Inspection on 11/01/07 for Ashley Phoenix Unit

This inspection was carried out on 11th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashley Phoenix Unit 11/11/08

Ashley Phoenix Unit 02/02/06

Ashley Phoenix Unit 05/09/05

Ashley Phoenix Unit 31/03/05

Ashley Phoenix Unit 26/07/04

Ashley Phoenix Unit 25/11/03

Similar services:

5 Seafield Road

Honeybourne House

Longrun House

Bodley Community Care Support Centre

Thomas Pocklington Trust

Chantry Gardens

Penkelly House

25-27a Alexandra Road

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

CARE HOME ADULTS 18-65 Ashley/Phoenix Unit RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN Lead Inspector David Smith Key Unannounced Inspection 11th January 2007 09:40 Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley/Phoenix Unit Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN 01225 332818 01225 480825 julie.sheppard@rnid.org.uk RNID Mrs Julie Kim Sheppard Care Home 11 Category(ies) of Sensory impairment (11) registration, with number of places Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 11 persons aged 18 to 64, requiring personal care. 2nd February 2006 Date of last inspection Brief Description of the Service: Ashley/ Phoenix Units are situated on the first floor of the central Poolemead building and provides support and care for adults with a single or dual sensory loss, and associated learning disabilities. The building is divided into two distinct areas, Ashely and Phoenix, with 11 bedrooms in total. Each separate area has a lounge, kitchen and dining space. There is no structural barrier between the areas, but each provides for a specific group of service users and retains its own identity. Staff employed are designated to work either in the Ashley or Phoenix unit. A patio and garden provides external space for service users to spend time in a relaxed and pleasant environment. The current fees for this service are from £1069.00 to £1600.00 per week, depending on the support needs of each individual. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a Key Inspection of this service. I gathered information during this visit through discussions with service users, the Manager, Activity Co-ordinator and Support Workers. Interaction and communication between staff and service users was also observed during the course of my visit. Care plans and associated records were examined together with Risk Assessments, accident/incident reports, complaints log, medication, staffing and health and safety records. I was also provided with a tour of the home. Other sources of evidence have been used as part of the Key Inspection process. These include the home’s action plan in response to the last CSCI inspection and notifications of significant events which have occurred within the home. The Commission also provided the home with a range of Comment Cards for stakeholders prior to this visit. Seven were completed and returned. What the service does well: Each person who responded by Comment Card said they were satisfied with the care provided by the home. Each member of staff spoken with said they enjoyed working in the home and were well supported in their role. The home continues to promote a person centred approach in providing care and support to service users. A core of experienced staff have a good knowledge of service users support needs and methods of communication. There is a clear management structure, which provides an open and inclusive environment for both service users and staff. The home is well maintained and there is a clear process of maintenance and renewal. This ensures a homely environment is provided for service users. The environment makes good use of both colour definition and tactile stimulation to support service users independence and comfort. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Staffing levels must continue to be kept under review. This is to ensure that service users opportunities are not limited unnecessarily. All staff must be provided with both mandatory and other relevant training. This will ensure all staff have the knowledge and skills to provide appropriate support to each service user All staff must be supervised on a regular basis. This will ensure all staff are supported to provide support the service users. Fire safety within the home must be improved. This will help to promote the welfare and safety of services users and staff. The home should continue to review its progress in providing information to service users in a format which is accessible to them. This will help each person to be involved in their care planning in a meaningful way. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides comprehensive information to enable service users to make an informed choice of where to live. This has recently been reviewed in accordance with the home’s policy. EVIDENCE: The home has a Statement of Purpose, which details the services provided by the home. The areas covered include Aims and Objectives, the Staffing Structure, Plan of the Home and Fee Levels. This document was updated earlier this month and now includes updated details regarding contact with the CSCI. The home also has an ‘Operational Plan 2007-2008’, which can be read in conjunction with the Statement of Purpose. This plan has a number of objectives for the home to work towards, which includes service users care and inclusion, staff development and partnership working. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provide good information in how to support each service user. Each care plan is now regularly reviewed and updated. The home continues to review the accessibility of information for each service user. The home’s staff team provide appropriate levels of support to service users. Staff also advocate appropriately for service users. There are Risk Assessments in place to support service users to take risks as part of their lifestyle. These are now reviewed and updated regularly. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 11 EVIDENCE: I examined three service users’ care plans during my visit. These files are separated into two, “Service Users Care Methodology” and “Evidence File”. These two files contain comprehensive information regarding the current support needs and guidelines for each service user, minutes of review meetings and outcomes, Risk Assessments, activity programmes, contact with families and health care professionals, medication profiles together with some historical information. Each care plan had clear records of the annual multi agency review and the outcomes of these meetings had been used to update each plan. The home now ensures that each Keyworker updates care plans at least twice a year or when service users support needs change. This process is recorded on an ‘Amendments to Care Plan’ form. When any changes are made to care plans, all staff members are asked to read and sign to confirm they have noted the changes. Some care plans contained written information and several photographs of service users, significant events such as holidays and family members. Other than this there is little information which service users would be able to access easily. The Manager told me that this may be a longer-term goal, although it was unlikely it would be possible to make information accessible for each service user due to their particular communication difficulties. The home is currently improving the information contained and collated within care plans, to ensure they are easier for staff to follow and that information is not repeated. It is apparent that these changes will improve the quality of each care plan once this process is completed. I did communicate directly with some service users during my visit, however most individuals who live in the home have limited communication skills and effective communication requires an extremely good knowledge of each person. I therefore observed interaction between staff and service users on both Ashley and Phoenix units at various times during the day. These interactions demonstrate the staff had a good knowledge of each service user’s communication method and ability. Various methods were used including British Sign Language, Deaf Blind Manual Alphabet, hands on signing, body language, gestures and clear speech. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 12 Staff use these methods to inform service users but make every effort to ensure they are supported to make choices. Staff gave each person time to make decisions and make best use of their skills and abilities. One social care professional who responded by comment card said the home works in partnership with them. Staff demonstrate a clear understanding of service users care needs and their advice is incorporated into care plans. They are satisfied with the overall care provided by the home and added they had been “particularly impressed over the last two years with the approach of staff”. Each service user has a number of person centred Risk Assessments, which support them to take risks as part of their lifestyle. These form part of each person’s care plan and are now subject to regular review. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 and 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers opportunities for service users to take part in appropriate social, leisure and educational opportunities in order to enhance their lifestyle. Staffing levels should continue to be reviewed to ensure the opportunities provided to service users are not limited unnecessarily. Service users are supported by staff to use community facilities, enjoy holidays and visit family and friends. Service users’ rights and responsibilities are supported through the daily routines of the home. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users have the opportunity to attend daily Educational Development Studies on the main Poolemead site, where are variety of activities are offered such as art and woodwork. Facilities in the wider community are also used, including horse riding, swimming, shopping, trips to local pubs and going out for meals. This is monitored and supported by the activities co-ordinator and I discussed the activities programme with this staff member during my visit. Her role is to help plan and facilitate the activities programme for all service users living in the home. She has a good knowledge of each person as she previously worked at the home as a Support Worker prior to working in her current post. During the past few months, service users have been supported to plan and attend holidays. Records show holidays to Blackpool, Lanzarote, Kent, Isle of Skye and Centre Parcs. There have also been day trips to parks, theme parks and the theatre to see the musical ‘Cats’ and the Chinese State Circus. Each service user is supported by their keyworkers in choosing and planning their activities programme. This is centred on each individual and new opportunities are offered. These allow service users the chance to develop, take new risks and experience new activities. Both the Manager and staff spoken with told me that there are vacancies within the staff team. This is covered by existing staff members working additional hours and the use of RNID relief staff. Agency staff are rarely used. The home is currently advertising these posts and hopes to conduct interviews shortly. The relatives who responded by comment cards had mixed views on the staffing levels within the home. When asked if they felt there were ‘always sufficient numbers of staff on duty’, three families said “yes” while three said “no”. Whilst it was evident that staff worked hard to ensure opportunities for service users were not limited, staff told me that it can be difficult to plan trips out of the home particularly on days when there are no staff working ‘mid shifts’ across the main part of the day. The Manager accepted this was occasionally an issue and told me that one of the posts currently being advertised would involve working mid shifts on weekends to provide more opportunities at these times. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 15 Individuals are supported to maintain close contact with their families and friends. The care records show that family members regularly visit the home and also attend review meetings. A record of correspondence for each service user is also maintained as part of their care plan. Six families who responded by comment card were complimentary regarding the service provided by the home. Each said they are always welcome to visit the home and able to visit their relative in private. They are kept informed of important matters affecting their relative and consulted about their care. One family added “We are very happy with the care provided” and another said “We are fortunate there is a place like this for our relative”. It was evident that the home respects individuals’ privacy; whilst touring the home, staff knocked on doors prior to entering each unit or individual rooms. Each service user is seen as an individual and respected as such. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans clearly explain the support each service users requires in relation to their personal and health care. Experienced staff have a good knowledge of each service user and how to provide appropriate levels of support. Any concerns are noted and acted upon. Medication administration is well managed in the home, to promote the welfare of service users. EVIDENCE: Each service user is registered with a local GP, Dentist and other relevant professionals such as an optician. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 17 There are varying levels of support from other health care professionals such as Speech and Language Therapist, Audiologist, and Occupational Therapist. Contact with these professionals was clearly recorded in each service user’s file and the outcomes acted upon. I observed staff interacting and supporting service users within the home. Staff spoken with displayed a good knowledge of the personal care they need to provide to service users and this was in accordance with the care plans examined. The knowledge staff have of each service user remains crucial to ensure their health and emotional needs are met. Due to their vulnerability and limited communication skills, service users rely on the support staff to recognise any changes to their usual patterns of behaviour or interactions and these are acted upon. Staff spoken with told me that some service users had recently been unwell and others were still suffering from a ‘flu type’ of illness. Another had been prescribed anti-biotics, which did not appear to suit them. Staff acted on this issue immediately and demonstrated an extremely good knowledge of each of these service users. They offered sensitive care and support to each one throughout the day. During this visit, medication administration on the Phoenix unit was examined. This home uses the Boots Monitored Dosage System of medicine administration. The medication records show profiles of each service user, recent photograph, details of their medication, times of administration and manufactures notes on each of the prescribed medications administered within the home. There is also a list of signatures for all staff who dispense medication and samples of the initials they use on these records. Most staff have completed ‘Protocol’ training in relation to medication administration. This is in the style of an NVQ unit and contains four elements; introduction to medicines, care workers role, administration and medicines of differing client groups. The pharmacist last visited the home in March 2006. Their report confirmed that the medication system was well managed and did not recommend any improvements. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The RNID has a robust system for dealing with all complaints. Service users are enabled to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Comprehensive policies and procedures are in place for the Protection of Vulnerable Adults. All staff have now confirmed they have read and understood these documents. Service users who exhibit behaviour which challenges the service now have clear reactive strategies, which form part of their care plans. This promotes the welfare and safety of service users and staff. EVIDENCE: The home has a complaints procedure, which all service users have explained to them. Each relative who responded by comment care said they are aware of this procedure. There have been no complains recorded since the last inspection. Clear records of all accidents and incidents are maintained. The home also notifies the Commission of any significant event which occurs within the home. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 19 Staff are provided with training in relation to the Protection of Vulnerable Adults, Child protection and are subject to Enhanced Criminal Record Bureau Disclosures. Some service users would be able to communicate to staff members if they were unhappy or felt they were at risk. Others would not have the necessary skills to clearly communicate these types of issues. Staff spoken with explained that they therefore also use daily observation when supporting service users. This would help alert them to any changes in behaviour, which may cause them concern. There has been one recent incident in the home, where staff members had raised concerns regarding one colleague’s professional practice. This was dealt with immediately by the home in accordance with the local Protection of Vulnerable Adults policy. The home has comprehensive details of Protection of Vulnerable Adults policies and procedures. These records include each Funding Authority Local Policy, BANES Local Policy and the RNID Policy and Procedure. Staff have now read the policies and signed to confirm they have understood them. The home now has clear guidelines in place for supporting service users who are distressed or presenting behaviours which may be perceived as challenging the service provided. These are described as ‘methods of approach’ and are clearly written and reviewed regularly. Staff receive training in responding to challenging behaviour using the NAPPI (Non Abusive Psychological and Physical Intervention) system, which is accredited by the British Institute of Learning Disabilities. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. The home is well maintained and has several adaptations, which complement both the skills and abilities of the service users and help to promote their independence. The home was clean and tidy on the day of my visit. EVIDENCE: Ashley Phoenix is a self-contained unit, on the first floor the main Poolemead Building. There are large communal grounds on the Poolemead site and the home also has its own attractive garden area, which can be accessed directly Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 21 from the home. The Manager told me this area has been such a benefit to the home. Service users enjoyed spending time in the garden during the summer and it provides a private area in additional to the communal grounds on the Poolemead site. The decoration shows good use of colour contrasting schemes throughout both of the units. This is particularly beneficial to the service users who have a visual impairment, as this will support them to mobilise independently around the home. Each unit also has several tactile features on the walls. This helps to ensure service users can map their environment and helps to provide a stimulating sensory environment. Each unit has photographs of the people who live there, together with pictures hung on the walls. This helps to personalise the home and add to the homely feel. The Manager told me of future plans to improve the environment further. This includes removing a wall, which currently separates one of the toilet/bathroom areas in the Ashley unit. This will create one room and will enable individuals with mobility problems to use these facilities more easily. The cupboard area in the Phoenix unit is due for replacement, as the corridor where this is located is quite narrow and difficult for service users to pass when the cupboard doors are open. It is hoped that both of these projects will be started shortly. Each unit was clean and tidy on the day of inspection. Each service user is supported by staff to help maintain the home, with regard to each person’s skills and abilities. Staff are also active in ensuring the home remains clean and tidy. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a core of experienced staff who have a good knowledge of their support needs. The staff team remains cohesive and effective in supporting the service users. However, vacancies within the staff team must be recruited to. The home’s recruitment policy promotes both individual’s rights and their safety. Staff are provided with training both by the organisation and external agencies. However, all staff must be provided with core training in accordance with RNID Policy and any specialist training to meet the needs of each service user. All staff must be supervised on a regular basis and a clear record maintained in their personnel files. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 23 EVIDENCE: There are some shortages within the staff team, however a core of experienced staff remain who have a good knowledge of each service user and they support needs. Staff were observed interacting with service users and discussions with staff showed they had a good knowledge of service users and how to offer them appropriate support. I spoke with six members of the staff team during my visit. Each staff member told me they enjoyed working in the home and that they felt well supported in their role. They felt the care and support given to each service user was of a very high standard. The relatives who responded by comment card made many positive comments regarding the staff working in the home. One family said they “always found the staff very helpful”, another “the staff are always polite and make us very welcome” and another family said “I’m always made welcome by all the staff. I’m satisfied with the care they provide”. The staff team meets monthly in each unit. All meetings are recorded and appropriate subjects are discussed in order to guide and direct staff practice. Records of meetings show that attendance levels are generally high. Staff are required to sign to confirm they have read the minutes of each meeting. The home operates a robust recruitment process and the records examined included application forms, job descriptions, two satisfactory references, documents confirming proof of identity, induction