Inspection on 22/11/06 for Blackdown Polden House

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Blackdown Polden House 25/09/07

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 Blackdown Polden House Somerset Court Harp Road Brent Knoll Highbridge Somerset TA9 4HQ Lead Inspector David Kidner Unannounced Inspection 22nd November 2006 09:30 Blackdown Polden House DS0000067303.V321067.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 Blackdown Polden House DS0000067303.V321067.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. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackdown Polden House 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) Somerset Court Harp Road Brent Knoll Highbridge Somerset TA9 4HQ 01278 760555 01278 760747 Vanessahalfacre@nas.org.uk National Autistic Society Mrs Yvonne Thomas Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: As part of Somerset Courts Modernisation Programme each previous accommodation area that comprised of Somerset Court, has now become a separate registered service. Blackdown Polden House comprises of a large detached bungalow situated in the extensive grounds of Somerset Court. The home is registered as one service and currently has two distinct accommodation areas. Six service users are accommodated in each living area with separate facilities. The Registered Manager is Mrs Yvonne Thomas. The National Autistic Society remains as the Registered Providers. The home was registered with the CSCI on 16/06/06 and is registered to accommodate twelve services users. Each accommodation area has a lounge/dining room, kitchen, single bedrooms with wash hand basins however; one service user has a separate flat with full en-suite facilities. There are adequate bathing and toilet facilities. The home has some laundry facilities but the majority of the laundry is sent to the main on–site facility. The home has a ‘fenced off’ garden area with areas laid to patio with garden furniture. Fees vary from £38,800 to £86,279 per annum but depends on the individual’s assessed need. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection conducted by the Commission for Social Care Inspection. This inspection was a Key Unannounced Inspection and was conducted by one Inspector. The inspection lasted one day (7.5hrs). The Inspector met a number of the service users and care staff. The Inspector was able to speak some service users in more detail than others. Some service users did not wish to engage in conversation with the Inspector. Service users who were able to express their opinion stated that they liked living at the home and that they were happy. One service user showed the inspector their photo album of their holiday; another showed the Inspector their woodwork that they had produced. The service users appeared very relaxed in their environment. Some time was spent observing care practices and how staff interacted with the service users. This was all very positive. Due to the complex needs of some of the service users feedback about the service they are receiving can be difficult to obtain. The vast majority of service users are unable to complete the comment cards that were sent to the home prior to this inspection. As part of the inspection process the Inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention, staff recruitment and viewed all most areas of the home. Comment cards were sent to relatives, care managers, GP and other health care professionals. The Inspector sent twelve comment cards to relatives/visitors. Nine were returned. All comments stated that they were made to feel welcome at the home, that they can visit their relative in private and the vast majority of comments stated that they are kept informed of important matters that affect their relative. All comments stated that they are satisfied with the overall care provided at Blackdown Polden House. The comments received from Health and Social Care Professionals also stated that they are happy with the overall care provided. All responses confirmed that staff demonstrate a clear understanding of the care needs of service users. The Inspector would like to thank the service users for making the Inspector welcome in their home and for their contribution in the inspection process. The care team were very welcoming and presented themselves in a professional manner. As a result of this inspection the home has three requirements and nine recommendations. Blackdown Polden House DS0000067303.V321067.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 home should ensure that if any restrictions imposed these are detailed in individual service users care and support plans. The home should conduct risk assessments in relation to the risks identified and protocols developed in order to support service users participating in independent living skills. The home should ensure that all interested stakeholders are aware of the home’s Complaints procedure. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 7 The home should consider promoting a more homely appearance in all areas of the home. Primarily, in the accommodation area known as Polden. Consideration should be given to the home providing all service users with the opportunity to have a shower if so wished. Some health and safety matters must be addressed. 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. Blackdown Polden House DS0000067303.V321067.