Inspection on 03/10/06 for Bailey Close

This inspection was carried out on 3rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bailey Close 20/12/05

Bailey Close 21/09/05

Bailey Close 14/03/05

Bailey Close 20/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Bailey Close 8 Bailey Close Haverhill Suffolk CB9 0LH Lead Inspector Deborah Kerr Unannounced Inspection 3rd October 2006 10:00 Bailey Close DS0000024329.V316536.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 Bailey Close DS0000024329.V316536.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. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bailey Close Address 8 Bailey Close Haverhill Suffolk CB9 0LH 01440 763290 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) Mrs Nemelita Seneviratne Mrs Nemelita Seneviratne Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Number 8 Bailey Close is a detached house, which is registered under the provisions of the Care Standards Act 2000 as a care home to accommodate a maximum of five people with a learning disability. There are currently four service users living at the home. The home is situated in a quiet cul-de-sac on a residential housing estate that is approximately one mile from the centre of Haverhill. There is a regular bus service within walking distance of the house. The accommodation is domestic in nature, providing five single bedrooms, three on the ground floor and two on the first floor, all with hand washing facilities. The home provides a communal lounge where service users can meet friends and relatives or watch the television. The lounge opens out to an enclosed garden laid to lawn with shrubs and a bird birth, a patio area with seating is also provided. The home has a statement of purpose and service users guide providing information for prospective service users. Each service user has an individual service agreement, which states the current fees charged by the home of £331 per week for 24-hour care. A separate contract of the terms and conditions setting out the agreement between the service user and the home were seen, these were signed and dated. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which focused on the core standards relating to adults, aged 18-65. The inspection was unannounced and took place on a weekday starting at 1:15pm with the assistance of Lisa Nurse who is known as an Expert by Experience and her supporter Lynne Ferdinando from Barking and Dagenham MENCAP and Barking and Dagenham Centre for Independent Living (CIIIL). They spoke with all the service users and a member of staff. Their findings are included within this report. The inspector reviewed a number of documents including those relating to service users, staff, training and health and safety records and the home’s Statement of Purpose and Service Users Guide. The inspector spent time with all of the service users individually and collectively, the manager and a member of staff. The report has been written using accumulated evidence gathered prior to and during the inspection. Throughout this report the people living in the home are referred to as service users, the homes manager informed the inspector this was the service users preferred form of address. This was confirmed when talking with service users. The expert by experience referred to the service users as clients in their report, the inspector has changed this term of address in line with the service users wishes. What the service does well: Bailey Close provides service users with a home that promotes their independence, dignity and well being. The expert by experience, their supporter and the inspector were all made welcome by the service users who were keen to show them around their home. The home is situated in a cul-desac providing accommodation that allows the service users to live in and be part of the community. Service users were observed living their lives through choice and taking control over the day-to-day running of the home. All four service users spent time talking with the expert by experience, describing what it was like for them living in the home. They told the expert by experience they were able to make a positive contribution to the household taking their turn on a rota basis to cook, clean and go shopping for groceries. The expert by experience joined staff and service users engaged in conversation around the dining table, they observed that service users have a very good relationship with staff and felt that the atmosphere resembled that of a family home. Information obtained prior to the inspection from relatives comment cards was extremely positive and complimentary about Bailey Close One relative commented, “ My relative has been living at the home for 5 years, they love being there, staff are great and easy going, a big thank you to all’ and another commented “my relative has been at the home for over 5 years and regards the other residents as their other family” and “ I have complete faith in the home and the staff” Residents commented “its nice” living at the home and “I like living here with the manager, I am happy”. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 7 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 Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 8 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): 1,2,3,4,5, Quality in this outcome area is good. Prospective service users are provided with information about the home before making a decision about where they live, however information needs to be available in formats suitable for the people for whom the home is intended. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes statement of purpose and service users guide contains information about the service and provides clear guidance on how the home deals with referrals and admissions. Although the home is registered for five people the manger was not anxious to fill the vacancy. They were very clear that any new admissions would need to be planned; they do not take emergency admissions into the home as this could dramatically affect the lives of the other service users. The most recent service user to move into the home was in November 1994. It was therefore difficult to fully assess standards 2,3, and 4, however evidence was seen in their care plan that they had had an admission interview and two planned visits to the home where they stayed for tea and met the other service users. Evidence was seen that a life history and detailed plan of care was in place, which covered all the service users needs. Each service user has an individual service agreement, which identifies their contractual fee and the terms and conditions of residence at the home. These had been signed and dated by the service user and the manager, however only two of the service users are able to read, the other two need to have information read to them. A discussion Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 9 was held with the manager about providing information in different formats suitable to meet the capacity and understanding of the service users so that they were able to make an informed decision to sign documents. Observations made by the expert by experience were that the service users and staff have a good rapport. Each of the service users spoken with by the experts by experience stated that they are happy at living at Bailey Close and that their needs are met. They told the expert by experience they were able to choose how they spent their time within the home and could have time on their own in the privacy of their own rooms. One service user informed the expert by experience that they were unhappy that their social worker came from where they originally lived rather than the area the home was in, but they were able to keep in contact by telephone. Bailey Close DS0000024329.V316536.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): 6,7,8,9, Quality in this outcome area is Good. Service users can expect to have care plans, which identify the personal needs but do not always reflect the level of support required to manage inappropriate behaviour. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has full and comprehensive care plans in place, which cover all areas of the service users health, social and welfare needs. The care plans of two service users were tracked during the inspection. These were divided into sections identifying the level and support service users needed to meet their individual health and emotional needs. Information taken from the pre inspection questionnaire identifies that the manager has arranged for staff training to improve the care plan further by introducing person centred planning. An incident report identified that one service user has a propensity to display behaviour that can be challenging. The report identified that the service user had been physically aggressive towards another service user. The manager and a member of staff spoken with explained when the service user became verbally aggressive, they generally do not respond to this, which usually results in them calming down. Although these incidents are relatively Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 11 infrequent there was no agreed strategy and consistent approach recorded in the service users care plan of how their behaviour was managed. The same service user informed the expert by experience that if they were having a bad day they could talk to the manager. The manager informed the inspector that they have arranged with the community psychologist to present some in house training for the management of aggression and challenging behaviour. Each of the service users informed the expert by experience that they had their own bank accounts and are able to draw their own money out of the bank when they want. Each service user has their personal allowance weekly to spend on what they want. One service user told the expert by experience that they chose to buy beer with their allowance. The manager informed the inspector that service users are in receipt of all their benefits, which are paid directly into their bank accounts. Direct debits have been set up to pay their individual contributions to their fees. One of the service users told the inspector they had looked after their own money and writes their own cheques to withdraw their personal allowance form the bank. They had also received an inheritance, which they had paid into a building society, and are able to manage the account. Evidence was seen that the service user kept their chequebook and statements in a locked draw in their bedroom. All service users bedrooms are kept locked and they are issued with their own key. Service users are actively encouraged to take part in the day-to-day running of the home. Through discussions with the service users the expert by experience was pleased to see that each of the service users were responsible for the domestic up keep of the home. They observed a rota, which involved staff and service users working together to do the chores. They observed service users being encouraged to wash and wipe up, and put away after their evening meal. The service users told the expert by experience they liked taking part in the rota and doing the housework, this kept them active and helped each other. Another service user was proud to show the expert by experience and the inspector the garden, they told the expert by experience they had a keen interest in gardening and was happy to take on the task of all the gardening. The inspector was informed that service users are encouraged to participate in the decision making process about what happens in the home; they attend regular staff and residents meetings. Through discussion with the manager it was acknowledged that information provided in the home is not in a suitable format that allows each service user to access information about services, policies and procedures without assistance. Two of the service users are unable to read; therefore the manager has decided to consult with the other service users about making audiotapes that contain all the information, so that the service users can access information as and when they need it. Evidence was seen in one service users care plan aims and objectives setting out actions to help them to develop their independent life skills. These were supported by individual risk assessments identifying the hazards and actions Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 12 taken to minimise the risk when undertaking daily routines such as using public transport, going to the bank alone, self administering medication, helping with domestic tasks and preparing meals. Evidence was seen that these were being updated on a regular basis. Bailey Close DS0000024329.V316536.