said they attend day centre most 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 14 weekdays. These two residents were met at the end of the day and told us they enjoyed attending the day centre and what they had done that day. At the time of this visit one resident had part-time employment. Leisure activities at the home include watching TV, of which there is one in the main lounge and most residents have their own in their rooms, DVD and video games, craft activities and barbeques in the finer weather. A resident was observed to be doing a large puzzle on the table and she told us that she enjoys doing puzzles a great deal. Other residents were observed to be watching the television in the lounge together. Residents also visit the neighbouring home within the organisation, to meet friends, play darts and pool. During this visit a resident from the neighbouring home was visiting the house to see his friends and the manager told us that the two homes do mix well. The home and staff do support the residents to go on holiday. We viewed photographs of a recent holiday that most of the residents chose to go on with the staff, to a holiday camp. Another resident was keen to show us her photographs of her holiday at Disney world the previous year. The manager told us that the residents really enjoy their holidays and integrate well with other people. Family links and friendships are supported and documented in the care plans. Residents told us about visiting and spending time with their families, one saying that she went to stay with her parents most week-ends. Resident’s relatives and representatives are invited to attend all the social functions that take place in the home. Visitors are welcome to the home at any time and this was demonstrated in the visitor’s signing in book. The registered manager confirmed that there are appropriate policies and procedures in place with regards to resident’s sexuality and sexual relationships. Residents go out into the community freely and this is risk assessed and documented. The manager said that the residents are involved with fund raising to buy a people carrier for the home and they had had a stall at the local church fete the previous week to sell the good they have been involved in making, which had been very successful. A resident told us that he and other residents had attended the church fete the previous week and had obtained some much wanted records and was keen to show us his room and his belongings. The manager said that residents from the home and neighbouring home enjoyed a good relationship with the neighbouring community. Service users have responsibilities for helping with the daily routines of the home and these were well documented. The AQAA stated that residents are 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 15 supported to do their own laundry, clean their rooms and help clean the communal areas. A resident spoken to told us that she does tidy her room and keep it clean. The manager said this is undertaken with the support of the key worker. The home was observed to be clean and tidy at the time of this visit. A service user confirmed that they had their own house and room keys and receive their own post, which staff assisted them with if required. Staff knock on bedroom doors and wait to be invited in and were observed interacting with service users in a friendly and respectful manner. Service users were seen to be able to move about the communal areas freely and could choose whether or not to be alone or in company. Food menus are devised on a week-by-week basis with service users taking turns to help plan and prepare the main meals whilst acknowledging the resident’s likes and dislikes. Residents are also supported by staff to accompany them to do the food shopping. Alternative meals are available if requested and drinks and snacks are freely available. All service users prepare their own breakfasts and lunches, including packed lunches when they attend the day service. The registered manager confirmed that currently there are no resident with special dietary needs or requirements. At the time of this visit the support worker was observed to be preparing the evening meal with the help of two of the residents, who were preparing the table. The AQAA identifies that the home has provided more outings, celebrations and house parties in the previous year and house activities have increased. 9 Victoria Square DS0000067404.V366992.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal and healthcare support to meet their individual needs and are protected by the home’s medication policies and procedures EVIDENCE: The AQAA stated that personal hygiene support preferences are established and respected. Cross gender care does not take place where this has been specified and where not specified is only provided in an emergency. The AQAA stated that personal hygiene support preferences are established and respected. Cross gender care does not take place where this has been specified and where not specified is only provided in an emergency. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 17 The care plans identify the individual support needs that each resident needs. Residents are encouraged to complete personal care for themselves to promote dignity and independence. The home has a good mix of both male and female staff and there is a written policy on staff members giving cross-gender personal care. A resident spoken with confirmed that they were well supported by the staff team and that they choose their own clothes and go to the hairdressers when they wish. The residents do choose when they get up and go to bed, but are encouraged to have set times for this if they are attending their chosen activity the next morning. Residents are registered with the local GPs and are able to attend surgery, with support, if they should need to do so. Residents are encouraged to discuss their own health issues when ever possible. All residents attend the GP surgery for a yearly health check. Optician, dentist and chiropody are available to residents in the community and home. The care plans evidenced that health care records are maintained and health care needs are monitored and met. Residents are accompanied to any outpatients appointments by the key worker. The residents do have support from the learning disability community team Resident’s support needs, with regards to medication, is detailed in their personal care plans. There are currently no service users who manage their own medication. There are written procedures for the receipt, recording, storage, handling, administration and disposal of medicines. At the time of the visit there was only a small amount of medicines kept in the home and these were stored appropriately in a secure environment. A sample of the administration records was checked, these were found to be appropriately recorded. The home also keeps a record of medication taken out and returned for when service users go away. Medication training is provided for all staff and this is being reassessed Boots who supply the medication. The manager said that the home is striving to communicate better to residents in words they understand, any information resulting from a medical visit and for staff to communicate faster when they observe any changes in a resident’s health status. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 18 9 Victoria Square DS0000067404.V366992.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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems for ensuring that residents’ views are listened to and responding to any complaints. Residents are protected by the home’s policies and procedures for responding to any form of abuse. EVIDENCE: The service has a complaints procedure that is available to residents and relatives in the Statement of Purpose. This procedure is also produced in a pictorial format, which is kept in resident’s care plans held in their rooms. This enables residents to better understand how and to whom any complaints or issues should be dealt with. The complaints procedure is regularly discussed with residents at their monthly one-to-one meeting with their key worker at which time they are asked if they have any complaints or issues they wish to talk about. The complaints log was viewed and the home has not received any complaints. The manager told us that if there are issues they are discussed at an early stage and resolved. The AQAA states that the home distributes surveys to service users and relatives, who are encouraged to air their views, which the manager said, are received by she and the staff with a positive attitude. The outcome of any complaints/issues highlighted, are discussed at the team meetings where any actions required are planned and discussed. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 20 All but one of the five surveys returned to CSCI from the residents said they would know how to make a complaint if they wished to do so. The service has a copy of the Hampshire ‘Safeguarding’ procedures. Residents are made aware of abuse using pictorial format to enable them to know what is acceptable behaviour from others and what is not. This procedure is also kept in resident’s care plans in their room. Staff are provided with training on safeguarding and abuse during their induction programme and further training is provided through NVQ training and in-house mandatory training by viewing a DVT and completing a questionnaire to test knowledge. The AQAA states, the service wishes to update on abuse and safeguarding training more frequently for staff to achieve greater awareness. The manager told us that because staff are shared between the two homes in the same locality, there had recently been an incident in the other home and this had made the staff more aware of how abuse is perceived. All staff undergo a Criminal Record Bureau check (CRB) and a Protection of Vulnerable Adults (POVA) clearance before they commence employment. 9 Victoria Square DS0000067404.V366992.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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, clean and well maintained environment. EVIDENCE: The house is spacious and homely with a garden both at the front and back. The AQAA says that over the last twelve months the communal areas have been de-cluttered and re-organised to give a tidier appearance to these rooms. We looked around the house and visited the rooms that service users were occupying or had been invited into. The rooms are well decorated and the residents spoken to say they had requested their rooms be redecorated and staff had done this for them and they had chosen the colours and fixtures and fittings for these. Service user surveys and speaking to service users indicated they are very happy living in the home and with their rooms. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 22 The bedding was observed to be colour coordinated and rooms were very individual in content with personal belongings evident. Since the last key inspection the laundry and shower room have been refurbished. The manager told us the back garden is a favourite place for residents to sit in the finer weather and that staff maintain this but it is hoped that it will be redesigned in the future. The service has a maintenance service provided to them with an annual budget to ensure furnishings etc are kept to a good standard. Records are maintained for this. The home was observed to be clean and hygienic and all staff have undertaken an infection control distance learning course, evidence of this was seen on the staff training matrix. Bathrooms and toilets were observed to have hand washing facilities and paper towels for use. Residents have been risk assessed for using cleaning materials. 9 Victoria Square DS0000067404.V366992.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): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s staff recruitment procedure and are supported by appropriately trained and supervised staff. The home supports and encourages staff to undertake relevant care qualifications. EVIDENCE: The AQAA states that the home has a stable consistent staff team with the shortest length of time in post being one year. The AQAA records that staff have developed good relationships with the service users and are aware of their needs. Residents are able to trust and rely on each staff member and are able to discuss more delicate matters with them. This was evidenced in the daily records and care plans that contain records of staff interactions with residents and also records the monthly meetings. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 24 The relationship between staff and the residents was observed to be good and residents said they were supported and were able to talk to staff at anytime The AQAA records that all staff are encouraged and supported to undertake NVQ training. 