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 Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a detailed Statement of Purpose and Service Users Guide. The Service User Guide is being reviewed to reflect the service provided at the home following Somerset Courts Modernisation Plan. Key Standard 2 was not assessed at this inspection EVIDENCE: The Inspector was advised that the Statement of Purpose has been reviewed and that the Service User Guide is in the process of being reviewed. The Statement of Purpose is very detailed and contains the required information as listed in Schedule 1 of the Care Homes Regulations 2001 There have been no new admissions to the home since July 1998. However, the service has a robust admissions procedure. The Fees vary from £38,800 to £86,279 per annum but depends on the individual’s assessed need. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 10 Blackdown Polden House DS0000067303.V321067.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 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has detailed care and support plans that reflect service user’s current needs. Service users are offered as much choice as possible and are encouraged to make decisions. The service undertakes detailed risk assessments Service users confidential information is kept secure. EVIDENCE: The Inspector viewed four care and support plans. The care plans viewed contained detailed information in relation to the care and support needed. They were nicely presented and easily accessible. All care plans had recently been reviewed and care reviews had taken place for some serviced users with Goals Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 12 identified and minutes to the meeting. Key Workers complete monthly summaries and daily records are kept of the care provided in the form of a monthly document. Records are kept of the activities that service users undertake when on a home day. The Inspector was advised that the service is in the process of implementing Person Centred Planning. The home has a member of staff who will be supporting the team to implement this. The Inspector noted that two of the care and support plans had been signed by the service user. This is good practice. Some service users use Somerset Total Communication (STC) to assist in expressing their views and needs. Staff were observed to be using STC to communicate with some service users. Communication needs are very individual and care plans identified the manner in which staff should interact with service users. The home has a notice board with photographs of staff that are on duty. Staff offer service users with as much choice as possible. At the time of the inspection it was noted that the care team were offering service users with choices in food, meals and activities. The care team keep day-to-day records of all activities and experiences. There was some discussion with the care team in relation to restrictions that may be imposed on service users due to their complex needs. It is recommended that the home ensure that any restrictions imposed are detailed in individual service users care and support plans. At the time of the inspection none of the service users were able to manage their own finances. Each service user has a risk assessment in relation to the management of behaviours and other potential risks. Following this and where needed a Behaviour Support Plan is developed. It was noted that risk assessments and behaviour support plans had been reviewed. The Inspector did not view any risk assessments in relation to the risks identified and protocols developed in order to support service users participating in independent living skills. It is recommended that this be addressed. It is also recommended that the home reviews the format in which the risk assessments are stored within the care and support plans. Service users records appear accurate and are kept secure and confidential. Blackdown Polden House DS0000067303.V321067.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): 12 13 14 15 16 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home supports service users to access a variety of social and leisure activities. Service users are encouraged to participate in household activities wherever possible. Contact with family members is good. The home provides menus that are varied and well balanced. EVIDENCE: All service users who live at Blackdown Polden attend the on-site day service facility. At the time of the inspection this facility was closed due to staff training and all service users were at home. The day service facility offers a Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 14 variety of activities including arts and craft, life skills, sensory room, gym, gardening and an IT Suite. Four service users are accessing the local college. Currently there are no service users accessing work placement, volunteer jobs or work-related training schemes. Blackdown Polden is located approximately three miles from Burnham town centre therefore there are very limited local community facilities that can be easily accessed. There is not a local bus service therefore all service user rely on the transport provided by the home. However, service users are supported to access a variety of leisure and recreation facilities in the local and wider community. These include visits to the pub, cinema, swimming, bowling, walking, Gateway Club, restaurants and cafés. Records are kept of all activities that individual access. The Inspector was advised that staffing levels have been good and service users have been readily accessing activities both at evenings and weekends. At the time of the inspection care staff were observed to be offering service users and supporting service users in in-house activities. The Inspector was advised that