Inspection on 15/02/05 for Alder Close (20)

Care Homes For Adults (18 ­ 65)Alder Close (20)20 Alder Close March Cambridgeshire PE15 8PYAnnounced Inspection15th February 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Alder Close (20) Address 20 Alder Close, March, Cambridgeshire, PE15 8PY Email address Tel No: 01354 654146 Fax No: 01354 657905Name of registered provider(s)/company (if applicable) Cambridgeshire Social Services Name of registered manager (if applicable) Margaret Hill Type of registration Care Home No. of places registered (if applicable) 5Category(ies) of registration, with (number of places) Learning disability (5) Registration number I030000348 Date first registered 2nd October 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 2nd October 2003 NO NO 10/08/04 If Yes refer to Part CAlder Close (20)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 315th February 2005 10:00 am Andy GreenID Code082257Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMargaret Hill ­ Registered ManagerAlder Close (20)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementAlder Close (20)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Alder Close (20). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Alder Close (20)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 20 Alder Close is a 5-bedded bungalow providing respite care for adults with a learning disability. The home was first registered in October 2003 and comprises five bedrooms, all with en suite facilities, a lounge, kitchen, two bathrooms, laundry and office. There are also extensive gardens around three sides of the bungalow. The home is situated one mile north of March town centre where service users have access to a variety of shops and leisure facilities.Alder Close (20)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This announced inspection was the second inspection of the home during the 2004 - 2005 inspection year. Not all of the National Minimum Standards were assessed during this inspection and this report should be read in conjunction with the report of the previous inspection on 10th August 2004. Choice of Home (Standards 1-5): 5 standards were assessed and 5 were met. The home has a Statement of Purpose and Service User Guide that meet the requirements of the Care Standards Act, 2000. The home provides 5 beds for respite care usually up to two weeks in length. All referrals are made through Social Services. Individual Needs and Choices (Standards 6-10): 4 standards were assessed and 4 were met. Care plans provide up to date information in conjunction with Social Service Assessments of service users needs and the way these are met at the home. The home invites local advocacy groups and relatives to comment on and contribute to the continued development of the service. Lifestyle (Standards 11-17): 4 standards were assessed and 4 were met. Service users are encouraged to continue with their own interests and hobbies, and to remain as independent as possible during periods spent at the home. Service users are also encouraged to participate in the day to day running of the home including meal preparation and laundry. The home maintains good links with the families of service users. Personal & Healthcare Support (Standards 18-21): 3 standards were assessed and 3 were met. The home has a medication policy and staff administer all medications during service users respite placements. Assistance with personal care is given where required. Concerns, Complaints & Protection (Standards 22-23): 2 standards were assessed and 2 were met. The home has a Complaint Procedure that has been reproduced in an accessible format for service users. No complaints have been received since the last inspection. Environment (Standards 24-30): 6 standards were assessed and 6 were met. The home is clean, tidy and communal rooms and bedrooms are maintained, furnished and decorated to a high standard. Alder Close (20) Page 6 Automatic door closing devises have been fitted to the lounge and kitchen fire doors. Staffing (Standards 31-36): 4 standards were assessed and 4 were met. Staff are regularly supervised and receive an annual appraisal. The home has a structured induction programme for newly recruited staff and training is well co-ordinated and improved. Conduct & Management of the Home (Standards 37-43): 3 standards were assessed and 3 were met. Records kept by the house are kept up to date and secure. Staff undertake training to ensure they are up to date with safe working practices in the home.Alder Close (20)Page 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action noneRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * none* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Alder Close (20) Page 8 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES YES NO NO NO YES YES YES NO YES YES YES YES YES YES NO YES 2 1 0 NA NA NO YES 13 0 15/2/05 10 7The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded Alder Close (20) (Commendable) Page 9 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Alder Close (20)Page 10 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The home has a Statement of Purpose and Service User Guide. The home provides respite care for up to 5 service users. The registered manager stated that the home does not provide a suitable setting for longer stay service users although there have been occasions in the last year where two service users had to wait for placements for long term housing.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All referrals are made through Social Services and the home receives a Level 2 Needs Assessment for all new service users. Many of the current service users have been known to the respite service for a number of years and their original assessment details are not on file but the registered manager stated that all new referrals would have appropriate assessment information held on file.Alder Close (20)Page 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home continues to meet the assessed needs of service users receiving a respite service. The staff are experienced and receive regular training to update their knowledge and skills.