Inspection on 04/09/06 for Abbotsford

This inspection was carried out on 4th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbotsford 15/08/07

Abbotsford 06/02/06

Abbotsford 16/08/05

Abbotsford 07/02/05

Abbotsford 18/10/04

Abbotsford 22/03/04

Abbotsford 01/03/04

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 Abbotsford 7 Bracken Road Southbourne Bournemouth Dorset BH6 3TB Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 4th September 2006 14:45 DS0000004002.V305529.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 DS0000004002.V305529.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. DS0000004002.V305529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 7 Bracken Road Southbourne Bournemouth Dorset BH6 3TB 01202 417847 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) wells4269@fsnet.co.uk The Stable Family Home Trust Mr Mark Wells Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000004002.V305529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: The registered service provider is The Stable Family Home Trust [S.F.H.T] a registered charity that provides residential care, a day service and related services for adults with learning disabilities. The day and residential services are interdependent with support from specialist staff at the day service being available to the staff and service users in residential care services to provide training, guidance and help with among other things, issues such as employment; risk assessments and personal relationships. Current residential care charges are £427 per week. However, this does not include day care provision, which is charged separately. The home is located in the residential area of Southbourne, within walking distance of the local amenities and cliff top. Local amenities include shops, a post office and places of worship. Public transport is readily available and Bournemouth town centre a ten-minute bus ride away. The accommodation provides for up to eight people in a detached house converted for use as a residential care home. Bedrooms are located on the ground, first and second floors of the premises. The home is centrally heated and all users have single rooms, en suite facilities and the use of a lounge and dining room. There is a small garden area to the side of the property and a garden and patio area to the rear. DS0000004002.V305529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place over approximately 5 hours. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. This inspection was a key inspection and therefore, assessed all identified key national minimum standards for care homes for adults (18-65). The inspector initially spent time with the manager of the home and examined various records and documentation including care plans, risk assessments, staffing records and health and safety records. The inspector conducted a tour of the premises viewing all communal areas of the home and a sample of 4 service users’ bedrooms. The inspector had the opportunity to speak with five residents both individually and in a group. They spoke positively about their experiences of living in the home including their rooms, their weekly activities, the staff and the food. The inspector also spoke with two members of staff who said they enjoyed working in the home. Additional information received by the inspector prior to the inspection was also taken into account. This included a completed pre-inspection questionnaire, monthly monitoring visit reports from the responsible individual of the home, previous inspection reports and any incident reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. What the service does well: Abbotsford has a relaxed atmosphere in which service users rights and choices are respected. There are excellent opportunities to develop independent living skills and service users felt their goals and aspirations were being listened to such as working towards more independent travelling and being able to spend time home alone. Since the last inspection, one service user had been successfully supported to reach his goal of moving into more independent accommodation. Service users are consulted informally and formally about the running of the home, and have opportunities to be involved in service development such as producing the Service User guide, staff recruitment and re-decoration of the home. Service users participate in all aspects of household routines such as shopping, cleaning, washing and meal preparation. Service users benefit from an ethos that is open and inclusive and feel confident about raising issues and that these will be listened to and acted upon. The home has an experienced manager who ensures the home is well run and effectively supports the staff team. Service users benefit from a competent DS0000004002.V305529.R01.S.doc Version 5.2 Page 6 staff team who work in a person centred way focusing on service users needs. Staff morale is good resulting in an enthusiastic workforce that committed to improving service users quality of life. Abbotsford offers comfortable, spacious accommodation and service users have an obvious pride in the rooms, which they were happy to show to the inspector. All rooms have ensuite facilities offering them maximum personal privacy. The home is ideally situated in the local community and service users regularly visit the local shops and amenities. Visitors are welcomed into the home and personal relationships are supported which greatly enhances service users social lives and family ties. What has improved since the last inspection? What they could do better: As a result of this inspection three requirements and three recommendations have been made. There is an outstanding requirement that the organisation needs to develop a policy on quality assurance and an annual development plan incorporating feedback from service users needs to be produced for the home to provide action points/targets to further improve the quality of service in the home. The home is not currently meeting the target of 50 of care workers achieving NVQ Level 2 or above, however, progress is being made towards establishing a workforce that achieves nationally recognised care qualifications. The manager is also still awaiting verification for the Registered Managers Award and NVQ 4 in care. DS0000004002.V305529.R01.S.doc Version 5.2 Page 7 The current plans are limited in some areas and there are gaps that have not been filled in. These could be improved to give clearer guidance to staff about residents’ particular support needs. This would be particularly important for service users with higher support needs who were less able to articulate their own preferences. The current system of logging complaints does not comply with the Data Protection Act and only one complaint should be logged per page to maintain confidentiality. There are still some outstanding policies and procedures that are needed. However, it is appreciated that these are being prioritised and produced as quickly as possible. 