Inspection on 16/03/04 for Alder Close (20)

Care Homes For Adults (18 ­ 65)Alder Close (20)20 Alder Close March Cambridgeshire PE15 8PYAnnounced Inspection16th March 2004 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 County Council 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 N/A 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 316th March 2004 10:30 am Matthew Bentley Kay WoodID Code082257Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Margaret Hill; Registered Manager the time of inspectionAlder Close (20)Page 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where 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 National Care Standards Commission (NCSC) 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 NCSC in respect of Alder Close (20). The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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 approximately a mile from the centre of March; a medium sized Fenland Market town. The home provides short-term respite care for up to 5 people aged between 18 & 65, with learning disabilities and possible associated physical disabilities. The premises are purpose-built and are on one level; specialist lifting equipment is provided to assist people with transferring. The home is part a re-provision of a large hostel run by the County Council; it opened on 15 September 2003. At the time of inspection the home had been open for 6 months; this was the first inspection of the service.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.) Choice of Home (Standards 1-5) All of these of these 5 standards were assessed; 3 were met, 1 had minor shortfalls, and 1 had major shortfalls The home had a statement of purpose which set out the services offered. It also had a service user guide, which indicated what services and facilities each person living at the home could expect to receive. Service user files inspected contained assessment information about each persons needs, and file notes, care plans and individual daily recordings indicated that the home was capable of meeting service users needs. Prospective service users were invited to visit the home on an introductory basis. No contract or statement of terms and conditions was provided to indicate to those using the service, what they could expect to receive and what their rights and responsibilities were, however, the manager stated that this was being developed. Individual Needs and Choices (Standards 6-10) Four of these 5 standards were assessed; 3 were met, 1 had minor shortfalls The information gathered through the assessment process had been used to compile individual plans of care, which would guide staff as to how to support each person. The plans were in need of further development and expansion; the manager stated that this was to take place in future months and team meetings would be held to develop care plans. Discussions with the manager and staff, indicated that they had an understanding of a service users right to make decisions and to take risks. The home had a confidentiality policy, which had been developed to suit the home and reflect the nature of the service. Lifestyle (Standards 11-17) Six of these 7 standards were assessed; all of these were met Service users were reported to be encouraged to get involved in the upkeep of the home and to develop their independent living skills. A range of activities was reported to have taken place both within and outside the home and staff were actively developing relations with service users families. Meals were provided and eaten in an appropriate setting and positive feedback had been received about the homes development of the social aspect of meals. Personal and Healthcare Support (Standards 18-21) Three of these 4 standards were assessed; two were met, one had minor shortfalls Service users were given the required level of support to manage their personal care needs and healthcare input was sought when needed. A small number of omissions were found in relation to recording of medication. Concerns, Complaints and Protection (Standards 22-23 Both of these 2 standards were met The home had a complaints procedure in a format which was appropriate to the service users present. A procedure for dealing with adult protection was also in place as was a Alder Close (20) Page 6 policy for reporting bad practice or `whistle-blowing. The service had received one complaint during the last 12 months, however, this related to an item of clothing that had been mislaid in the large home which 20 Alder Close, in part, replaced. There had been no occasion to use the adult protection or whistle-blowing procedures. Environment (Standards 24-30) All of these 7 standards were assessed; 6 were met, 1 had minor shortfalls The home was clean airy and free from any offensive odours. Communal areas were furnished to a high standard and bedrooms were also comfortably furnished and reflected the interests and personalities of the individuals concerned. All rooms were for single occupancy and had en-suite facilities including showers. Laundry facilities were sited away from areas where food was stored, prepared or eaten. The garden area needed to be provided with suitable furniture and the grass was overgrown and was becoming inaccessible. Staffing (Standards 31-36) All of these 6 standards were assessed; 4 were met, 1 had minor shortfalls, 1 had major shortfalls Staff were present in sufficient numbers to meet the needs of the service users and staff appeared clear about their roles and were competent and experienced, however, staff members spoke of a need to increase the number of core staff in order to reduce stress and lessen the need to use agency staff. Records relating to the recruitment of staff were available for inspection and were satisfactory, and