a number of service users have been on holiday and was shown a photo album by one service user of their recent holiday. Some service users go to stay with their parents/relatives on a regular basis. Due to some service users complex needs providing holidays may not be in the persons best interest, as they could not cope with the change within their personal routine. However, care staff commented that day trips out are arranged. The home encourages contact with family and friends. Records are kept of the contact made. The Inspector sent twelve relative/carers comment cards and a total of nine were returned. All comment cards indicted that all the relatives/carers are satisfied with the overall care provided, that they can visit their relative in private and that staff make them feel welcome. Service users have keys to their bedroom doors. Staff that the Inspector spoke to demonstrated on how they promote privacy and dignity. At the time of the inspection the Inspector observed care staff addressing service users in a polite and courteous manner and addressing service users in the name they wish to be called. Staff were very sensitive to the needs of the service users. Each service user has a ‘home day’. This time is spent usually with their key worker and service users are encouraged to participate in the cleaning of their bedrooms, laundry, basic cooking skills and other household activities. A record is kept of the home day and forms part of the key worker monthly report. At the time of the inspection the Inspector observed a number of service users participating in various household activities including; cleaning and polishing their bedroom, laundry tasks, cleaning of communal areas and assisting with cooking a meal and making drinks. Smoking is not allowed in the home. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 15 As previously stated all service users attend the on-site day service. When attending day services all service users access the main dining facilities at Somerset Court. This is a refectory style service. There is a varied and nutritious menu on offer with a number of choices. Blackdown Polden has two separate kitchens and dining areas. Some service users are able to prepare their own breakfast and prepare a small snack. The home has a menu that service users have contributed to compiling. However, service users are able to have alternatives if so wished. On the day of the inspection service users were accessing snacks and drinks as they so wished. The kitchen cupboards, freezer and fridges were well stocked. Blackdown Polden House DS0000067303.V321067.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. Care staff are aware of service user’s needs in relation to personal care and support. Service users have access to a variety of healthcare professionals. Medicines are well managed at the home. EVIDENCE: Wherever possible, intimate personal care is provided by a person of the same gender. The service users have very differing care and support needs. Some service users are able to fully meet their personal care needs and may only require guidance. Other service users require more support other than general prompts. The staff that the Inspector spoke to were able to describe the type of care and support individual service users required and appeared very knowledgeable and fully aware of individual needs. Times for meals and getting up and going to bed are flexible. On the day of the inspection service users appeared well attired. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 17 Service users have access to all other health care providers. The Inspector was able to view the records that are kept in relation to visits to a variety of health care professionals. The Inspector viewed the arrangements for the management of medicines. The home has a policy for the management of medicines and designated staff are nominated to dispense medicines and sample signatures are kept within the MAR sheet file. The home’s policy is that two staff dispenses the medicines. The home keeps two records of the medicines that are administered. The second person signs a separate MAR sheet to witness the actual administration. The MAR sheets were viewed. All records were satisfactory and were well maintained. The home keeps a record of all medicines that are returned to the pharmacy. The home currently does not have Controlled Drugs. Blackdown Polden House DS0000067303.V321067.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. The home has a robust Complaints procedure but it appears that not all interested stakeholders are aware of the process. The home has policies and procedures in relation to the protection of vulnerable adults. EVIDENCE: The home has a Complaints Policy and Procedure. There have been no recorded complaints at the home. The feedback that the Inspector received from relatives/carers comment cards is not all relatives were aware of the complaints procedure. The Manager should ensure that all interested stakeholders are aware of the process. The service users have a copy of the complaints procedure. This is presented in STC. The home has policies for the protection of vulnerable adults including policies for adult protection and the management of service user’s finances. Care staff that the Inspector spoke to was aware of the home’s Whistleblowing Policy. The home is in the process of training all staff in the use of the SPELL approach and the Studio 111 procedures for the management and defusing of challenging situations. The home keeps records in relation to incidents that occur at the home as a result of challenging