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. DS0000004002.V305529.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 DS0000004002.V305529.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is available about the service in a format that is accessible to adults with learning disabilities ensuring prospective residents have a good idea about what it is like to live in the home. Suitable assessments are carried out and service users have good opportunities to “test drive” the service prior to moving in, so they can be confident the home is able to meet their needs. Service users are provided with contracts that fully set out the terms and conditions of living in the home. EVIDENCE: There was an outstanding requirement at the last inspection to complete a Service User Guide. The manager showed the inspector the completed version of this that is now available for service users. This has been produced to a high standard using pictures and giving excellent information about living in the home including current residents’ views. One service user had moved out since the last inspection into more independent accommodation. A new service user had moved in on the DS0000004002.V305529.R01.S.doc Version 5.2 Page 10 31st August 2006. This service user had actually transferred from one of the other Stable Family Home Trust’s homes at his own request. The service user, therefore, knew the home and the residents, although he had the opportunity for some introductory visits prior to moving in. As he was an existing service user within the organisation all the relevant paperwork was transferred across from the other home. The manager confirmed the move was carried out in consultation with the social worker who was happy that it was the service users choice to move. Discussion with the resident confirmed he had chosen to move and had opportunities to visit the home before moving in. He showed the inspector his room that had been re-decorated in the colour of his choice. A sample of service users’ contracts was seen as part of the inspection. These now contain information about individual service users’ fees and give a full guide to terms of residency. These can be kept in the service users rooms or by the home if the resident wishes. DS0000004002.V305529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Staff have a good working knowledge of service users needs and service users are helped to work towards personal goals, although care plans could be improved to provide clearer guidance of individual support needs and how these are to be met. Staff recognised and supported service users rights to make decisions giving residents choice and control in their daily lives. The home has good systems in place for assessing and managing risks, which are based on enabling service users to take responsible risks rather than preventing them from doing so. EVIDENCE: A sample of 2 service users’ care plans was tracked as part of the inspection. The home current uses person centred plans and the manager informed the inspector that they were in the process of introducing a new format. An DS0000004002.V305529.R01.S.doc Version 5.2 Page 12 example of this was shown to the inspector. The current plans are limited in some areas and there are gaps that have not been filled in. There was evidence that service users had been consulted and involved in filling in the plans and some of their individual goals had been recorded such as wanting to improve skills in using domestic appliances and spending time home alone. There was evidence that staff had been involved in assessments and working with service users towards these goals. Discussion with members of staff on duty demonstrated they had a good knowledge of service users individual needs and were regularly kept up to date with any changes by a weekly meeting and a daily communication book that all staff read when coming on duty. Some service users living in the home were clearly able to articulate there needs and could inform staff of their personal preferences when necessary. However, the inspector felt care plans could contain clearer guidance to staff about residents’ particular support needs. This would be particularly important for service users with higher support needs who were less able to articulate their own preferences. Discussion with residents indicated they felt they had more opportunities to increase their independence and this included many examples of how they were able to make decisions about their lives, e.g. going out at weekends, inviting friends and family to stay, decorating their bedrooms. Observation during the evening confirmed service users were encouraged to make decisions such as making their own evening meal (with support if appropriate), and deciding what to do during the evening. Staff spoken with also saw it as part of their role to encourage service users to make their own decisions and said, “We are here mainly to support what they want to do”. Information about advocacy was available in the home and various services and helplines were displayed on noticeboards around the home. The home takes a pro-active approach to risk assessment and there are ongoing programmes to risk assess service users skills in various aspects of their lives such as staying home alone, travelling independently and using domestic appliances. These assessments are used to look at ways to encourage service users to gain more independent living skills where possible whilst minimising the risk. For example, staff will shadow service users when using public transport to ensure they can complete the journey safely whilst working towards them being able to complete the task independently. Risk assessments are now being regularly reviewed. DS0000004002.V305529.