staff were receiving regular formal supervision. Staff were receiving an induction, however, this was not in line with Social Skills Council/Topps standards and there was a need for ongoing training in relation to providing support specifically to people with learning disabilities. Conduct and Management of the Home (Standards 37-43) All of these 7 standards were assessed; two had minor shortfalls, one had major shortfalls The manager was experienced in working with people with learning disabilities, she did not hold the NVQ level 4 in Management and Care; however, she had until 2005 to achieve this. Staff were positive about the management arrangements, and relatives who responded to the NCSC questionnaire were complementary about the manager and the staff. The homes policies and procedures were comprehensive and had been updated to suit the home specifically. Not all of the staff team had received the required training in health and safety issues including moving and handling and first aid. Records relating to service users were in need of updating to fully meet the requirements of the relevant Regulations, and formal quality assurance systems needed to be developed.Alder Close (20)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Alder Close (20)Page 8 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action Each service user must have a written and costed contract/statement of terms and conditions between the home and themselves Service user plans must be further developed to include detailed information in respect of each individuals needs, and how they are to be met Records relating to medication must be fully and accurately maintained. Outdoor space must be provided with sufficient and suitable furniture Lawns must be properly maintained to ensure their accessible to service users Staff must receive structured induction training to Skills Council/Topps specification Staff must receive training relevant to the service user group using the Learning Disability Award Framework (LDAF)15(1)(b)(c)YA5By 30 June 2004215YA6All plans must be updated by 31 July 2004313(2)YA20From the date of this inspection (i.e. 16 March 2004) and ongoing By 30 May 2004 From the date of this inspection (i.e. 16 March 2004) and ongoing An induction programme must be in place for new staff by 30 June 2004 An training programme must be in place for staff by 31 July 2004423(2)(g)YA28523(2)(o)YA28618(1)(c)YA35718(1)(c)YA35Alder Close (20)Page 9 824YA39Effective quality assurance and monitoring systems, based on By 31 July 2004 seeking the views of service users, must be put in place Records relating to service users must be updated to include all the information required to meet this standard and associated Regulations917 & YA41 Schedule 3By 31 July 20041013(3-6)YA42All staff must receive training in matters of health and safety, including moving and handling, By 31 July 2004 fire safety, first aid, food hygiene, and infection controlRECOMMENDATIONS 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) No. Refer to Good Practice Recommendations Standard * 1 YA33 The provider should consider methods of expanding and building on the numbers of personnel in the core staff group* 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 Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire YES YES YESAlder Close (20)Page 10 · 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 NO NO NO YES NO YES NO YES YES YES YES NO YES NO YES 2 1 0 NO NO YES YES 11 0 16/03/04 10:45 5.5The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met Alder Close (20) (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 11 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 12 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, 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. 59.00 90.00 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Personal items such as toiletries, magazines, newspapers etc. 3 Key findings/Evidence Standard met? The charge indicated is dependant on entitlement to benefits and includes accommodation, food, care and support, and the full use of the facilities. The relatively low cost to the service user reflect the fact that the service is heavily subsidised by the Social Services Department. Service users are expected to bring with them personal items such as toiletries, and are asked to bring with them spending money (£3.00 is suggested) to pay for leisure activities and to ensure they have money to spend if a shopping trip is organised. The home had a statement of purpose and service user guide; these were examined as part of the recent registration process and were found to be satisfactory. The manager stated that the documents were to be updated later in the year and would be provided in a form that should help people with limited communication understand the services that were offered.Alder Close (20)Page 13 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? Service user files inspected contained information about each persons needs including assessment information provided by care managers and other professionals involved in the persons care, such as community nurses and psychologists. The manager stated that the aim was to replicate, as far as possible, routines and events that occurred in a persons own home. To this end staff members were beginning to undertake visits to each service users home to build up a clear picture of their lifestyle, preferences, and routines and to ensure that staff had a consistent approach to providing care and support to individuals. 