Inspection on 15/08/06 for Breakaway

This inspection was carried out on 15th August 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Breakaway 10/08/07

Breakaway 27/01/06

Breakaway 02/09/05

Breakaway 31/08/04

Breakaway 23/03/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Breakaway Park Lane Aveley Essex RM15 4UB Lead Inspector Mr Trevor Davey Key Unannounced Inspection 15th August 2006 09:15 Breakaway DS0000018070.V308460.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 Breakaway DS0000018070.V308460.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. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breakaway Address Park Lane Aveley Essex RM15 4UB 01708 861520 NO FAX 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) East Living Limited Post vacant Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service category: Care Home only. Service user categories: learning disability and physical disability. Maximum number of registered places: 4 (both sexes). Placements must be arranged to ensure that the two categories of service users (learning disability and physical disability), are not accommodated together in the home for the same period of short-term care. The home is to provide short-term care for periods of no longer than four weeks at a time. 27th January 2006 5. Date of last inspection Brief Description of the Service: Breakaway is a detached property which has been adapted and refurbished as a care home to provide respite care for up to four adults with a learning or physical disability. The accommodation includes four single bedrooms, a lounge and dining room, kitchen, bathroom and shower facilities. The accommodation and facilities have been specifically designed for disabled people. There is a large garden with a patio area to the rear of the property and off-road parking to the front. A vehicle provided with a tail-lift is available and is used regularly for the benefit of guests to give them easier access to the local community and surrounding area. There are also good bus and train links. A variety of social and leisure activities are arranged involving both staff and guests to take account of individual interests and choice. The fees for a one day and night stay is £399 50 per person. This is a standard rate and is subject to variation to accommodate need. Guests bring in their own pocket money to cover any additional expenditure such as hairdressing, toiletries and chiropody. The Fax. No. for the home is 01708868857. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 5.50 hours and was spread over two half days. This was because on arrival at the home by the Inspector, arrangements had already been made by the staff team to take the guests out for the day. The visit mainly focused on the progress the home had made since the last inspection and covered all key standards. A tour of the home took place. Staff and guests were spoken with doing the site visit who were helpful in their contributions and the assistance they gave to the Inspector. In addition, case tracking took place using some of the personal care records another official records within the home were also assessed. Letters had also been sent out to guests/parents as well as the funding authority, requesting feedback of the service provided by the home. In addition, survey forms were also available in the home, which guests had completed after each respite stay. From the responses received, these were positive and complimentary regarding the standard of care provided during the course of the last twelve months, since the home had been registered for the purpose of providing respite care. During this time, the pre- inspection questionnaire, which had been completed by the acting manager, showed that 26 guests had been admitted for different periods of respite care. This report also outlines new initiatives, which have been taken by the home to increase interaction and participation of guests/relatives, to improve the quality of individual life experiences. Other information was also taken from the preinspection questionnaire, which had been submitted. What the service does well: The home is able to demonstrate its continued effectiveness in communicating with guests who have a variety of needs, which had been identified and clearly recorded in some of the personal care records sampled. A good rapport has been established with relatives and guests with the result that improvements have been made to accommodate individual needs and aspirations of guests. Person centred planning is at the heart of the care and service provided. The management regularly monitor the quality of the service and have introduced changes where these have been necessary. This includes modifying and updating the layout of care plans, which is still in the process of being completed. The home is good at utilising the various skills and knowledge of staff in creative ways, which has resulted in a variety of social and recreational activities being provided which guests enjoy taking part in. After completing a period of respite care, guests are provided with a photo- pack of visits and activities in which they have been involved during their stay. Individual surveys forms have also been modified by using imaginative artwork and Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 6 picture symbols which guests are invited to complete after their stay at Breakaway. The Inspector was advised that at least 80 of the survey forms issued, are normally completed. Positive comments included Enjoyed my stay very much. I was very well looked after, I enjoy coming in with my friend and would like to carry on doing this as we get on well and It really is a huge relief to us to know that there are some people out there that can look after our son as well as we do. Thank you for your kindness and consideration. The management are also aware of the need to match staffing levels and skills in order to respond effectively to the individual needs of guests who may be accommodated at the time. Staff spoken to, confirmed that they find their work very rewarding and the ongoing working relationships with guests has improved as a result of getting to know each other better with each successive period of respite care. Regular monitoring of staff training needs take place and courses are made available. What has improved since the last inspection? What they could do better: Although the acting manager has been in post for some time, it is only just recently an application for registration has been received by the Commission for Social Care Inspection. It is understood that staff have received training from health care professionals for administering rectal diazepam. Although protocols for this and other clinical procedures had been drawn up, written confirmation from the health care professional concerned and/or certificates were not available to show that named staff had been approved for carrying out these procedures. This was highlighted in the previous inspection report. It is acknowledged that the format of care plans has been updated for many of the guests but this process needs to be completed to ensure there is a consistency in the information being recorded as well as practice and Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 7 procedures followed. A master list of authorised names and sample signatures should be maintained regarding staff who have responsibility for administering medication in the home. 