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Changes to the way the home is staffed have provided service users with more choice and flexibility in their daily activities. The home has good access to the local community and supports service users to feel confident about accessing local amenities. The home makes visitors feel welcome and offers service users excellent support with their personal relationships enabling them to develop healthy social lives. Routines in the home offer choice and flexibility promoting service user’s individuality and independence. A whole range of individual dietary choices are offered and service users are encouraged to be involved in the planning and preparation of menus. DS0000004002.V305529.R01.S.doc Version 5.2 Page 14 EVIDENCE: All service users were engaged in daytime activities and these were recorded on their individual files. The SFHT has its own integrated day service that provides a variety of courses such as art & craft, pottery, woodwork, personal relationships, current affairs and horticulture. Most service users attend the day service during the week, although the manager said that he now has bank staff that he can call on during the daytime to support service users if they wish to remain in the home giving greater flexibility and choice to the residents. Some service users now choose to spend regular days at the home doing alternative activities, another service user told the inspector they were currently working at a local café. All service users said they were happy with their weekly activities. Service users also told the inspector they regularly accessed the local community and gave examples such as going to local shops, banks, pubs, cinema and leisure centres. The home has good access to public transport and some service users told the inspector they were able to use the buses independently or that they were hoping to work towards this. The home welcomes visitors and family and friends can stay overnight if appropriate. Service users confirmed they could have visitors and see them in the privacy of their rooms. Service users can access the house phone to make personal calls to family and friends and residents were observed using the phone during the inspection. The organisation has a policy on Personal Relationships and service users are given support and advice on this subject. Discussion with service users demonstrated they had a good understanding of their rights in relationships and felt fully supported by staff. Observation throughout the evening showed service users were able to use the communal areas of the home freely or enjoy some privacy in their bedrooms. Staff were observed interacting closely with service users. In discussion with service users they all confirmed that their privacy is respected and that that staff knock on their doors before entering and allow them private time. Service users are able to lock their doors if they wish to and where appropriate have a key to the front door of the home. Service users are encouraged to keep the house clean and tidy and take responsibility for household chores. There is a daily rota for housekeeping chores, which is discussed and planned by the residents at their meetings. Service users attending the SFHT day service are provided with a cooked lunch. Arrangements during the evening for food preparation are flexible with all residents being encouraged to make their own meals or snacks independently or with staff support according to individual need. This means DS0000004002.V305529.R01.S.doc Version 5.2 Page 15 that service users are able to choose exactly what they want to eat. Service users told the inspector they enjoyed the food and were involved in shopping for the weekly provisions. DS0000004002.V305529.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of service users’ personal care needs and support is offered in a sensitive way that promotes service users privacy and independence. Improvements to recording ensure service users’ health is effectively monitored and there is good liaison with health care professionals making sure service users health needs are appropriately met. The systems for managing medication are satisfactory and staff are familiar with the procedures for administration ensuring service users medication needs are met. EVIDENCE: Discussion with service users confirmed their personal care needs were met and they were comfortable asking for assistance from staff. They said they were treated with respect and routines such as bedtimes, getting up, meal times and baths/showers were flexible. The majority of service users at DS0000004002.V305529.R01.S.doc Version 5.2 Page 17 Abbotsford can manage their personal care independently with staff providing advice and prompting when necessary. Discussion with staff demonstrated they had a good understanding of service users’ individual needs and their likes and preferences. Service users personal files contained information about their physical and mental health. Visits to healthcare professionals were recorded such as dentists, opticians and hearing tests and there was evidence that these were being carried out on a regular basis. There was further evidence that the home was liaising with healthcare professionals and making referrals where appropriate when they were concerned about health issues. For example one service user had recently been referred for a full psychiatric assessment, as they appeared to be depressed. The home has a written policy and procedure concerned with the management and administration of medication. Records were checked and currently only five of the residents are taking prescribed medication. Details were available of all current medication and the numbers of tablets received from the pharmacist are recorded to facilitate monitoring of medication in the home. The member of staff on duty gives out medication once they have been signed off as competent to administer medication, any new staff are supervised. Staff then sign to say they have witnessed the service user taking the medication and records were checked and found to be up-to-date and accurate. One service user was self administering their medication and one service user was managing some of their own medication and this was based on recorded risk assessments. Members of staff confirmed they had undertaken training in the management of medication and were fully aware of the procedures for administration in the home. DS0000004002.V305529.