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? File notes, care plans and individual daily recordings indicated that the home was capable of meeting the assessed needs of the people using the service, however, as noted in standard 35, there was a need to develop the knowledge base of staff in relation to the service user group as a whole. Records, and discussions with the staff and manager, indicated that those working in the home had the skills to deliver the services and care which the home offered. Service users had access to specialist learning disability services, including psychology and psychiatric input when needed, and a local advocacy service was reported to have been involved in the setting up, and development, of the service. 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? People who were interested in using the service were reported to be invited to visit for at least two `tea visits, during which they would be helped to get to know the staff and gain an idea of what they could expect from the home. This would ordinarily progress to an overnight stay, however, this would depend on individual circumstances and extended introductory periods would be arranged if needed. The manager stated that, whilst the home did not ordinarily accept emergency admissions, they had occurred when no suitable alternative was available. The manager stated that she would ensure that as much information as possible was obtained prior to an emergency admissionAlder Close (20)Page 14 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. 1 Key findings/Evidence Standard met? Service users and their representatives were provided with a financial contract between themselves and the Council, however, no contract or statement of terms and conditions was provided to indicate to those using the service, what they could expect to receive and what their rights and responsibilities were. The manager stated that a contract was in the process of being developed in a number of formats, possibly including a video, to ensure that the requirements of this standard were met.Alder Close (20)Page 15 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. 2 Key findings/Evidence Standard met? Service user plans were available to guide staff when supporting service users, the manager stated that she and the staff were in the process of building on the information held, to more clearly set out the support that was needed. The need to include detail of how staff should, in practical terms, approach the task of providing support and assistance to each individual was discussed with the manager. A keyworker system was in place whereby certain staff members were responsible for developing and reviewing care plans and liaising with family members and with other professionals involved in a persons care. It was reported that service users choice would be taken into account when identifying which staff member would take on the role of keyworker. 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? Discussions with the manager and staff, indicated that they had an understanding of a service users right to make decisions about what they did inside and outside the home. One service user was involved in a local advocacy group and, as noted above, advocacy services had been involved in the setting up and development of the serviceAlder Close (20)Page 16 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? The homes ability to meet the requirements of this standard was not assessed during this inspection.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? Discussions with the manager and staff indicated that had an understanding of a service users right to take risks. Risk assessments had been carried out in relation to everyday tasks in the home which may include an element of risk and action had been taken to minimise risks that may have limited residents preferred choice of activity. A possible risk had been identified due to personal safety issues outside the home and risk assessments had been carried out and appropriate action had been taken. 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? The home had a confidentiality policy, which had been developed to suit the home and reflect the nature of the service. This and other policies were discussed during team meetings and staff were required to sign that they had read and understood the homes policy on how to handle sensitive confidential information.Alder Close (20)Page 17 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 were reported to be encouraged to get involved in the upkeep of the home, if they wished, and to develop their independent living skills including areas such as shopping and (within a risk assessment framework) food preparation. Support was given by staff when needed. and the home had its own cash funds to pay for food shopping.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? The homes purpose was to provide short breaks for the people using the service and their carers rather than developing individuals programme of activities. The majority of the people who used the service had daytime activities in place either at the local day services, colleges or other placements and it was usually the case that people using the home for a period of respite would continue to attend whatever daytime activity they ordinarily undertook if this remained available.Alder Close (20)Page 18 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? The community of March is well served with a range of facilities and staff were aware of a number of events and activities taking place which those using the service may like to become involved in. As noted in standard 1 service users were requested to bring with them spending money to pay towards activities and any personal shopping they may like to do. The home is located in a community that does not have a high level of cultural diversity; the staff members employed and those who use the service reflect this.