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): 11,12,13,14,15,16,17, Quality in this outcome area is excellent. People living in the home are supported to make decisions and choices about their daily lives and have a lifestyle that matches their expectations. They can also expect to receive a good standard of fresh and appealing food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The expert by experience joined the inspection late afternoon when service users were returning from day care activities. They spent time talking with the service users individually and collectively. One service user took pleasure in showing the expert be experience and their supporter around the home and their private bedroom. During conversations with the service users the expert by experience ascertained that they all go to day centres for different activities. This was reflected in service users care plans seen by the inspector. Day care activities include attending the Haverhill Community Resource Unit. Service users are able to access variety of activities and educational opportunities. They attend drama and dance classes and certificates seen in their rooms showed that they had all obtained a National Vocational Qualification (NVQ) in food hygiene. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 14 Service users have access to a sports centre through the resource unit. One service user informed the inspector they had won two games of table tennis that afternoon. Service users informed the inspector they attend local clubs, such as Gateway and the Local Association for Mental and Physical Handicap (LAMPH). They also enjoyed going out to the pub in the evenings and attending a drop in café called Sunflower. One of the service users has a work placement on a Thursday at the local social services office, where they are responsible for sorting the mail. They informed the inspector they have been invited to the works Christmas dinner. Two of the service users belong to the Suffolk befriending Scheme. They have each been allocated a befriender who supports them to access shops in the community independent of the home; they keep in contact by telephone. One of the service users informed the inspector they were scheduled for a day out with their befiender this week. The expert by experience observed service users meeting together and watching television in their own rooms or in the shared lounge. Service users told the expert by experience they liked to listen to music together in the lounge or they chose to listen to their preferred taste in music in their own rooms. During their visit the expert by experience observed service users and staff working together to complete the chores listed on a rota. The service users were happy to take part in the housework, and were observed washing and wiping up, and put away the dishes and cutlery after their evening meal. Whilst the service users were taking part in these chores the expert by experience noticed that there was a good rapport and general conversation taking place between the service users, staff and manager. On completion of the washing up service users and staff were observed sitting around the dining table and talking together, the expert by experience reported that their overall impression was that it was like a real family home. One of the service users commented “I am happy living at the home, the manager is very nice to me, I get on well with them” and a comment received in a relative comment card prior to today’s inspection commented “my relative has been at the home for over 5 years and regards the other residents as their other family”. All of the service users told the expert by experience they felt that they could talk to the manager if they had any problems and observed service users calling the manager and staff by their first names. They also said that they were able to maintain important relationships they could have friends and relatives to visit or go to visit them whenever they choose. One service user told the inspector they use public transport to visit their relative every other weekend. Another service user has been to Cambridge and Ipswich with their relative to watch football matches. Whilst being shown around the home the expert by experience noted that service users were able to follow interests and hobbies of their choice. One service user spoke of their keen interest in gardening and took on the task of all the gardening at Bailey’s Close and informed them that staff support them to buy bulbs and plants for the garden. Other examples seen was a collection Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 15 of porcelain dolls, soft toys and sports medals won by one of the service users at a sports event. Another interest of a service user was seen throughout the home, they had a rug-making machine in their bedroom and showed the inspector their talent for making rugs. These were seen in individual’s rooms and in the shared lounge. Service users informed the expert by experience that they liked to use the local shops to purchase magazines, access bank facilities, go for walks with staff and visit a friend around the corner. One service user said they liked