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an ethos of openness throughout the organisation and service users were confident about how to raise complaints feeling their views would be listened to and acted upon. There is clear guidance and training in place for staff concerning the protection of vulnerable adults ensuring service users welfare is safeguarded in the home. EVIDENCE: The home has a complaints procedure offering comprehensive guidance to staff about dealing with minor complaints and more serious ones. There is a clear line of accountability throughout the organisation and information is given about other agencies that can be approached including CSCI. An accessible format has been developed for service users called “Making things better”. This includes a simple written format and symbols to explain the procedure and a form that the service user can complete with appropriate support if necessary e.g. an advocate. Service users confirmed they were fully aware of the procedure and how to use it. The also were confident that any issues/problems raised would be resolved by the organisation, although they did know they could talk to other agencies such as social services and CSCI if necessary. It was noticeable that the organisation encourages an ethos of openness and “welcome complaints as they can bring something wrong with the service to our attention and enable DS0000004002.V305529.R01.S.doc Version 5.2 Page 19 us to improve what we do”. The home has a separate complaints procedure for anyone other than service users. The complaints log was seen during the inspection and there had been 2 complaints from a neighbour about noise levels in the home. This had been dealt with appropriately. It was recommended that one complaint be logged per page to comply with the Data Protection Act. The home has a number of policies concerning with the protection of vulnerable adults and these were made available to the inspector. These included Adult Protection and Dealing with Abuse, Personal Relationships and Sexuality, Bullying in the Workplace, Acceptance of Gifts and Financial Procedures. Discussion with the manager confirmed his awareness of adult protection procedures and staff also receive training in adult protection and dealing with challenging behaviours. DS0000004002.V305529.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Further investment to the environment ensures the home maintains a good standard of décor providing residents with an attractive and homely environment. The home is provides a clean and hygienic environment for service users. EVIDENCE: The inspector completed a tour of all communal areas of the home including the lounge, dining room, kitchen and laundry room. A total of 4 residents’ bedrooms were also viewed. Since the last inspection the dining and kitchen area had been redecorated and there were new tables in the dining room. Three residents’ bedrooms had been redecorated and observation showed they were clearly personalised to the individual’s taste. Residents confirmed they had chosen the colours for their rooms and were happy to show them off to the inspector. DS0000004002.V305529.R01.S.doc Version 5.2 Page 21 On the day of the unannounced inspection the home was found to be hygienic and free from offensive odours. Certificates were in place confirming staff have completed training in infection control. The home has a separate laundry area which is situated outside of the kitchen and has hand-washing facilities. Fouled laundry can be washed at appropriate temperatures to control the risk of infection. DS0000004002.V305529.R01.S.doc Version 5.2 Page 22 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is making progress towards establishing a workforce that achieves nationally recognised care qualifications and service users have confidence in the skills and experience of the care workers. Staff records are now available in the home meaning it is able to demonstrate robust recruitment procedures have been followed for vetting and recruiting staff ensuring the protection of service users living in the home The home demonstrates a commitment to providing good quality training and all staff have the opportunity to complete a number of courses that reflect the homes aims and meet service users needs. EVIDENCE: There are currently four members of staff working in the home. Any gaps in the rota are covered by regular bank workers who are employed by the SFHT. There is a mix of male and female staff and most staff had previous experience of working with adults with learning disabilities. Analysis of the rota showed that one member of staff was provided from 7.00 – 9.00 am and two members DS0000004002.V305529.R01.S.doc Version 5.2 Page 23 of staff from 5.00 – 10.00 pm (Mondays to Fridays) and two members of staff throughout the day at weekends. Historically the home has not provided staff support during the hours of 9.00 am and 5.00 pm. This is because the service users attended day care outside of the home. However, service users needs and wishes have changed and service users are requesting more flexible day opportunities. Staffing support is now offered during the day in the home so service users have greater choice about daytime activities. Although the staffing hours provided are less than those recommended by the Department of Health guidance, observation during the inspection demonstrated that sufficient staff were available to meet service users’ needs. One member of the staff team currently holds an NVQ or equivalent qualification and all members of staff are working towards NVQ qualification meaning the home is well on track to meeting the target of 50 qualified staff. Three members of staff have completed LDAF induction and foundation training. The inspector had the opportunity to speak to two members of staff who demonstrated a good knowledge and understanding of the residents’ individual and collective needs. They told the inspector they enjoyed working in the home. Observation of practice showed there was a high level of interaction between staff and service users and it was clear positive relationships had been formed. Service users told the inspector they liked the staff, found them approachable and were able to discuss any problems or concerns with them. A recruitment policy is now in place setting out clear guidance about the procedure to be followed. Staffing records are kept at the