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users were reported to be encouraged to pursue their hobbies and to bring with them any items they may wish to use during their stay, though items of electrical equipment should conform to the relevant safety standards. Activities outside the home that had been accessed included the local club for able bodied people and people with disabilities, swimming, trips to the coast, and shopping trips to town and to Peterborough.Standard 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). 3 Key findings/Evidence Standard met? Respondents to the questionnaire sent out on behalf of the Commission indicated that relatives were able to visit at any time and were made welcome by staff. Service users were able to see people in their own rooms if they chose and due to the nature of the service, those using the home for short term respite care were likely to expand their social contacts by having the opportunity to meet new people, however, contact with people who did not have a learning disability would be likely to be limited.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). 3 Key findings/Evidence Standard met? The homes ability to meet this standard was not actively assessed, however, routines appeared to be flexible and encouraged individual choice and decision-making.Alder Close (20)Page 19 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? The home had its own budget for food shopping and it was reported that those using the service were offered the opportunity to get involved with shopping and (within a risk assessment framework) the preparation of food. Meals were reported to be taken in the kitchen/dining room, and those using the service tended to eat together as a group to take advantage of the social aspect of the meal; the local advocacy group which had been involved in setting up the service was reported to have made positive comments about this aspect of the service. Advice had been sought from dieticians in relation to individual service users and menus were reported to be planned flexibly to take account of the preferences of the individuals who were currently living there.Alder Close (20)Page 20 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 procedure 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? Observation during the inspection, coupled with information in care plans, discussions with staff and the manager, and feedback from relatives indicated that the personal support that was given was provided in a sensitive and respectful way, which paid regard to the wishes and preferences of the individuals concernedStandard 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) 103 Key findings/Evidence Standard met? Service users were registered with their own practices at their usual address; however, advice would be sought from the local GPs if it were need. The manager reported that most service users had contact from professionals within the specialist Learning Disability Partnership including occupational therapists, nurses, dieticians and speech and language therapists, and records and discussions confirmed the effective use of health care services to promote each persons physical and mental well being.Alder Close (20)Page 21 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. 2 Key findings/Evidence Standard met? Medication records were inspected and found to be generally in order, however, on occasions records showed medication having not been given, but no indication for the reason for this was recorded. Medication was stored securely in a locked cabinet, advice had been sought from the pharmacist who supplied the home and action had been taken to ensure their recommendations were followed. The need for rigorous checking and recording of medication which was brought into the home by service users or their relatives had been recognised by the manager and appropriate procedures were reported to be in place to avoid errors. 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? The homes ability to meet the requirements of this standard was not assessed during this inspection.Alder Close (20)Page 22 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days 1 1 0 0 0 0 100 3 Key findings/Evidence Standard met? The service had a procedure to be followed if a person wished to make a complaint; this was also available in pictorial form. The manager stated that she aimed to ensure that she and the staff were open and available to deal with complaints and concerns before they became serious issues. The service had received one complaint during the last 12 months, however, this related to an item of clothing that had been mislaid in the large home which 20 Alder Close, in part, replaced. The manager stated that the complainant had been satisfied with the outcome of the investigation.Alder Close (20)Page 23 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 had procedures for ensuring the protection of vulnerable adults and had a policy for `whistle-blowing. These were reported to be made available to all staff; however, in this service there had been no occasion to test their effectiveness. The Protection of Vulnerable Adults (POVA) register, by which national records of workers deemed unfit to work with vulnerable people were kept, was not yet available for use.Alder Close (20)Page 24 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? The home is in a quiet cul-de-sac on the outskirts of the market town of March. The building is a large bungalow that had been purpose built and provided with aids and adaptations to meet the needs of the people using the service. The building was found to be well maintained, decorated to a high standard and was comfortable and homely.Alder Close (20)Page 25 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 XX X 0 03 Key findings/Evidence Standard met? All service users rooms were for single occupancy and all had en-suite facilities including a shower. All rooms had been designed to meet the requirements of this standard.Alder Close (20)Page 26 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. 