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. Breakaway DS0000018070.V308460.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 Breakaway DS0000018070.V308460.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Pre-admission assessment details were available to give staff appropriate information to determine whether the needs and aspirations of potential guests could be met by the home. EVIDENCE: From the sample check made, pre-admission assessment information was available showing nature of disability together with social development and sexuality, as well as emotional development. This included daily and nightly routines, likes and dislikes as well as family history. Information relating to other agencies involved was also included. Records containing this information had been signed by a social worker and the parents. One of the guests spoken to by the Inspector confirmed that he had an introductory day to visit the home when a pre-assessment had been carried out by the manager and members of staff. This took into account individual preferences and other information to ensure needs could be met. This guest had come to stay in the home for respite care on several occasions since first attending in September 2005. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 10 Feedback from the survey information provided to the home from a relative stated that A member of their family had stayed just two nights as a trial period and they were amazed at how well they had done especially as they have never been on their own before. Another guest commented in a questionnaire, That although a bit apprehensive at first, I now really enjoy going to the home. Staff were said to be suitably trained and that individual expectations/needs were being met. Breakaway DS0000018070.V308460.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 Quality in the outcome area is good. This judgment has been made using the available evidence including a visit to the service. Care plans together with risk assessments were in place, which had been drawn up following discussion with guests and parents, taking account of individual needs and showing how support is to be provided. Some of the care plans and information and not been updated in accordance with the new format introduced by the home. EVIDENCE: Case tracking took place in respect of two guests who were in the home at the time. This included an inspection of personal care records as well as talking with guests and observing interaction by staff. From the sample check made, some of the personal care information was clearly laid out, easy to follow and Person centred. Information included personalised introduction of guests including medical and background history as well as the staff support and supervision required. Social worker contacts were also listed. Behavioural and communication needs including day and night routines, were clearly documented and included the action and response required by the staff team. Risk assessments were also clearly identified together with the measures Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 12 necessary for staff to follow. These included moving and handling, driver safety, falls and slips and the staff ratios required. Review summaries had been carried out for each respite stay and had been dated and signed by staff and where possible, the guest concerned. Regular daily/nightly log reports had been completed for each guest. Grab plans giving details of known allergies and medical conditions as well as local doctor phone numbers/next of Kin information, were easily assessable by staff for emergencies. Guests spoken to, were positive regarding the staff interaction and support received and that they were included in the conversations and decision-making process. During the inspection, staff were observed to be responding sensitively and appropriately to the individual needs of guests who were in the home at the time. Some of the personal care plans and risk assessments inspected were still in the process of being updated into the new format. From the information available at the time for one other guest, risk assessments were in place for hoisting, choices and decisions and mobility but the last recorded review date was May 2005. Other information in the personal support plan had last been reviewed in November 2005. Self-help abilities, dressing/undressing requirements had been reviewed in August 2006. The Inspector was advised that approximately 40 of the care plans for guests were still in the process of being updated. The latest version of the care plan is far more user-friendly and is a positive tool, which is increasingly being used for the benefit of both the staff team and guests. Once the exercise of adapting and updating to the new version has been completed, this will provide continuity in the way information is recorded and care/support is provided for guests when attending the home for respite care. Breakaway DS0000018070.V308460.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to the service. The home provides an imaginative and creative activities/recreational programme in accordance with individual interests and choice. Successful links with families and friends have been achieved with positive outcomes for the lifestyle of guests. The rights of guests are respected and daily responsibilities in the home encouraged. EVIDENCE: As part of the Person centred plan, details of what activities guests enjoy participating in was recorded. This included favourite hobbies, colours and the use of sensory items e.g. musical instruments. Swimming, horse riding and dancing, together with the support required in following these activities, was documented. Some of the care plans, which had been updated, were creatively laid out in colour to reflect the personal interests of guests (e.g. music hall characters). This had proved positive in attracting the attention and involvement of guests when going through their care plans with staff. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 14 Risk assessments had also been completed for each recreational activity including driver safety and the loading/unloading of passengers. During the first day of the inspection, arrangements had been made to take guests out on a boat trip and risk assessments had been prepared to cover the correct use of safety clamps and seat belts as well as accessing emergency services should these be required whilst on board. Similar risk assessments had been prepared for horseriding, swimming as well as the activity of guests in the kitchen, including the use of a colour matrix. Daily log reports included entries showing meals eaten as well as activities completed. A colourful menu had been provided for each week in picture form and residents are involved in selecting choices and alternatives are available. Where possible, residents are encouraged to assist in meal preparation. The staff team are developing opportunities for increased interaction with guests to meet a diversity of need including Things I like to do at Breakaway, Places I would like to visit, and “My own ideas. Dreams or goals of individuals are also encouraged e.g. to hold a cup unaided . As part of this process, the skills guests would like to learn, the things they can do and things that make them unhappy are taken into account. Relatives have been very supportive and encouraged in this personal development and written compliments were available. Feedback from one guest who had completed the questionnaire prepared by the home stated, the London Eye and riverboat trip is something I had always wanted to do. But I never thought it was possible. It was the icing on the cake for my stay. Thank you all. Other activities have included themed social activities e.g. St Patricks Day and staff together with guests, were preparing for Notting Hill Carnival celebrations. This is to be held in the rear garden of the home to which families and friends have been invited. Comments on one of the questionnaires completed by a guest stated that they particularly liked the big garden. Guests spoken to confirmed that staff respected privacy, dignity and independence was encouraged wherever possible. Opportunities are always available to visit local shops with staff and the outing, which included the recent boat trip, was enjoyable. Feedback from one of the questionnaires completed by a guest stated that they particularly liked the big garden. From conversation, observation, feedback from surveys and the inspection of records, there was evidence to show that the core values of rights, privacy, choice and independence were being upheld. The management and staff team were able to demonstrate an awareness of how to meet the cultural and diversity needs of guests and of developing innovative ways of improving the service in accordance with the expectations of guests and their families. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Assessed and identified care/health and emotional needs were being met appropriately, which included the added support of other healthcare professionals as required. Evidence of approved training given to staff in respect of protocols for clinical procedures, was not available. Medication procedures were being maintained in accordance with Royal Pharmaceutical Society Guidance. EVIDENCE: Personalised care plans included details of specific background medical history including conditions and explanation of symptoms. Details were given of staff support and supervision required. Records were available to show fluid intake as well as continence, which was being regularly checked and recorded together with the comments of staff. Comments from guests confirmed that staff were supportive in assisting with personal washing, bathing and dressing but also allowed guests to be independent in providing their own self-care where this was possible. Comments from questionnaires confirmed that staff were caring and they looked after guests very well. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 16 Some parents have found it difficult to let go but feedback was available to show that as the months have gone by, it is quite apparent that Breakaway had become like a second home. Acknowledgement has also been made of the care and attention to detail residents had received during their respite stay in the home. Where there has been intervention by other health care professionals during respite stays, this had been recorded. Individual summaries of respite stays for guests are sent to social workers at the local funding authority, Thurrock Social Services Department. Protocols were in place for clinical procedures such as peg feeding and training was provided to staff in August 2005. However, there was no evidence or certificates available to show that named staff had been approved to carry out these procedures or the name and designation of the health care professional who had provided the training. (This has been highlighted in the previous two inspection reports). A sample check was made of the medication administrative records and these had been properly maintained and recorded with the correct dosage being given and signed for by staff concerned. Details of medication requirements on the M.A.R. sheets coincided with prescription details on original containers and packets. Individual lockable metal drug cupboards are provided in guests bedrooms. It is suggested as good practice, that a master sheet be introduced to include sample signatures and names of all staff in the home who have been authorised and are responsible for the administration of medication. Staff have received appropriate training in medication procedures. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. There is an established complaints procedure in place and the views of guests are listened to and acted upon. Staff have an understanding of the reporting procedure for the prevention of harm of vulnerable adults, ensuring that the safety of guests in the home is of paramount importance. EVIDENCE: The home has a complaints procedure and copies of this are available in the home. There have been no recorded complaints since the last inspection. It was noted from one of the questionnaires completed by a guest who attends for respite care, that they were not aware of the process as to how to make a complaint. As already referred to in this report, regular consultation and liaison takes place with guests and their families. Comments received from guests on the day of inspection, indicated that their views were listened to and acted upon. When guests return to the home for respite care, the summary of their previous stay is discussed and any changes, which have occurred in the intervening period, are implemented into the care plan accordingly. The updated policy and whistle blowing procedure for reporting concerns of actual or suspected abuse, was available in the office. Two of the staff who were on duty during the inspection, had an awareness of the P.O.V.A. reporting procedure and said they had received training. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The accommodation and facilities provided are purpose-built and meet the needs of guests in a comfortable and safe environment. The premises were being maintained to clean and hygienic standards. EVIDENCE: Bedrooms, communal areas and all facilities are situated at ground floor level and provide easy access to all guests, including those who have a physical disability and are wheel chair dependent. Bedrooms are suitably furnished with suitable ensuite facilities as well as space and storage for personal items and equipment. Some of the feedback from questionnaires completed by guests included comments such as, bedroom is ideal for me because of my two wheelchairs. Easy access is provided into the home through the main entrance as well as to the spacious rear garden without the need to negotiate steps or other hazards. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 19 Since the last inspection, a new purpose- built bathroom has been completed together with overhead tracking and hydraulic seat. This has proved ideally functional for assisting guests with bathing. A separate ground floor shower facility is also available. The home was clean and hygienic and staff are aware of infection control procedures, which are adopted. Plastic aprons, gloves and disposable arrangements were in place. The senior support worker also advised the Inspector that some of the guests and parents had mentioned the possibility of the home providing automated toilet facilities, which some families use in their own homes. This suggestion was being looked into by management for further consideration. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The number of staff on duty, with support and supervision, was able to meet the needs of guests. Guests were supported and protected by the homes recruitment policy and practices. EVIDENCE: At the time of the site visit, the acting manager was on annual leave although telephone contact was made with the Inspector offering to come to the home to assist if required. Brief discussion took place but the senior support worker, who was the designated shift leader, along with other rostered support workers contributed to the inspection. Staff rotas were available and these clearly showed the designation of staff and hours worked. Staff cover and ratios are arranged on the basis of the assessed identified needs of residents together with the support required. At the time of inspection, two residents were being accommodated and one of these required two- to -one ratio. Staff spoken to confirmed that they were involved with updating and working with care plans and that their work was very rewarding as there have increasingly developed closer working relationships with guests and their families. Staff training needs are assessed and courses attended are recorded. Some staff are currently studying for Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 21 N.V.Q.3 and over 50 of the staff have obtained N.V.Q. 2 or above. A training course has been planned for staff to attend in October 2006 dealing with physical restraint/managing aggressive behaviour. At the time of inspection, there were three support worker vacancies but these are covered by regular bank staff employed by the Registered Provider. Staff recruitment records were in place and included records of Criminal Record Bureau checks, references, proof of identification and application forms. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The acting manager has submitted an application to be registered with the Commission for Social Care Inspection. The management ensures that guests benefit from a home, which meets its stated purpose, aims and objectives for providing respite care. Systems are in place to ensure that the needs and views of guests are taken into account for improving the service. Acceptable standards for health, safety and welfare of guests and staff are maintained. EVIDENCE: The acting manager has developed increasing experience in managing the home and is supported by the service manager who undertakes regular monitoring visits. The staff team have demonstrated their ability to work well together and individual skills are encouraged which have produced positive and innovative/ creative outcomes for the benefit of guests. This has resulted in positive comments received from guests and their families through the surveys and questionnaires, which the home has introduced. Links with families and Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 23 friends have been strengthened and this includes regular meetings, which are held in the home and also at a local coffee shop to look at ways of improving the service. Minutes of these meetings were available for inspection. All staff have received health and safety certificates, which are regularly updated. Any items in the home, which require attention, are recorded and major items are listed in the health and safety file. Risk assessments for a safe working environment were in place, which included the use of the tumble dryer and other equipment as well as the control of substances hazardous to health guidelines. Notifications under Regulation 37 of the Care Homes Regulations have been submitted to the C.S.C.I. as required. The pre- inspection questionnaire included details of current servicing and maintenance safety certificates, which had been issued many of which, were checked at the last inspection. Dates were also recorded showing the dates of fire drills, fire alarm and equipment checks. Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 24 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 x 2 3 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 4 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 4 x x 3 x Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement Timescale for action 30/11/06 2. YA18 13 &14 The Registered Person shall continue the process of updating/transferring care plan information and risk assessments into the new format and keep the plans under review. 30/09/06 The Registered Person shall make arrangements for health care professionals to include evidence of training given to staff and for protocols to be completed for any clinical procedures, which need to be carried out. (Previous timescales of 31/10/05 & 31/03/06 not met). Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 26 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 YA20 Good Practice Recommendations Arrangements should be made for a master list to be compiled, as part of the medication policy, showing the names and signatures of all staff in the home, who have a responsibility for administering medication. Arrangements should be made to ensure that all guests and their relatives/representatives are fully aware and have a copy of the home’s complaints procedure. 2 YA22 Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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 Breakaway DS0000018070.V308460.R01.S.doc Version 5.2 Page 28 - 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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