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The registered manager stated that new referrals are able to make visits to the home before commencing a placement. An overnight stay is usually offered. A relative visiting the home on the day of inspection confirmed that the staff had been very welcoming and helpful during the beginning of the placement of her daughter.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? Service users and their representatives are provided with a financial contract between themselves and Social Services. The registered manager reported that a service user contract / statement of terms and conditions is now in place which would be included in all service users files.Alder Close (20)Page 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Three service user care plans were seen during the inspection. They contained detailed information regarding the service users needs. These are set out in a number of `Continuity Guides. These provided information about different areas of the residents life, e.g. health, daily routines, personal care etc. The care actually provided for the service users was recorded in daily record sheets. Staff spoken to on the day of inspection stated that service user plans were more accessible since the overall layout had been reorganised. It was noted during the inspection that some documents need to have names and dates added to ensure they are accurate and up to date. The registered manager stated that care plans are reviewed as part of an ongoing process. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Each service user meets with their key worker to discuss individual needs and preferences, which are recorded in individual care plans. Due to the nature of the service group meetings are not regularly held. The registered manager stated that at weekends the service users and staff meet to organise outings, activities and meals. The registered manager stated that service users are encouraged to take part in the day-to-day running of the service where possible.Alder Close (20)Page 13 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? There is a separate Risk Assessment file, giving individual needs with details of the actions and procedures to be taken/followed. The registered manager stated that these assessments were updated as required. There was sufficient evidence to suggest that assessments are reviewed appropriately.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? There is a Confidentiality Policy in place and this is explained to all staff at their interview, induction and during supervision. Confidential records are kept securely in the home.Alder Close (20)Page 14 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users usually stay for up to two weeks in the home and it is not always feasible to set up a programme of activities but individual activities and trips into the local community are organised where possible especially at weekends. Service users are encouraged to take part in preparing meals and snacks during their stay and individual risk assessments are in place to ensure health and safety.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Service users carry on with their agreed programmes of education and day service placements. The registered manager stated that staff attend reviews at these placements as part of the care planning process to ensure the home has relevant and up to date information regarding individual progress.Alder Close (20)Page 15 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Service users are encouraged and assisted to make visits to the local town and area and there are frequent visits made to local shops, garden centres, bowling alley, pubs and cinema.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This standard was not assessed on this occasion.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Alder Close (20)Page 16 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Individual food preferences are discussed with service users and recorded in the weekly menus. Special diets are catered for as necessary. Meals were not inspected on this occasion. Snacks and drinks are available throughout the day and service users are encouraged to participate in the planning and preparation of meals in the home depending upon their individual abilities.Alder Close (20)Page 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Staff provide some personal care to service users as detailed in individual care plans. Nursing care is not provided but the home has good contact with a local GP practice who provide medical support if required e.g., district nurses and a diabetic nurse specialist.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Since the last inspection there have not been any hospital/accident service admissions. The registered manager stated that if a service user is unwell they would not usually make use of their respite stay but would receive care from their own local GP practice.Alder Close (20)Page 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? There is a medication policy in the home. It is agreed with service users that all medications are kept locked in the office and administered by the staff during respite placements. Any new prescribed medications are recorded the pre-visit form. Medication records were inspected and found to be accurate.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Alder Close (20)Page 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 100 3 Key findings/Evidence Standard met? There is a clear complaints procedure in place, which is explained to service users and their relatives. There have been no complaints received since the last inspectionAlder Close (20)Page 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home has a Whistle blowing policy and guidelines regarding adult protection. The registered manager stated that training regarding protection of vulnerable adults is being organised/booked for the staff team.Alder Close (20)Page 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Magnetic door closers have been installed to fire doors and all wedges have been removed. The accommodation is maintained to a high standard and the communal rooms are presented in a bright and homely manner. There is adequate equipment to meet the service users needs and individuals usually bring their own aids and adaptations where required.Alder Close (20)Page 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 5 5 0 0 5 00 0 0 03 Key findings/Evidence Standard met? There are 5 single bedrooms, which are all en-suite. Two of the bedrooms have overhead tracking in place. There are adequate furnishings in each bedroom and due to the short nature of each placement it is difficult for rooms to be personalised to meet individual tastes. One bedroom has recently been redecorated and all other rooms are decorated and refurbished as required.Alder Close (20)Page 23 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed on this occasion. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities, which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? All bedrooms are ensuite including a shower facility. There is one bathroom with a shower facility. The bathroom also has overhead tracking in place. There are two further WCs in the property. These facilities are adequate to meet the needs of service users during their placement in the home.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is one lounge, which is well decorated and furnished to a high standard. Service users also meet in the dining area of the large kitchen. There are extensive gardens available to service users and there are plans to develop these areas in a more creative fashion and also add more garden furniture.Alder Close (20)Page 24 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? All rooms are wheelchair accessible and two bedrooms have overhead tracking. There is also a portable hoist available. There are handrails in all corridors to provide further assistance. Service users also bring their own equipment or aids where required.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The premises are kept in a clean and homely manner and free from odours. Service users are encouraged to keep their bedrooms tidy and assistance is given by the staff where needed. Service users have access to a well-equipped laundry and they are assisted with washing clothes by the staff if required.Alder Close (20)Page 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? All staff have clear job descriptions and are clear about their roles and responsibilities. This is also explained during induction. This was confirmed during conversations with individual members of staff during the day of inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? One of the senior support workers has the delegated task of co-ordinating training in the home. Training records have improved and are well maintained. There was evidence of updates and refreshers, which included health and safety and client based issues. Staff spoken to on the day of inspection confirmed that they received a variety of training including NVQ courses.Alder Close (20)Page 26 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXKey findings/Evidence This standard was not assessed on this occasionStandard met?0Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home operates a thorough recruitment procedure in line with Local Authority policies. All adequate checks are made including POVA/CRB and two references are sought.Alder Close (20)Page 27 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? There is a thorough induction Period and the registered manager stated that all new staff would also commence a LDAFF based programme. Training is well co-ordinated in the home and staff gave examples of training including NVQ, moving & handling, fire safety, epilepsy, and autism training.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not assessed on this occasion.0Alder Close (20)Page 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO3 Key findings/Evidence Standard met? The registered manager has worked in the respite service for a number of years and updates her knowledge and skills on an ongoing basis. She is enrolling on an NVQ Level 4 course in Care & Management to meet the requirements detailed in this standard. This would help to develop her management skills, which would be beneficial for the home.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The management style of the home is open and inclusive and service users and their relatives are encouraged to approach the management team with queries and concerns. Staff meetings are held and there is an open agenda for these meetings. The registered manager stated that an equal opportunities policy has been developed. Staff spoken to on the day of inspection confirmed that the management style was open and responsive.Alder Close (20)Page 29 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed on this occasion.Alder Close (20)Page 30 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? There is a health and safety policy in place in line with Local Authority procedures. All cleaning/hazardous substances are now kept locked securely to prevent any potential harm to service users. One of the care staff has taken on the role of health & safety representative and keeps the home up to date with legislation and ensures that health & safety risk assessments are monitored in the premises. Fire records were found to be accurate. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed on this occasion.Alder Close (20)Page 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorAndy GreenSignature Signature SignatureRegulation Manager Cathryn Bramham Date 6th April 2005Alder Close (20)Page 32 Public reports It should be noted that all CSCI inspection reports are public documents.Alder Close (20)Page 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 15th February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Thank you for this report. I would like to inform you that I have applied to register on the Registered Manager courseAction Plan is held on file and is available upon request.Action taken by the CSCI in response to provider comments: Alder Close (20) Page 34 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 30th March 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Alder Close (20)Page 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: MARGARET HILL Margaret Hill Registered Manager 24-03-2005Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Alder Close (20)Page 36 Alder Close (20) / 15th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000050387.V203235.R01© This report may only be used in its entirety. 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