3 Key findings/Evidence Standard met? Service users rooms were equipped with furniture and fittings designed to meet the requirements of this standard. Observation confirmed that service users chose the layout of their bedrooms, and had been able to bring with them personal possessions to personalise their rooms.Standard 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? The home had one shared bathroom and each bedroom had en-suite facilities including shower facilities. Three communal toilets were provided for those living and working in the home, and for visitors.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. 2 Key findings/Evidence Standard met? The bungalow had a shared lounge and a spacious kitchen/diner to which the residents had free access. It also had a laundry room and a large entrance hall. The home had an enclosed rear garden with lawns and some planted areas and other areas which were yet to be fully cultivated. All areas appeared accessible to the service users; however, there was a need for the provision of garden furniture including furniture suitable for the use of people with disabilities, and the lawn was rapidly becoming overgrown and would soon be inaccessible.Alder Close (20)Page 27 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? Advice had been sought from an Occupational Therapist to ensure that suitable aids, adaptations and equipment were provided to meet the wide range needs of the people likely to use the service. Equipment in place included overhead tracking, hoists, and a specialist bath. Information supplied, indicated that satisfactory arrangements were made for the repair and maintenance of the homes aids and equipment.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 inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? On the day of inspection the home was found to be clean and appeared hygienic and no unpleasant odours were present. Policies and procedures were in place for the safe handling and disposal of clinical waste, and laundry facilities were sited so that soiled articles, clothing and infected linen were not carried through areas where food was stored, prepared, cooked or eaten.Alder Close (20)Page 28 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? Each staff member had a job description which set out their responsibilities and duties. Staff members spoken to demonstrated that they had a clear understanding of their roles and confirmed that they felt supported by the manager and the person overseeing the service. They also confirmed that they would be able to approach the manager or others within the organisation if they felt unsure about something or needed advice or support.Alder Close (20)Page 29 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. 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 3 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 XXX3 Key findings/Evidence Standard met? Staff were on duty at the time of inspection in sufficient numbers to meet the needs of the current service users, the manager stated that staffing levels would be dependent on the needs of the people using the service at the time. Staff spoken to demonstrated that they had a good understanding of the needs of the people who were using the service and showed a high level of commitment to the home and the service generally.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. 3 Key findings/Evidence Standard met? The staff group at the home was relatively small, reflecting the size of the home. Staff who were interviewed stated that they were happy to be working in the home, however, it was reported that there were insufficient staff in the core team which was leading to stress amongst staff members and agency staff were frequently used; this was also shown to be the case in recent staff duty rosters.Alder Close (20)Page 30 Standard 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? Staff files were examined and were found to contain the information required to ensure as far as possible, the protection of the people using the service, including two references, job descriptions and satisfactory Criminal Records Bureau (CRB) checks. As noted in standard 23 the Protection of Vulnerable Adults (POVA) register by which national records of workers deemed unfit to work with vulnerable people were kept, was not yet available for use. Cambridgeshire County Council has a countywide commitment to equal opportunities. 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. 1 Key findings/Evidence Standard met? Staff spoken to confirmed that they had received training to help them meet the needs of the service users including areas of health and safety such as moving and handling. The manager reported that the induction of staff took place over a 2-week period, however, she was unsure as to whether the programme was in line with the Social Skills Council/TOPSS induction standards. Information about where to find the TOPSS induction standards was provided to the manager during the inspection A record of staff training was seen and showed that a number of staff were in need of training in areas of health and safety including moving and handling and first aid. Training was also needed in subjects specifically relevant to the service user group; the need to arrange this using the Learning Disability Award (LDAF) framework was discussed with the manager. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The manager reported that supervision was scheduled to take place on a monthly basis, however, this was not always achievable. Supervision covered the philosophy of the home, training and support needs, and matters relating to individual service users. Discussions with staff confirmed that supervision took place regularly and they appeared clear about its purpose and the importance of effective supervision.Alder Close (20)Page 31 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 or equivalent. NO3 Key findings/Evidence Standard met? The registered manager is Margaret Hill. Mrs Hill has worked for the Social Services Department with people with learning disabilities for many years and was assistant manager of the service which 20 Alder Close, in part, replaced. Mrs Hill has the City & Guilds Advanced Management & Care award and also holds a National Examining Board for Supervision and Management (NEBS) introductory Certificate. Mrs Hill is aware of the need for her to gain the Registered Managers Award by 2005.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? Staff spoken to said that they felt that the staff and manager worked as a team and they felt the home was run in an open manner that ensured service users received a quality service that was able to meet their needs effectively. The service was aimed at providing short term care to people with learning disabilities, however, staff were concerned that a number of the beds in the home had been allocated to individuals who had been admitted as an emergency, but who were now semi-permanent at the home as there were no suitable alternative placements available.Alder Close (20)Page 32 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. 1 Key findings/Evidence Standard met? The home did not have formal systems of quality assurance, the manager stated that she and her staff were readily available to service users and their relatives if they wished to comment on the service, and the local advocacy group had been closely involved in gaining service users views. The need to develop formal systems of gaining the views of service users was discussed with the manager.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 Younger Adults. 3 Key findings/Evidence Standard met? The inspectors were provided with copies of the homes policies and procedures; these had been updated by the manager to ensure they were relevant to the home specifically, and they appeared comprehensive and covered the required topics satisfactorily.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. 2 Key findings/Evidence Standard met? Records inspected were up-to-date, appeared accurate and were held securely, however, not all records to be kept in respect of each service user (Schedule 3) were present and the manager stated that she and the staff were working to ensure all service users files contained the required information. Not all records to be kept in a care home as detailed in Schedule 4 were inspected, however, those seen were satisfactory.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. 2 Key findings/Evidence Standard met? Staff spoken to confirmed that they had received training to ensure their own safety and that of service users, however, the manager was aware that further training was needed to ensure that all practicable measures to ensure health and safety were taken. The manager was aware that there was a need for further training to take place and confirmed that the training required to ensure safe working practices would be scheduled to take place in the coming months.Alder Close (20)Page 33 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. 3 Key findings/Evidence Standard met? The financial viability of the business was not assessed, however, the service is managed by the Local Authority and the inspectors had no reason to doubt the financial viability of the home.Alder Close (20)Page 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMatthew Bentley Kay Wood Sue PinnerSignature Signature SignatureAlder Close (20)Page 35 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Alder Close (20)Page 36 PART EE.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 16 March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Standard 6 ­ 10 Medication recording was amended immediately. Standard 22 ­ 23 The grass has been cut now that the weather is better. A Patio Table and chairs have been purchased. The Manager is attending a LDAF training course in May 2004. As discussed I am working towards becoming an NVQ Assessor. I will do the Registered Managers course. In due course. Standard 8 (8.1 ­ 8.5) Although this was not assessed Services Users do contribute to the running of the home for example choice of food when being supported to shop and assisting with food preparation. Standard 13 (13.1 ­ 13.5) Alder Close already employs one Support Worker from Romania and two Relief staff one from Russia and one from Malaysia. Standard 20 (20.1 ­ 20.14) This was due to an error on the form and has since been rectified. Standard 28 (28.1 ­ 28.3) Lawns now cut. It has been to wet to cut them previously. Standard 39 (39.1 ­ 39.10) We had also introduced a questionnaire which will go to families shortly.Action taken by the NCSC in response to provider comments: Alder Close (20) Page 37 Amendments to the report were necessaryYESComments 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. E.2 Please provide the Commission with a written Action Plan by 13 May 2004, 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 planYESNONOOther: enter details here Alder Close (20)Page 38 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.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 E.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 10th MAY 2004Print 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 39 - 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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