Inspection on 09/11/06 for Barley Close

This inspection was carried out on 9th November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Barley Close 18/10/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Barley Close Barley Close Axminster Road Musbury Axminster Devon EX13 8AQ Lead Inspector Belinda Heginworth Unannounced Inspection 9th November 2006 08:50 Barley Close DS0000063867.V312748.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 Barley Close DS0000063867.V312748.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. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barley Close 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) Barley Close Axminster Road Musbury Axminster Devon EX13 8AQ 01297 552913 01297 553973 Voyage Ltd Mr Nicholas John Phipps Care Home 10 Category(ies) of Learning disability (10), Physical disability (5) registration, with number of places Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/01/06 Brief Description of the Service: Barley Close is registered to provide personal and supportive care for up to ten service users with a learning and or physical disability. The home is run by Voyage Ltd, which has a number of similar homes throughout the region. Barley Close is a large detached house situated just outside the village of Musbury, close to the town of Axminster. The home has beautiful views of the countryside and hills and has large gardens and ample parking. The home is on two levels, the ground level has five en-suite bedrooms, a large conservatory, a lounge, dining room, kitchen, laundry room and sensory room. The second floor, which can only be accessed by people without mobility problems, has five en-suite bedrooms and two offices. Information received from the manager, prior to the inspection, indicate that current fees are £1428 and upwards. Additional charges will be made for transport, the actual cost of this has not yet been determined. This will be the first full inspection report the home has received. The manager intends to explain the report to service users and make it available to others upon request. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.75 hours during a weekday, starting at 8.50am. The registered manager was present throughout the time. Barely Close has been registered as a care home since April 2005 but until recently had no service users living there. This is the first Key Inspection the home has received since being registered. Some of the service users living at Barley Close have limited verbal communication skills. They were therefore unable to contribute verbally to the inspection process. Time was spent with all service users and observations were made during the inspection. Four service users currently live at the home with plans to admit more in the near future. Prior to the inspection the Commission sent surveys to service users and staff and comment cards were sent to professionals involved in the home. The responses provide information about the service before a site visit takes place. At the time the surveys were sent only three service users were living there. Three service user surveys were returned, these were completed by service users, with the support of staff or relatives. Nine surveys were sent to staff, four were returned. Four comment cards were sent to health care professionals, two were returned, although a comment card from a GP said they had had no contact with the home. All other responses received were positive about the services the home provides. Prior to the inspection the manager completes a questionnaire, which provides information about service users, staffing, fees and confirms that necessary policies and procedures are in place. The inspector “case tracked” three service users. This means the inspector spoke with staff about individual care, read service users’ records in depth and made observations. The inspector looked around the building and other records were inspected. These included, fire safety logbook, staff training records, staff rotas, menus, quality assurance records, financial files and service users’ care files. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The information (Statement of Purpose & Service User Guide) provided to potential service users, their representatives and relatives should be updated to ensure the information is accurate. For example, some communal areas of the home (kitchen, sensory room and doors leading to the garden) are not freely accessible to service users because of the potential risk. Another example is – small coded keypad locks are fitted to bedroom doors, these locks may not suit everyone’s needs or disabilities. There is no information to say that more suitable locks will be provided if necessary. Equally, care plans do not reflect or encourage a more independent approach, for example, the goals within care plans, in some instances, could have information that encourages the free accessibility to these areas, with guidelines on how to reduce the risk rather than keep the doors locked. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 7 The manager should ensure that all information prior to admission is available for staff to read to ensure they understand the needs and risks of service users before and during admission to the home. Information on service users (care plans & risk assessments) should be more detailed to ensure staff are provided with clear guidelines on how to meet service users’ needs safely and consistently. Any decisions made on behalf of service users, that may infringe on their freedom of movement, choice or privacy should be discussed and agreed within a multi-disciplinary setting. This will ensure such decisions are reached with multi-agencies and are made in the best interests of service users and are recorded, monitored and reviewed regularly. The manager needs to ensure a policy relating to “over the counter” medicines is in place and such medicines are available when necessary. Any handwritten entries on medication administration sheets should be checked and signed by two people to ensure entries are recorded correctly, therefore protecting service user’s safety and welfare. 