SFHT Head Office and copies are now available for inspection in the home. A sample of 2 staffing records was viewed as part of the inspection. Examination of records showed that all the required documentation is now in place. All staff receive terms and conditions and an employee handbook is also available, which contains amongst other things information on the SFHT’s grievance and disciplinary procedures. Staff are employed subject to a six month probationary period and a form completed to record the outcome of this was observed during the inspection. Service users are included on the interview panels for staff recruitment and are given training in how to carry out interviews. The home has an annual training plan identifying training needs for the whole staff team. Examination of staff files showed they had attended a number of training courses including first aid, health and safety, food hygiene, fire training, prevention of abuse, medication, manual handling and infection control. It was noted that as well as the required courses ensuring safe working practices the home promotes additional courses that reflect the home’s aims and service users needs such as Makaton, personal relationships, risk assessment and challenging behaviour. Staff confirmed the training was “very good”. DS0000004002.V305529.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from an experienced manager who ensures the home is well run and meets its stated aims and objectives. There has been some attempt to gain feedback about the quality of service from service users but this needs to be included in a formal plan setting out aims and objectives for future service development. The home follows good health and safety practices making sure service users are well protected. EVIDENCE: The registered manager of the home is Mark Wells. He is experienced in working with adults with learning disabilities and has been in his present post for approximately 5 years. Mark Wells has completed the work for the DS0000004002.V305529.R01.S.doc Version 5.2 Page 25 Registered Managers Award and NVQ 4 in care; however, the organisation that was responsible for assessing the work had gone into receivership and therefore, his work had not been verified. He has re-registered with another organisation and currently waiting verification of his qualifications. There was further evidence that he was up-dating his training and he had recently completed a course in “Train the Trainer in Adult Protection” and was planning to attend a fire-training course in October 2006. Staff spoken with during the inspection felt well supported by the manager both with formal supervision and informally. There has been some progress in setting up a quality monitoring programme in the home. Questionnaires have been designed for service users to gain feedback about the quality of food in the home. Discussion with service users evidenced that their views were regularly sought and they had been involved in a variety of ways in service development such as the development of a service user guide, staff recruitment and redecoration of the home. The organisation has made a commitment to working in a person centred way focusing on individual’s wants, needs and aspirations and there was evidence that this had brought about changes e.g. a more flexible approach to day care and supporting service users to gain more daily living skills to enable them to move onto more independent living. The organisation still needs to develop a policy on quality assurance and an annual development plan incorporating feedback from service users needs to be produced for the home to provide action points/targets to further improve the quality of service in the home. The responsible individual makes regular monthly monitoring visits to the home and a report of these is made available to CSCI. The organisation is also reviewing its policies and procedures to provide consistency and promote a corporate identity in line with current legislation and best practice guidelines. The inspector examined records that showed that the home was meeting the requirements of other agencies such as Dorset Fire and Rescue Service and Environmental Health Department. Certificates were in place demonstrating that equipment and facilities were regularly serviced and maintained. Records of fridge, freezer and food temperatures were kept as well as water temperatures. A fire risk assessment was in place, although the manager was in the process of up-dating this and staff carry out weekly visual checks on equipment. A record of fire drills and fire training records are kept. The home had clear policies and procedures relating to health and safety practices. The manager confirmed his awareness of relevant legislation and certificates were in place showing staff had attended various training courses in safe working practices. DS0000004002.V305529.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 1 2 X 3 X DS0000004002.V305529.R01.S.doc Version 5.2 Page 27 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 YA32 Regulation 18 Requirement The registered provider needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. The registered manager needs to complete NVQ 4 in management and care. Timescale for action 01/04/07 2. YA37 9 01/04/07 3. YA39 24 The registered provider must 01/12/06 develop an annual plan for the home in order that the success in achieving the aims and objectives set out in the Statement of Purpose can be measured. (Previous timescale of June 2003 not met.) DS0000004002.V305529.R01.S.doc Version 5.2 Page 28 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 YA6 Good Practice Recommendations It is recommended that care plans contain clearer guidance to staff about residents’ particular care needs and the support they require. The home needs to ensure the complaints log complies with the Data Protection Act and only one complaint is logged per page to maintain the complainants complete confidentiality. It is recommended that the registered provider should produce written policies and procedures for all the topics set out in Appendix 2 to the National Minimum Standards (2nd Edition). This recommendation is carried forward from 2003. 2. YA22 3. YA40 DS0000004002.V305529.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000004002.V305529.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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