to celebrate their birthday with other people by having a drink and going to a nightclub, another service user told the expert by experience they were going to a Cliff Richard concert on their birthday. The service user stated that they liked to share their birthday with the manager, as they are a friend. All service users said that they like to celebrate Christmas at Bailey’s Close by decorating the home with Christmas decorations and a tree. Bailey’s Close have a no smoking policy, however there is one service user that smokes, the expert by experience spoke with the service user who acknowledged the no smoking rule and said they were happy to smoke outside in the garden. The expert by experience report reflects that they spoke with one service user who did not want to join in an activity and said this was undertaken when they were out of the home. They also reported speaking with another service user whom felt they were unable to choose where they go, however there is no additional information to support these statements. The home has a weekly menu and cleaning rota. This was seen fixed to the fridge in the kitchen. Each day listed tasks, including whose turn it was to cook and what the service users had agreed for the menu on that day. The menus reflected a well balanced diet including fresh vegetables and fruit. Evidence of this was seen in a well-stocked fridge and cupboards. The expert by experience noted that service users had a varied diet, which was chosen and cooked by them. They observed service users eating their evening meal; and commented that they appeared to be enjoying what they were eating. The food was healthy. One service user spoken with has specific dietary needs, they explained what they can and can’t eat and why. The resident was very clear on their health needs. The service user showed the inspector bread they had baked and explained that they shop for food items, which they can eat. These were reflected in the weekly menu. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is Excellent. Service users are encouraged to manage their own healthcare needs and support provided only when they request. They are encouraged to take responsibility for the control of their own medication and are protected by the home’s policies and procedures for dealing with medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was seen that service users receive care and support as required. One of the service users had remained at home on the day of the inspection as they had the beginnings of a cold. The service user decided to have a bath and go to bed early. When talking to a member of staff the expert by experience was informed that the service user had been poorly that day and they were allowed to stay indoors in the warm rather than going to the day centre. They observed the member of staff providing the service user with individual attention whilst helping them with medication and a drink. Service users told the expert by experience they were able to decide how they spend their time; this was flexible to take into account day care activities and choice. During the week service users told the expert by experience that they needed to be up in time for day care services, staff wake them or they use their own alarm clock, but at weekends they choose when they go to bed and Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 17 when they get up and how they spend their time during the day. This involved cleaning their rooms, gardening and shopping for groceries and personal items. Service users also told the expert by experience they are able to choose what they wear and demonstrated this by showing them a good selection of their own clothing and makeup. During the visit the inspector observed one service user using a walking frame. A physiotherapist provided them with the frame following an assessment to help them maintain their independence and mobility, especially when walking up steps. The physiotherapist provides ongoing support and visits the service users alternate weeks. The service user told the inspector they were very happy with the frame, as it had given them more confidence. The expert by experience acknowledges in their report that service users have access to the doctors and dentist in the local community. Evidence was seen in one service users care plan that they choose to access healthcare independently. It states that they can visit the general practitioner (GP), dentist and optician on their own but needs support to attend out patient’s appointments. Evidence was seen in the daily progress records that service users health and well-being is monitored on a day-to day basis. A record of appointments were being made and the outcomes of the visit. Appointment cards and letters were being kept in the care plans which gave an audit of appointments with consultants, and if these were cancelled and remade by the hospital and for future consultations. Two residents choose to administer their own medication. They are able to store their medication in a lockable drawer in their bedroom, and have a copy of their own Medication Administration Record (MAR) record, which reflects the medication they are taking. They enter a tick when they have taken their prescribed medication at the recommended time, however one of the service users was ticking their MAR chart to say they were taking their evening medicine a 8am in the morning, on closer inspection of the MAR chart the service user was taking their medication as instructed by the pharmacist but this had been recorded on the MAR chart incorrectly. The MAR charts for the other two service users who have their medication administered by the staff were seen and these were found to accurately completed and up to date. The inspector viewed the homes policy and procedures for administering medication and for self-medication. These had been reviewed in August 2006 and provided evidence that the home’s manager had consulted with the pharmacist for advice on ordering and disposal of medication. They also stated that service users medication is reviewed on a regular basis with their GP or psychiatrist. Evidence was seen that this happens in the service users care plan. Bailey Close DS0000024329.V316536.