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. Barley Close DS0000063867.V312748.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 Barley Close DS0000063867.V312748.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&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with good recorded information about the home prior to admission however improvements are needed to ensure the facilities in the home are accurately described. Service users are assured their needs can be met by the home with good assessment and admission practices but improvements are needed to ensure information is available to staff. EVIDENCE: The home has a Statement of Purpose, which sets out what facilities and services the home provides. A summarised and easier to read version is produced for service users (Service User Guide). Information relating to suitable locks on bedroom doors and access throughout the home needs to accurately reflect what is provided. For example, the home has coded keypads on bedrooms, kitchen, front and back doors and many other areas of the home. The Statement of Purpose does not say that more suitable locks would be provided if the coded keypads were not suitable to meet someone’s needs. Currently, the kitchen, front and back doors are kept locked with only staff able to use the code for entry. The staff team are trying to protect service users from harm but service users do access the kitchen under supervision. The Statement of Purpose should clearly reflect this current practice and be reviewed regularly. (See section 6 –10) Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 10 The Statement of Purpose also states that facilities within each of the organisation’s homes can be used by other homes. For example, Barely Close has a sensory room and other homes within the organisation have used it. However, this has not been discussed and agreed with the service users at Barley Close. Although the facilities are good and service users might benefit from seeing other people and perhaps make friends, it should be discussed and agreed with them first and be reviewed regularly to ensure they remain happy about sharing their facilities. Information was gathered prior to admission for two service users. The assessment covered all areas of need, ranging from health, emotional, mobility, dietary, spiritual, likes and dislikes and much more. However, some of the information only summarised the need and provided no detail of what it was and what might be needed to meet that need. This means that staff are potentially not provided with a true picture of someone’s needs and therefore might be unable to establish if the home was suitable for that person. The manager felt that through visits to potential service users and additional information gathered from relatives or past carers would ensure the correct information was provided. One service user who had moved in to the home recently had no assessment available, the manager felt confidant this might be at head office. However, staff are not provided, in this instance, with information to read before admission or information to refer to after. Since the inspection the manager has found out the assessment was with another home where it was originally thought the service user was to move to. However, it is important that such important information is available at the home where someone lives. Service users were unable to talk about the admission process but two said they were happy living at the home. One service user said “staff are very kind”. Staff were able to describe the transitional work that is completed before someone moves to the home. This involves visits to the service user’s home and trial visits and overnight stays at the home. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with information to help them to meet service users’ needs, but improvements are needed to ensure they are met safely and consistently. Decisions made on behalf of service users are not always done in consultation with others therefore ensuring the decisions are in service users’ best interests. EVIDENCE: Some service users were unable to discuss their care plans due to their limited verbal communication skills. One service user showed the inspector their daily records and knew what was written about them. Staff demonstrated a good understanding of service users’ needs and risks and said they were involved in formulating care plans. Three service users’ files were read in depth. Two files had care plans that described individual needs and provided some action that was necessary to meet the needs. Hazards to service users were assessed with action on how to reduce any risks. However, some areas did not provide enough detail to ensure Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 12 staff work consistently, for example one care plan described potential self injurious behaviour, the reason given was “for attention”, but no detailed assessment or monitoring had been completed to evidence this. The action described to reduce the behaviour was “more attention to be given throughout the day to prevent it happening”. There were no clear guidelines or risk assessment on how this would be achieved and what type of attention was needed. No goals were set to occupy the service user and no structured activities in or out of the house had been recorded. The home will eventually have 10 service users living there; therefore it is important that staff follow clear guidelines to avoid this behaviour occurring when the house will become busier. Another example described “setting clear boundries” but there was no description or interpretation on what these boundries were and how they would be implemented. This could result in staff working inconsistently. Discussions took place with the manager about ensuring that any risks highlighted within care plans should be cross referenced with risk assessments to enable staff to find the appropriate information easily, to reduce any risks to service users. One service user did not