situations. The Inspector was able to view detailed care plans, behaviour management guidelines, and risk Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 19 analysis and risk assessments in relation to the management of behaviours. The Inspector was provided with an audit of the incidents and accidents at the home. Each accommodated area has a breakdown of the nature of the incident/accident and if any intervention was used. The main type of intervention used is one-person escort. However, this is minimal. The care team mainly reassures or uses verbal distracters to diffuse a situation. The audits are very detailed and comprehensive. All staff have an Enhanced CRB disclosure. The Inspector discussed the arrangements for the management of service user’s finances. The National Autistic Society has corporate appointeeship for all but one of the service users. Service users have individual bank or building society accounts. The Inspector sampled the records kept on the behalf of four service users. Records are kept of the transactions undertaken via the building society and the home also maintains records of financial transactions of monies spent from personal spending. The Inspector was able to follow an audit trail for transactions sampled. Receipts are kept of all transactions and balances were correct. The Inspector recommends that wherever possible two staff signatures be obtained for all financial transactions. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 27 28 29 20 Standard 28 was not fully assessed. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Most areas of the home are homely and comfortable. Some areas would benefit from being made more homely. Bathing/showering facilities in one accommodation area would be improved if service users had the option of showering facilities. The home is clean and hygienic. EVIDENCE: Balckdown Polden consists of two main accommodation areas but is registered as one service. Both accommodated areas have a lounge/dining room with adequate seating and dining facilities. There is a television and DVD player and a HI-FI for communal use in each area. There is a good-sized domestic style Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 21 kitchen, all bedrooms are of single occupancy and have wash hand basins, there are adequate bathing facilities however, one accommodation area has no facilities for service users to have a shower if so wished. There are adequate toilet facilities. The home has some laundry facilities located in the kitchen area and this is mainly used for the washing of tea towels. The majority of the laundry is sent to the main on–site facility. Both areas have ‘fenced off’ garden area and patio area with garden furniture. Most of the home is comfortable and homely but some areas would benefit from being more homely. The Inspector viewed all areas of the home with the exception of service users bedrooms. The home has a planned maintenance and renewal programme. As previously stated the home has a total of four bathrooms. One service user has full en-suite facilities. One accommodation area does not have the facility for service users to have a shower. This should be given further consideration as part of the homes refurbishment and redecoration programme. It was noted that one shower facility did not have a shower curtain in situ. It was also noted that these areas were not personalised to promote a homely environment. However, on the day of the inspection bathing and toilet areas were clean and hygienic. The Inspector requests that the home provides the CSCI with a floor plan of Blackdown Polden detailing the communal space. All service users are fully ambulant and at present do not require any specialist aids and adaptations. On the day of the inspection most areas of the home was clean and hygienic. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff demonstrated their awareness in the support required to meet service user’s individual needs. The home is pro-active in ensuring the care team achieves NVQ qualification. An action plan is requested to address this. Adequate staffing levels are maintained. The home has a robust recruitment process. The home is committed to providing a well-trained workforce. EVIDENCE: At the time of the inspection it was evident that the care team were aware of the service users individual needs. Staff were able to describe how complex needs are met. Staff were observed to be interacting with service users in a Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 23 professional and sensitive manner and used alternative methods of communication. Staff appeared motivated and committed. Staff have received specialist training in areas such as diabetes, SKIPP, autism awareness, Studio 111 and Somerset Total Communication (STC). Refresher dates are set for staff as needed. The Inspector did not view staff individual records at this inspection. The Pre-Inspection Questionnaire stated that 42 of the workforce has an NVQ qualification. The National Minimum Standards state that 50 of the workforce achieves a minimum of NVQ qualification. An action plan must be developed to address this and a copy sent to the CSCI. The Inspector spoke to a number of staff at the time of the inspection. All staff stated that they felt that they had adequate staff on duty to meet the needs of the service users. Staffing levels are adjusted to meet the needs of the service users. Of a morning each accommodation area usually has two-three staff on duty. Service users then attend the on-site day services facility. On ‘home days’ staffing is provided on a 1:1 