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): 22,23, Quality in this outcome area is good. Service users can expect to have their views listened to and be protected from abuse by the homes policies and procedures, however information needs to provided in a suitable format to enable the service user top make a complaint should they wish to do so. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that if any of the residents wanted to talk in private, they are able to and from time to time disagreements do arise. As the home is so small and the service users know each other well, issues are sorted out immediately. The manager said that they have not received any complaints, but if they did it would be dealt with straight away. They showed the inspector the complaints procedure and complaints log. There were no entries in the complaints log. If a complaint is made the manager showed the inspector a complaint form, which logs the nature of the complaint, the action taken and the outcome. A service user had made a comment about being confused about the complaints procedure in the ‘Have your say about’ comment card. This had been completed and sent to the inspector prior to the inspection. They said that they had been informed of information in the complaints procedure but were a little confused how to make a complaint. The need for the complaints procedure to be explained and available in an appropriate format was discussed with the manager. A copy of the homes adult protection policy and procedure was shown to the inspector, this clearly refers to the Suffolk inter agency guidance of June 2004 and refers staff to inform Customer First team at Social Care Services if an allegation of abuse is made. The manager is in the process of updating the policy to elaborate on what constitutes abuse and refer staff to the ‘whistle blowing’ policy. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,29,30, Quality in this outcome area is excellent. Service users can expect to live in a home that meets their individual and collective needs in a safe and homely atmosphere. The home is discrete and is set in a non-institutional environment where service users can enjoy maximum independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 8 Bailey Close is situated in a quite cul-de-sac in Haverhill, it provides accommodation appropriate for the lifestyle and needs of the service users which is comfortable, homely, clean and safe. There were no unpleasant odours. The home is well maintained and nicely decorated throughout, service users were proud to show the experts by experience and inspector around their home. There are lots of ornaments and memorabilia in the communal living areas, which personalise the home including rugs made by one of the service users and photographic portraits taken individually and as a group by a professional photographer at Christmas last year. The expert by experience report reflects that service users are comfortable in their home. Service users are able to meet together in the communal lounge or watch television in their own rooms. Service users had individual bedrooms, and they had been encouraged to choose their own décor and there were lots Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 20 of pictures around the home of the clients making them feel secure. Their rooms were personalised with their own possessions, including a fish tank, medals won at sports events and private collections such as porcelain dolls, soft toys and a selection of compact discs, cassettes and long playing records. All service users had their own keys to their rooms. The dining and kitchen area are combined, there is a large dining table with sufficient seating for all residents and staff on duty. The kitchen area is domestic in nature and promotes the service users involvement in domestic tasks. The laundry room is on the first floor; this room is clean and tidy with shelving, a washing machine and a drying machine. One of the service users had been doing the ironing. There is a lounge area, with comfortable seating and a new widescreen television. The home has an attractive garden area, which one service user maintains. The garden has a good selection of shrubs, ornaments and a patio providing a seating area, which has an awning to protect those wishing to sit outside from the sun. The home has recently purchased new table and chairs and a bar-b-que for the patio and some additional outdoor lighting. There is a separate sleeping in room for staff, which had recently been redecorated. There is a lock on the door for staff to store personal items whilst on duty. The home has two toilets, a bathroom and a shower. The shower room was being used as a store area with boxes and the Hoover. One of the service users informed the expert by experience that they could not use the shower, as there was a crack in the ceiling. The manager explained that due to subsidence a crack had appeared, however this has now been repaired and the shower is fully operational, if service users wish to use it but they tend to prefer the bath. The home is furnished with good quality fixtures and fittings, which are domestic in nature to meet the needs of the service users. The service users they are totally independent and mobile and do not require any special adaptations, however one service user has been assessed by a physiotherapist to use a walking frame to help them maintain their balance. They were observed using this to move freely around the home. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36, Quality in this outcome area is good. Service users can expect to be supported by a staff team that provide continuity and are available in sufficient numbers to meet their needs. Service users can expect top be protected by the home’s recruitment policy and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s staffing team is made up of three care staff and the manager. The staff roster reflects that one member of staff is allocated to work from 4 – 8pm to supervise the service users on their return from their day time activities. A member of staff is on the premises between 8pm to 9am to provide assistance to service users as required and to cover the sleep-in. At weekends one member of staff works from 10am – 7pm, when another member of staff takes over until 10am the following morning. The manager is available for on call in case of emergencies. The home has two volunteers that have undergone all recruitment checks that help to cover holidays and sickness. One service users who was unwell on the day of the inspection had decided to stay at home during the day, staff cover is provided in these circumstances. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 22 The inspector spoke with the member of staff on duty. They had been in post for nine months. They told the inspector that they had been fully supported by the manager during their induction and had attended training with Suffolk County Council as part of their induction. They had completed six units of the Common Induction Standards covering, skills development, value base, adult abuse, health and safety, communication and moving and handling of inanimate objects. The records of the member of staff reflected that the home has appropriate recruitment procedures in place. The relevant paperwork had been obtained prior to employment. These included a completed application form, two written references, a protection of vulnerable adults (POVA first) check, criminal records bureau disclosure (CRB), job description, contract, terms and conditions and copies of birth certificate, driving licence and passport. However the application form did not have details of their continuous employment history. This was discussed with the member of staff who was able to provide evidence of their activities during this period of time. This was discussed with the manager who will ensure that the staff completes this section of the application form. The CRB check on file was a photocopy of the original; the manager informed the inspector that they had not received the original copy from the Criminal Records Bureau. The photocopy seen was of the staff’s original copy. The manager informed the inspector they would ring the CRB office to request the original. Their records had a copy of the terms and conditions of employment, which they and the manager had signed and dated. They also had a job description for a support worker. The member of staff spoken with was clearly aware of the expectations of their role and demonstrated a clear knowledge of the service users they support. The previous reports of September and December 2005 identified some staff did not wish to complete their NVQ award. The registered manager was informed they should consider how they would support staff in achieving their NVQ in order to meet targets of 50 of staff to have achieved at least NVQ level 2. At the December inspection it was reported that the manager is was making arrangements for the staff to undertake NVQ level 2, but was looking into finding some additional funding. Discussion with the manager and the member of staff present confirmed that they have both commenced an NVQ. The manager has completed three units of the Registered Managers Award and the member of staff has started their NVQ level 2 at West Anglia College. They told the inspector they have set up their portfolio and assignments. They are learning to learn again as they have been out of education system for a long time, but they were really enjoying the courses. Listed in the pre inspection questionnaire was the details of other training that has taken place within the last 12 months. These included food hygiene, moving and handling, abuse, first aid, fire safety, health and safety and administration of medication. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 23 A recommendation was made at the previous inspection for the manager to ensure staff have regular, recorded supervision meetings at least six times a year. The manager showed the inspector supervision templates they had devised. Each of the three staff had had two supervision sessions each since these were implemented in July this year. These were well structured, and documented the outcomes of the agreed agenda with action points. These were signed and dated by the staff and the manager and a date set for the next supervision session. Each member of staff had been issued with a supervision agreement, which they had agreed and signed. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42, Quality in this outcome area is good. Service users can expect to benefit from a well run home and can be assured that they benefit from the ethos and leadership of the manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager at Bailey Close holds a registered nurse qualification for people with learning disabilities. They have 15 years experience of working in a local hospital as a ward sister and left to open their own home to provide care for people with a learning disability within the community. They have established funding from Skills for Care to undertake the Registered Managers Award equivalent to National Vocational Qualification (NVQ) level 4. They informed the inspector they commenced this in January 2006. Service users and staff spoke well of the manager, they felt they were approachable and provided a clear sense of direction and leadership to the home. There is a good working relationship between the service users, staff Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 25 and the manager. The expert by experience confirmed this stating in their report that they observed ‘the home to be like a family home’ and