checklists, training records and Enhanced CRB Disclosures. The home is in the process of improving its record keeping in this area, by introducing a new indexed filing system. A small number of files were therefore not yet complete, as they were being transferred to the new system. These will be focused upon during my next visit. Staff are provided with a variety of training opportunities, provided either by the organisation or external training providers. Records examined showed that staff are provided with mandatory training such as First Aid, Food Hygiene and Protection of Vulnerable Adults. More specialised training includes epilepsy, mental health, NAPPI, Diabetes and LDAF. Each staff member has a separate training file, which includes a training matrix and copies of certificates of each training session they have attended. These records show varying levels of attendance at staff training. Some staff have Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 24 been provided with all of the mandatory and specialist training they are expected to undertake. Other staff members have had limited training and one staff member has no record of attending any training other than first aid. Staff are formally supervised during 1:1 meetings with their line manager. I did note that some staff members are not being provided with regular supervision. Whilst I acknowledges the recent shortages within the team is a factor, it is important to re-establish regular supervision meetings as staff spoken with feel these sessions are valuable and support them in their roles. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed ensuring that service user’s interests and rights are promoted and protected. The manager promotes a person centred approach and this is clearly communicated throughout the service. There are systems in place designed to promote and protect the health & safety of service users and staff. The Risk Assessment process has been improved, however fire safety within the home must be improved. The processes of managing the home are efficient and transparent. This helps in providing the support for each service user. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Registered Manager, Mrs.Sheppard, has worked in the home for three years. She has considerable experience of working in the social care sector. She has an NVQ Level 3, City and Guilds Advanced Management for Care and is currently working towards both NVQ Level 4 and the A1 NVQ Assessors Award. The management approach is open and positive, with a clear sense of direction and leadership. The ethos of the service is person centred with each service user being seen as an individual and treated as such. Staff spoken with said their views are listened to, and that they are well supported by the manager. The Manager told me that she enjoys her role and finds the RNID a very supportive employer. The current management team within the home, which consists of herself and two Senior Support Workers, appears to work well. There are defined roles within this management structure and this team also meets both formally and informally to ensure the home runs efficiently. This team is, in turn, supported by the Residential Services Manager, who is Mrs.Sheppard’s line manager. The management systems and structures are efficient. The record keeping is of a good standard. Files and documentation are generally well organised and easy to access. The Manager told me that the home always looks for areas to improve in. The improvements in the care planning and personnel record keeping are examples of where this is taking place. The registered provider’s representative makes regular visits to the home, and produces a comprehensive report of his findings, which is send to the Commission on a monthly basis. There are recording systems in place to support Health and Safety within the home, which are generally being used consistently. Records examined included water temperature checks, food stock rotation, a visual check on all electrical appliances and hazardous products used within the home. The Fire Log shows that service users and staff take part in regular evacuation drills, the latest on 11/11/06, and that staff receive appropriate training. However, there was no record of the fire alarm system being tested during three of the last sixteen weeks and no record of the emergency lighting being tested in September or October 2006. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 27 The home has several generic Risk Assessments in place. These are now subject to regular review and all staff now sign to say they have read and understood these documents. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 X X 3 2 3 Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18 Requirement Staffing levels at weekends must be kept under review. (This requirement is repeated fro the last inspection report.) 2. YA35 18(1) All staff must be provided with a) training which meets all RNID core standards. b) training which provides all staff with additional relevant skills to support service users. 3. YA36 18(2) All staff must be supervised on a regular basis and a clear record of each meeting be maintained. Ensure the Fire Alarm system is tested at the frequencies stipulated in the Avon Fire Log. Timescale for action 11/01/07 11/07/07 11/01/07 4. YA42 23(4) 11/01/07 Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The home should continue to review its progress in providing information in accessible formats to each service user. Ashley/Phoenix Unit DS0000040650.V324646.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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