basis. Of an evening and weekend the rota is adjusted to meet the needs of planned activities. The home has cross over shifts to ensure that activities can take place; therefore there is usually a minimum of three staff on duty. Some service users receive extra funding to meet their needs. The home has not recruited any new staff recently. The service has a robust recruitment process and has systems in place to ensure that the home obtains all the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. The service has a Training and Development Manager and each staff member has a training and development plan. Records are kept of each staff member training. The staff spoken to confirmed that they receive regular mandatory and specialist training. The Inspector did not view individual records. However, the Inspector has been advised that recent training includes food hygiene, POVA, SPELL, TEACHH, STC, epilepsy, first aid, medication and first aid. Blackdown Polden House DS0000067303.V321067.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 42 Standard 39 was not assessed at this inspection 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 The home promotes health and safety, however some areas need addressing. EVIDENCE: The Registered Manager is Mrs Yvonne Thomas. Mrs Thomas is currently on Maternity Leave. Mrs Thomas is a Registered Learning Disabilities Nurse, has a Bsc in Health and Social Care and has twelve years experience working with people with autism and learning disabilities. She has also obtained A1 Assessors qualification and a variety of courses including SPELL, Studio 111 Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 25 and person Centred Planning. Staff spoken to stated that Mrs Thomas is very person centred, is approachable and offers direction and leadership. The Inspector viewed a number of documentation in relation to health and safety. Fire Safety: Both accommodation areas had good records in relation to fire safety. The fire alarm system and emergency lighting system in both areas was last serviced on the 21/09/06. Fire fighting equipment was serviced in June 2006. The emergency lighting, fire points and the homes torches are tested weekly with records kept. The home conducts monthly fire drills with service users. However, it was noted that there are no records relating to staff receiving regular fire drills. This must be addressed. All staff have received regular fire training. Hot Water/ Legionnella: The home conducts weekly checks of the hot water. Records confirmed that the temperature is within suggested guidelines by the Health and Safety Executive. It is uncertain that the home has received a certificate in relation to complying with Legionella. This must be addressed. Electrical Hardwiring Certificate: This Inspector requests that a copy of this certificate is sent to the CSCI. PAT: Portable Appliance testing was last conducted on the 14/10/05. This must be addressed. Gas Safety Certificate: This is dated 20/07/06 COSHH: The home has a policy in relation to this. All products are stored securely. Fridge/Freezer: The home keeps daily records of fridge and freezers. Food was stored appropriately in the fridge. Risk Assessments: The home has a detailed risk management policy. First Aid: Staff receive training in first aid. The first aid boxes are checked monthly. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 26 Blackdown Polden House DS0000067303.V321067.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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 1 X Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 28 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. 1 Standard YA42 Regulation 13 (3) Requirement The home must ensure that a certificate re Legionella has been obtained to ensure prevention of infection at the home. The home must ensure that Portable Appliance Testing is conducted. The home must ensure that all care staff receive fire drills and practices at suitable intervals. Timescale for action 31/01/07 2 3 YA42 13 (3) 23 (4) (e) 31/12/06 31/12/06 YA42 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 2 Refer to Standard YA7 YA9 Good Practice Recommendations The home should ensure that if any restrictions are imposed these detailed in individual service users care and support plans. The home should conduct risk assessments in relation to the risks identified and protocols developed in order to support service users participating in independent living skills. The home should review the format in which the risk assessments are stored within the care and support plans. DS0000067303.V321067.R01.S.doc Version 5.2 Page 29 3 YA9 Blackdown Polden House 4 5 6 7 8 9 YA22 YA23 YA24 YA27 YA27 YA32 The home should ensure that all interested stakeholders are aware of the home’s Complaints procedure. The home should ensure that two staff signatures are obtained for all service users financial transactions. The home should consider promoting a more homely appearance in all areas of the home. Primarily in the accommodation area known as Polden. The home should explore the possibilities in promoting a more homely appearance of the bathing and showering facilities. The home should consider providing shower facilities in one identified accommodation area as part of the homes refurbishment and redecoration programme The home should submit an action plan to the CSCI to address the need for 50 of the care team to achieve an NVQ qualification. Blackdown Polden House DS0000067303.V321067.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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