have a full care plan in place. Some information was provided through relatives but it did not formulate a care plan. The manager felt the assessment was at head office and this information would help them to compile a detailed care plan. Although the service user had only recently moved to the home an assessment and care plan must available in the home to help staff understand and meet the service user’s needs safely. Some areas of the home are not freely accessible to service users due to the risks to them. For example, the kitchen has a coded keypad, which only staff can unlock. Service users can use the kitchen but only under supervision, two service users were observed using the kitchen with staff and one service user talked about making their own breakfast that morning. However, the care plans do not describe long term goals that eventually work towards service users becoming more independent, for example reducing the risk through other methods and knowing the code to the kitchen to have free access. Listening devices are used for two service users to monitor health needs at night. One is used at the request of the service user, the other at the request of a relative. The use of the monitors were not clearly described in care plans, for example, there was no guidelines on what staff should do if another service user got up in the night and joined the staff in the same room as the listening devices and would therefore be able to hear the noises from the devices. The decision to use them had not been discussed and agreed within a multidisciplinary setting, such as a Good Practice Committee. It is important that decisions that may infringe upon someone’s freedom of movement, choice and privacy is discussed and agreed within a multi-disciplinary setting to ensure the decision is reached in the best interests of the service user and is recorded within care plans and risk assessments and their use is monitored regularly. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 13 Care plan meetings are held with service users and their representatives. The care plans had areas for relatives and care managers to sign to say they agreed, but no area for service users to sign. The manager said they were unable to obtain signatures from care managers but agreed to record they had been discussed with them and he agreed to ensure service users, where able, are given the opportunity to sign to say they agree with the content. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 14 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from accessing the local community and taking part in appropriate activities. Service users’ rights are respected at all times and relationships with families are maintained. Service users benefit from a varied and healthy diet. EVIDENCE: Some service users were able to talk about going out to the shops, trips to the beach and accessing the local library. One service user had requested “talking books”, which the home had supported them to obtain. The same service user had also gone shopping for inter active games and was observed telling staff that they wanted another one as the one they had bought was unsuitable. Staff were observed being very supportive and reassuring. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 15 Staff said that at the moment, while the home is not full and while staffing is not at full capacity, activities take place each day depending on the needs and requests of each person. Throughout the inspection staff were observed being kind, patient, caring and respectful. One service user described the staff as “kind” and said they liked them all. The home currently has one vehicle to transport service users to activities. The manager said there will eventually be two and service users will contribute towards the costs of running them. No structured activities have been arranged yet but the manager intends to implement this once the home is has more service users and there is a full compliment of staff. Currently activities take place on an add hoc basis and at the request of service users. Daily records described a variety of outings and activities that have taken place. Some service users were able to confirm they are supported to maintain contact with relatives and friends. Service users’ care records had a section on family contact, where staff recorded, visits and telephone contacts. The inspector joined service users and staff for lunch this was macaroni cheese, which everyone seemed to enjoy. Menus demonstrated a varied, healthy and balanced diet is provided. Fresh fruit was offered at lunchtime and plenty of bowls of fruit were seen in the kitchen. A service user confirmed that alternative choices are available on request if they do not want what is on offer. The main meal tends to be at lunchtime although the staff and manager said this can be flexible to suit service users’ needs and activities. One service user said they had requested that the menus be in larger print to meet their needs. The staff intend to support this service user in compiling a more suitable menu. Barley Close DS0000063867.V312748.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 good. This judgement has been made using available evidence including a visit to this service. Service users’ dignity and privacy is respected and they benefit from their health needs being closely monitored to ensure they are well met. Medication practices fully protect service users’ health and welfare. EVIDENCE: Service users were observed receiving support in a respectful manner. One service user said they did not want a bath, just a wash, staff respected this and carried out their request. Care plans describe how service users preferred to be moved and supported and manual handling assessments are completed. This ensures that staff are aware of how to move someone correctly, therefore protecting their safety. Health needs are identified in care plans and medical appointments will be monitored and recorded. The service users have only lived at the home for a short time so were unable to discuss medical appointments, but those who were able seemed very content with the care they received. Service users had confirmed this at a recent service users’ meeting. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 17 The current service users are unable to keep or be responsible for their own medicines and some service users would be unable to consent to staff giving them. Discussions took place about consent issues being part of the assessment process prior to admission. Although adults are unable to consent for another it is good practice to discuss the issue with relatives and care managers and record the outcome. Where service users are able to consent this should be recorded. This ensures that medication issues are discussed and agreed with service users or the home is open and transparent with service users’ representatives. Medication is supplied in some monitored dosage systems, bottles, boxes and liquids. Medication is held in a secure cupboard in one of the offices on the second floor. The medication cupboard is too small to store medication appropriately. The manager said a new and larger medication cupboard has been ordered, which will enable the home to have most of their medication in a monitored dosage system. The home also stores some medicines in a locked cupboard in the kitchen. Medication recording systems (MAR) were found, on the whole, to be used correctly. Some handwritten entries had not been checked by two people and signed accordingly. This means there is a risk or errors being made on the entry. The manager assured the inspector this would be carried out from now on. Good records were kept of quantities of medicines received and returned. This provides an audit trail to ensure medication is being used correctly and safely. Guidelines and protocols were in place for the use of occasional medication (PRN), however, over the counter medicines (Homely Remedies) did not have a Homely Remedy Policy agreed with the pharmacy or GP. Currently only one homely remedy was being used and this had been agreed with the GP for that individual. However, it is important that homely remedies are available, such as pain relief, cough medication and so on and should only be used as part of the homely remedy policy. Only senior staff, who have received suitable training, as able to administer medication in the home. Assessments of competencies are also completed. The manager is aware that these assessments should be completed at least every six months to ensure staff remain competent to administer medication. Barley Close DS0000063867.V312748.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. This judgement has been made using available evidence including a visit to this service. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Service users are protected from potential abuse. EVIDENCE: One service user said they would talk to the staff if they were not happy with anything and felt their concerns would be dealt with properly. Service users are provided with a complaint’s procedure within the service user’s guide. This is completed in a format that is suitable for some communication needs but not all. The manager intends to produce a variety of formats individual to service users’ communication needs. All staff have received The Protection of Vulnerable Adults training. They were able to demonstrate an excellent knowledge and understanding of various types of abuse and knew what do to if they suspected any. The home also has polices on abuse awareness including the local Alertor’s guide. Service users’ finances are well managed. Some relatives maintain apointeeship and provide the home with monies when necessary. Voyagers Ltd are appointees for some. Fees are paid directly to the company and personal monies are managed through individual service users’ bank accounts. Records of all financial transactions are kept with receipts. Barley Close DS0000063867.V312748.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with clean, safe and comfortable surroundings that meet their needs. EVIDENCE: Service user appeared very relaxed and content in their surroundings. One service user’s family had helped chose and paint the colour scheme of the room. An appropriate door opener had also been fitted because the service user preferred to keep their door open but because it was a fire door it could not be left open without a suitable opener being fitted. Another service user indicated they would like a similar system. The manager intends to look into this. All bedrooms are decorated and furnished to a high standard and are personalised to individual tastes and preferences. All bedroom doors are fitted with coded keypad locks. The current service users either choose not to lock their doors or would be unable to operate these small keypads. The manager said suitable locks would be fitted if necessary. The home has a large lounge with a sensory room, a large dining room and a beautiful large conservatory. The lounge and conservatory have a TV and Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 20 music system. This enables service users to get away from each other if they choose but still have the same facilities. The kitchen area is of medium size and has a “training” kitchen to the side of it. The kitchen door is locked by a coded keypad when no staff are around. This means service users are unable to access the kitchen without supervision. (See sections 1-5 and 6-10) The standard of decorations and furnishings throughout is excellent, creating a warm, friendly and homely atmosphere. There is a large paved area outside and ramps to all entrances of the home and gardens to enable people who use wheelchairs or those with poor mobility easy access. On the day of the inspection the home was warm, bright and clean. A separate laundry room is provided with hand washing facilities. Barley Close DS0000063867.V312748.