that there was good relations between service users and the staff. They also commented that they had found the manager was very friendly to them as a visitor. They were pleased to see that service users were encouraged to take part in the day to day running of the home and that each of them were included in the rota so that they did their share of the domestic tasks. Whilst talking with the service users the expert by experience established that service users felt they were able to talk to staff about any problems they may have and that they enjoyed being able to have group discussions. When the expert by experience and their supporter left they were pleased that the staff and clients said thank you for coming and hoped to see them again, however, they were concerned that they were not asked to sign in or out by a member of staff. The manager was asked to demonstrate how they monitored the quality of the service. They explained they did this through development and updating of their policies and procedures, training and supervision and use of documents, for example the better food better business pack which continuously reviewed their practice. A system for effective for quality assurance monitoring was further explored with the manager based on obtaining the views of service users; relatives and other people involved with the service users lives, which is used to evaluate how the home is achieving the aims and objectives set out in their statement of purpose. A recommendation was made at the previous inspection for the manager to ensure that all the documents in regard to health and safety are kept up to date as well as checking the water temperatures. Evidence was seen that risk assessments were in place for all areas of safe working practice, which included Control of Substances Hazardous to Health (COSHH) and hot water temperatures. A record of hot water temperatures was being kept weekly, these were being monitored, the manager had noticed that the water temperature in the upstairs washbasins was decreasing and called in a plumber to investigate. To enable service users to access to hot water they readjusted the thermostatic valves, the plumber has ordered new thermostatic valves to replace them. The fire and rescue service visited the home on the 27th June 2006, following their visit they wrote to the manager making recommendations to comply with the Fire Precautions (Workplace) Regulations 1997. Evidence was seen at the inspection that the manager had complied with these recommendations ensuring that the kitchen and laundry door closing devices had been replaced. They were no longer using door wedges to keep fire doors open. All portable electrical equipment had been tested by a qualified electrician, who has agreed to undertake this on annual basis and will inform the manager when the next test is due. The fir log book was seen and now reflects fire drills and staff training have taken place and the fire risk assessment has been amended, all Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 26 staff have been made aware of the risk assessment which is kept in the staff office. Evidence was seen throughout the inspection that records and information relating to service users and staff were kept locked in the office upstairs. Service users were aware that their information was in the office and had access to them on request. Evidence was seen that service uses care plans, files, staff files and other records held by the home were accurate up-to-date and in good order. The incident and accident book was seen; the manager had two books, one for staff and one for service users. There had been no entries in the staff book since August 2005 and only one entry made in March 2006 for an incident of inappropriate behaviour, which had been investigated. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 27 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 3 3 3 4 3 5 3 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 4 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 3 2 X 3 3 X Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 24/11/06 2 YA34 Sch 4 (6) (f) 3 YA39 24 Care plans must establish individualised procedures, which have been discussed and agreed with the service user dealing with incidents of inappropriate behaviour. These procedures must be recorded in a plan with clear guidelines as to what actions staff should take in each circumstance to protect the rights and best interests of all the service users Any gaps in employment records 24/11/06 must be explored prior to the appointment of staff and Original CRB documents must be seen not photocopies. The home’s quality assurance 08/12/06 (QA) system must be undertaken at least annually taking into account all persons connected with the home. A copy of the report made available to service users, staff and a copy sent to the CSCI, to reflect how information is used to improve the service. Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 29 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 YA1 Good Practice Recommendations The service users guide and other information about the home are available in formats suitable for the people for whom the home is intended, for example appropriate language, pictures and where possible photographs. The MAR charts for Service users that self medicate need to be checked when received from the pharmacy to ensure they have the correct times medication is to be administered. Any changes should be discussed with the service user. Storage boxes and the hoover should be removed from the shower room to allow service users this as an alternative to a bath should they chose to do so. 2 YA20 3 YA27 Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. Extracts may not be used or reproduced without the express permission of CSCI Bailey Close DS0000024329.V316536.R01.S.doc Version 5.2 Page 31 - 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. 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