7 of the 8 support staff have now achieved their NVQ level 2 or 3. Five staff are to commence their NVQ level 3 training in October 2008. The AQAA told us that four staff have been inducted to pilot the Learning Disability Qualification and it is anticipated that within the next year they would have achieved this qualification and that all staff will have achieved a minimum care qualifications of NVQ level 2. There was evidence that this has now been achieved. The inspection report of July 2006 states that in addition to the registered manager, there are two members of staff on duty at any time during the day and a sleep-in duty at night. This was evidenced on this visit. Two carers were on duty and the manager. There is a good mix of both male and female staff at the home. The staff surveys returned to CSCI, two of the fifteen indicated that cover could be better to cover sickness and annual leave, however, there was no indication that people are being put at risk and the manager said that existing staff are willing to cover absences. The remaining survey comments say that: ‘The staff put residents first and give them choices. Support them to have control over their own lives’. ‘The service meets the needs and wishes of the service users’. ‘The service and organisation are a very friendly environment to work within and if ever I am unsure about anything the correct information is available’. ‘ Lovely atmosphere’. ‘We support the service user to go to college and clubs and visiting friends’. A sample of three recruitment files was viewed and contained CRB, POVA checks and two references. All staff have a job description and the manager told us that at the present time staff are being profiled and performance assessed against their appraisal and supervision record. There was evidence in the recruitment files of an induction programme. The manager told us that the service has introduced a new induction programme over a three month period using a DVD method of training and uses the induction foundation workbook to test the candidate’s knowledge, which is supervised and signed off by a senior person. There was evidence of a completed induction workbook in the latest recruit’s personal file. Staff have individual training files. Each file has a matrix of the training staff have undertaken and the date this has taken place. The certificates are stored in this file. The files viewed, demonstrated that staff do receive regular and 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 25 appropriate training, which is funded. Other training such as Challenging Behaviours and Medication training was evidenced in the staff training files. The manager told us that the organisation has adopted a DVD training method for all mandatory training, which is delivered in house and is followed by discussion and staff completing a work sheet to test gained knowledge. The staff gave back positive feedback about this method of training. The staff undertake a practical moving and handling update yearly. Service specific training is accessed if it is requested. The manager is able to access the budget for this training. Staff comments on surveys returned to CSCI were: ’Good induction and we have the right support and knowledge to meet the needs of the people who live in the service’. ‘We have regular house training and I am doing the LDQ3’ ‘We have on going training, which is very helpful’’ The organisation has introduced a more structured supervision programme. This is now an agreement between the staff member and the supervisor, who equally prepares and contributes to the supervision meetings. The manager said as a result of this staff have more input into the meetings and now think of them as a two way information and idea sharing time. Records of the supervision meetings and annual appraisals were evidenced in the staff personal files. 9 Victoria Square DS0000067404.V366992.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): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home that seeks their views and promotes the health, safety and welfare of service users and staff. EVIDENCE: The registered manager has completed the NVQ level 4 Registered Managers Award (RMA) and has managed the home for four years. She also manages the sister home in the close proximity of Victoria Square. The manager told us that her development within her management role is through the training courses provided by the organisation and she and her team leaders have attended an in depth management development course throughout the previous twelve months, which she considers has resulted in a stronger more confident management team. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 27 The Sanctuary Group has a quality assurance system in place for measuring outcomes for residents. The organisation has distributed questionnaires to service users and relatives in the past twelve months. The results from this have been represented in a graph like format and also posted on the organisations website. One of the outcomes from this survey was that the questionnaire is not designed specifically for learning disabilities and some questions are not applicable and have distorted the results of the survey. This issue has been addressed at the SHIRE (Sanctuary Help to Involve Residents Equally), which is a group, that meets once a month, and is represented by residents from all the Sanctuary homes and is chaired by a resident from another area. It is at this meeting that issues can be aired and discussed, and it is at this forum that appropriate questions are being put together to formulate a new questionnaire, which will be presented in a graphic format to be distributed to residents. Regular staff meetings are held and the minutes for these are recorded and maintained in the home. The manager said these are well attended and are an open forum for discussion on any issues. The operational manager visits the home once a month and reports on the findings of this visit. The monthly audits that take place are care plans, medication charts, the environment, health and safety and training and development. We observed that the company policies were reviewed in 2007. A sample of the servicing certificates for systems and equipment were viewed and found to be up to date. Staff have received training in safe working practices and risk assessments are in place. The fire log was examined and records of the fire alarm checks are recorded appropriately. The fir log demonstrated that staff have had fire drills and training, which has been recorded as taking place in March 2008. Accidents to staff and residents are recorded and maintained in personal files. No accidents had recently been recorded. 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 28 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 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 29 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 Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 9 Victoria Square DS0000067404.V366992.R01.S.doc Version 5.2 Page 30 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. 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