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): 32, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by enough caring and trained staff to meet their needs. Service users are protected by robust recruitment procedures. EVIDENCE: On the day of the inspection two staff were on duty for four service users. The manager said as more service move into the home more staff will be provided. Two staff are currently being provided at night. During the inspection service users’ needs were observed to being met with the level of staffing. Staff said they were looking forward to having more staff to enable more structured activities to take place. The management of the home currently has limited time for administrative duties but the manager hopes this will improve in the future. This will enable the management to ensure, for example, care plans and risk assessments are detailed and up to date. Recruitment procedures were found to be robust, with appropriate checks, including police checks being completed before staff started working at the home. Good recruitment procedures ensure service users are protected from potential abuse. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 22 All staff have received a good induction, including completing units 1 & 2 of the Learning Disability Award Framework (LDAF), these are standards expected within homes that provide services for people with a learning disability. The induction training also covered health & safety training, total communication, epilepsy, autism and company policies. Over 50 of the staff team have also obtained NVQ qualifications at level 2 or above. The manager said further training on total communication has been arranged and staff will be working toward units 3 & 4 of the LDAF. This excellent training ensures service users’ needs are better understood by staff. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 23 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, 39 & 42 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 and being run in the best interests of service users. There are good systems to review, develop and improve the home. This will be developed further when the home has been opened longer. Service users safety and welfare are well protected. EVIDENCE: The registered manager has many years of experience in care work but is new to this post. Previously he worked as a deputy manager in another of the organisation’s homes. He is about to start the Registered Manager’s Award and then NVQ level 4 in care. Service users and staff spoke highly of the manager, staff said he and the deputy manager were supportive and provide clear leadership and direction. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 24 Feedback from an outside professional praised the manager for the high standards of care that seem to be delivered to service users. One comment said– “the home is run professionally”. The manager and deputy currently have little admin time to carry out management work. The manager hopes this will improve in time when the home has more service users and staff. Staff meetings have just started and minutes indicated that good guidance and support is given to staff. The manager intends to have systems in place that regularly monitor the quality of care delivered to service users. These will range from team and service user meetings, staff supervision, care plan and policy reviews. Discussions took place about formalising this to ensure all staff are aware of when these monitors are due and what action needs to be taken. Voyage Ltd also completes monthly inspection visits and will complete quality audit reviews. This will include satisfaction questionnaires to service users where appropriate, to relatives and outside stakeholders. The fire logbook was found to be up to date and accurate. Fire risk assessments and staff training were completed, therefore protecting service users’ safety and welfare. The CSCI obtains information prior to inspections. The information includes conformation that all necessary policies and procedures are in place and are up to date. These are not inspected on the day but the information is used to help form a judgement as to whether the home has the correct policies to keep service users and staff safe. In this instance policies and procedures were in place. These along with risk assessments will be reviewed regularly and will be up dated where necessary, to ensure they are appropriate and reduce risks to staff and service users. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 25 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 2 2 2 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 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 26 N/A Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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 information in the statement of purpose should reflect accurately the facilities provided. (This refers to some communal areas being inaccessible to service users at risk from harm) The manager should ensure that assessments prior to admission are available for staff to read before admission and during. Care plans should provide enough detail that staff fully understand the needs and actions necessary to meet them. Any risk should be clearly cross-referenced with risk assessments. Any decisions made on behalf of service users that may infringe upon their freedom of movement, choice or privacy is limited only through the assessment process, involving the service user, and as recorded in the individual service user plan and should be discussed and agreed with community professionals and the outcomes agreed, recorded and reviewed regularly. (This refers to DS0000063867.V312748.R01.S.doc Version 5.2 Page 27 2 3 YA2 YA6 4 YA7 Barley Close 5 6 YA9 YA20 the use of listening devices and areas of the home that are inaccessible to service users) Risk assessments should include clear details and actions on how to reduce risks. The home should ensure a Homely Remedy Policy is obtained and agreed with a Pharmacy or GP. All handwritten entries to MARS sheets should be checked and singed by two people. Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Barley Close DS0000063867.V312748.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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