Inspection on 06/11/07 for Byways

This inspection was carried out on 6th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Byways 23/10/08

Byways 01/08/06

Byways 24/10/05

Byways 05/05/05

Byways 07/12/04

Byways 07/07/04

Byways 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Byways 80-82 London Road Warmley South Glos BS30 5JL Lead Inspector Odette Coveney Key Unannounced Inspection 6th November 2007 09:30 Byways DS0000003400.V351900.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 Byways DS0000003400.V351900.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. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byways Address 80-82 London Road Warmley South Glos BS30 5JL 0117 9612426 0117 9709301 max@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust 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) Mr Jeffery Parry Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 8. Date of last inspection 1st August 2006 Brief Description of the Service: Byways is a care home that provides accommodation and support for eight people with learning disabilities and additional needs. Aspects and Milestones Trust, a non-profit making Trust, operate it. The home is situated in Warmley, five miles from the centre of Bristol. It is approximately a twenty-minute walk from a range of shops and the local bus service. The property is a two storey; extended detached house situated in good-sized well-maintained gardens that are fully accessible. The home provides single rooms with wash hand basins. There is ground floor accommodation for two service users. All other bedrooms and a staff sleeping in room are situated on the first floor. There is a passenger lift between floor levels. All areas of the home are accessible to service users. Hallways and corridors are spacious and doors have a clear opening width to accommodate wheelchairs. The home has assisted bathroom facilities and a separate toilet on each level. One Bathroom has a shower. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken in an 8 hour period by one inspector for the Commission. This inspection was very positive and overall a judgement of good was made. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for three individuals were reviewed. The registration certificate for the home was reviewed at this site visit and the information contained within it was found to be accurate. Seven comment cards were received prior to the inspection, three of these were from relatives of those who live at the home, two were from individual’s who live at the home, two comment cards were from visiting health/social care professional who visits individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the manager on duty and have been incorporated within this inspection report. As part of this inspection visit an ‘expert by experience’ and their support worker accompanied the inspector. Their focus was to spend time with those who live and work at the home, to view the facilities and to provide an unbiased view from the perspective of those who live at the home. What the service does well: The staff team at Byways are caring and have developed good relationships with individuals at the home; they have a sound understanding of the needs of those living at the home. There is a low staff turnover and individual’s can be confident that they will receive support from people they know. It was clearly evident that the management and staff team are committed to ensuring that all of the needs of individual’s at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individual’s. The ways in which staff communicate with individuals at Byways are effective and have been well recorded, techniques used at the home include makaton, Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 6 sign language, use of symbols, pictures and photograph’s. Each individual’s method of communication is well recorded at the home with clear direction for staff to ensure that individuals are communicated with and are not excluded in decision-making processes. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs, hopes and goals assessed and recorded before they move in to the home so that staff know how best to support them. EVIDENCE: The Statement of Purpose was in place and this was found to be fully comprehensive and contained all of the relevant information required. The Statement of Purpose contained the aims and objectives of the home and spoke of treating individuals with dignity and respect, to promote independence and encourage individuals to make choices with aspects of their lives. The home have three qualified nurses as part of the staff team at the home and the home makes use of both the community learning disabilities team and the primary healthcare trust in order to ensure full assessment of individuals needs are made and then met either by the home or externally from other professionals. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 9 There are individuals living at the home who do not use spoken language as their main method of communication. Information seen in care records clearly showed that staff have established professional caring relationships with individuals and have recorded the complex indicators that individuals use such as body language and behaviour, this demonstrates a commitment from the staff team to ensure that the needs of individuals are met. Information seen in care records showed that when specialist advice had been required in order to fully support individuals this had been sought; examples of external support included care mangers and consultant psychiatrists. During the visit staff were observed interacting with individuals, using appropriate methods of communication required for individuals such as sign language and for others living at the home staff used body language and appropriate tone of voice and communication pitched at a level of understanding for individuals. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning documentation at the home contains clear, detailed information to enable client’s personal, emotional needs to be well met, with individuals being supported and encouraged to make decisions that affect their life. They are supported and encouraged to risks as part of their independent lifestyle EVIDENCE: Information held for individuals was extremely detailed and it was evident that the information in place had been gathered over a long period of time; all of the service users records had been written in a person centred way and had been tailored to the specific requirements of individuals. It was clear that information had been gathered through observation of individuals and that their preferred lifestyle had been well documented. Information recorded in care plans covered areas such as personal, physical, healthcare and emotional areas of support with guidelines in place to direct and guide staff practice. Information in place is monitored and kept under review in order to ensure it reflects individual’s needs. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 11 Information within individuals care records also included ‘how to support me well with my communication’ and covered individuals specific support requirements such as facial expressions, reassurance and respecting an individual’s decision to say no. Within these records were evidence of how individuals are enabled to make choices and decisions about the way they wish to live their lives and the support they required to do this. Advocacy has been arranged for individuals in the past and this would be again should the need arise. Daily diary’s provided further evidence to show that individuals are encouraged to maintain relationships with their family and friends, this is done through social visits, assistance with transport and correspondence. The manager and staff at the home ensure that individuals are offered opportunities to participate in the day to day running of the home, service users have been consulted about the homes business plan, which in turn feeds into the Trust’s organisational plan. The home ensures that information is provided to service users in an understandable format and it was noted that` staff have completed training in communication, training specific to the needs of individuals living at Byways. Individuals are supported to take risks where appropriate, and staff work hard at trying to make sure that they are aware of any potential risks. Risk assessments had been done for each individual and these included things such as travelling and drinking alcohol, with ways of minimising these risks identified, without hindering the lifestyle and choices of individuals. The staff were observed going about their duties in a friendly and calm manner and responding to the service users in a familiar style. There was friendly banter between the service users and the staff, evidencing that the home is a good place to live. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. Individuals at the home are well supported to participate in activities of their choice, individuals are respected and responsibilities are recognised in individual’s daily life. EVIDENCE: The manager and staff support service users to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enable individuals integration into community life through knowledge and support to enable individual’s to make use of services, facilities and activities in the local community, such as shops, bingo pubs, college and individual leisure activities. Individuals can choose when to be alone or in company, and when not to join in an activity. Staff enter bedrooms only with the individual’s permission, and were seen to knock on the bedroom door before entering. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 13 Daily routines are flexible, with people choosing what they want to do and when. Those living at Byways have unrestricted access to the home and garden. Menus are chosen weekly using picture cards and service users choose the meals from these, these menus include a wide range of culturally diverse meals. On the day of the site visit services users were offered choices and were observed enjoying their lunch, staff ate lunch with service users, interactions were positive making it a pleasurable experience. The home supports service users to ensure equality and diversity; the home supports one person in particular to access cultural diverse areas within Bristol as they had expressed an interest in the culture, food and music of different communities. The home supports service users to attend different churches. The ‘expert by experience spent time with both service users and staff and feedback to the Commission that ‘Residents have different activities they chose and like to do. They range from college, Resource and Activity Centres, skittles, bingo, cookery, music, gardening, eating out, pub, and shopping. Staffing. Residents are encouraged to clean and tidy their rooms. There is a rota for residents doing different activities on different days when residents are at home. Residents sit with staff and plan a weekly menu using pictorial cards.‘ No areas of concern or complaint were raised to the ‘expert’ by either service uses or staff. It was noted by the inspector though observation, discussions with staff and an overview of the staffing rotas that staff at the home are very flexible with their hours on shift and alter these accordingly in order that individuals are supported to participate with activities of their choosing. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 14 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, 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The aspirations, personal, social, end of life preferences and individual needs are well documented and clearly show how these needs are to be met. Individual’s healthcare needs are met including the handling and administration of their medication. EVIDENCE: Care records and health action plans showed how the home have monitored an individual’s wellbeing and much was done via observations, as individuals did not always articulate their needs coherently and logically. This further evidenced that staff had a good awareness of the needs of those individuals with communication differences. It was also noted that individuals had in place a ‘personal care statement’, which outlined clearly individuals preferred methods of support. Individuals had a ‘day to day’ support folder which contain individuals personal care statements, mental capacity act statement, outlining individuals rights and choices, individuals person centred plans and their essential lifestyle information and recorded things which were important to individuals. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 15 The health needs of individual’s are well met with evidence of good multi disciplinary working taking place on a regular basis. All of those living at the home are registered with a general practitioner; evidence was in care records to confirm that individuals are supported with their primary healthcare needs such as optician, dentist and chiropody and that specialist advice is obtained when needed. Prior to the site visit the Commission received two comment cards from general practitioners who visit the service users, both recorded that the home communicates clearly and works in partnership with them, that staff demonstrate a clear understanding of the needs of service users and that they are satisfied with the overall care provided at the home. A requirement was made by the pharmacy inspector for the Commission during a site visit undertaken to the service in September 2006 that the home must maintain a receipt of all medication to be recorded, that records to be kept of changes in medication dose, that action be taken to ensure that all medication is administered as prescribed. It was found that these areas had been satisfactory addressed by the home. Systems of medication administration, storage and recording were reviewed at this inspection. The inspector has seen at previous visits that the home has clear policies and procedures in place to direct staff and provide instruction. Medication is stored in a locked cabinet with an additional facility for the storage of controlled medication. A monitored dosage system of medication administration is in place at the home and this appears to work well. Medication records clearly outline in what circumstances ‘as and when required’ medication is to be given. It was noted that end of life choices of those living at the home were recorded and outlined individuals wishes. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 16 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. There are clear processes in place in which individuals can raise concerns; individuals are protected from potential abuse. EVIDENCE: The home has a procedure which outlines the steps to take if there are any complaints, and all have had this procedure explained to them on a one to one basis by staff and a copy of this in their care records. They are also made aware of how to contact the Commission for Social Care Inspection (CSCI). A complaints book is kept in the office, and any complaint would be recorded there. No complaints have been received either by the home or to CSCI. All individuals are encouraged to air their views, and both support workers and the manager are keen to hear any suggestion from individuals about how the service could be improved. The registered manager has contacted the Commission for Social Care Inspection to inform of incidents that have affected the wellbeing and safety of those living at the home and have demonstrated that incident have been responded to effectively. The policies and procedures relating to the Protection of Vulnerable Adults were in place. There was good evidence that the home systematically ensures that staff are trained to enable them to identify abuse and follow correct procedures for reporting suspected or alleged abuse. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 17 Two Individuals money held for safekeeping at the home was checked to ensure it corresponded with records held, it did. Receipts are kept for transaction and there are clear audit processes in place. Byways DS0000003400.V351900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of furnishings and fittings in the home are good and overall a comfortable environment has been created ensuring individuals needs are met, however the Trust must ensure that the organisation maintain the home to a suitable standard. EVIDENCE: Byways registered with the Commission to provide a service for up to 8 persons aged 18 – 65 years, currently there are seven individuals living at the home, five men and two female. The home comprises of two houses and has suitable communal and private areas for individuals use. There have been no changes in the services and facilities provided at the home since the previous inspection. The location and layout of the home is suitable for its intended purpose. Byways is an attractive home, with airy rooms and comfortable furnishings. There are large mature gardens at the rear of the home which individuals have enjoyed using over the summer. Service users bedrooms were homely and each contained individual personal items Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 19 At the time of the visit all areas seen were clean, tidy and odour free. All of those living at the home have access to their personal and communal space. The home has a large and very pleasant rear garden; this was seen to be well tended. When the inspector arrived at the home it was found that their had been a situation during the night where water had leaked from a tank in the roof, causing the fire alarms to be activated and water was dripping through a light fitting. The staff on duty are to be commended for their prompt response in ensuring the safety and wellbeing of those living at the home. Appropriate contractors were contacted to respond to and deal with the emergency situation minimising the effect on service users. Three requirements were made during the site visit to the home undertaken on 1st August 2006; these were that that due to wear and tear the lounge carpet should be replaced, this has been undertaken. Another requirement was that the kitchen ceiling light to be cleaned, this had been done, it was also required at the last site visit that the lock on toilet door to be repaired, this lock as found to be working correctly ensuring the privacy for those who use this facility. It was noted that there is water staining to the ceiling at the top of the stairs, this must be addressed in order to provide a well maintained environment for those who live at the home. Staff and the manager confirmed that some carpets had been replaced since the last site visit, however it was noted that the entrance hall carpet is worn in areas, particularly by doorways, it is recommended that consideration is given to replacing this before is potentially becomes a hazard. There is a small ‘domestic’ type kitchen, this was found to be clean and tidy and general well maintained. It was recommended at the last site visit to the home that consideration to be given for the redecoration of the kitchen, this had been undertaken and this area looked much improved. Due to its jaded appearance it is recommended that the ground floor toilet area is redecorated, it is further required that the wall fan in the first floor bathroom is cleaned of dust. Due to indiscretion it was recommended at the previous site visit to the home that the consideration to be given to better storage facilities for continence products, the home now have bags for this and this has improved the situation at the home. Byways DS0000003400.V351900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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. The home had sufficient, staff on duty and staff are qualified to provide good level of support. All staff are clear regarding their role in what is expected of them. Recruitment practices safeguard individuals living Byways. EVIDENCE: The manager was able to demonstrate that she and the staff team have developed good relationships with those who live at the home and have a sound understanding of their needs, wishes and aspirations. These are well recorded in individual’s records. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 21 Staff spoken with and certificates seen in the office provided confirmation that the training had been undertaken and staff were positive about how training, including National Vocational Qualification in care practices, had influenced their practice and improved their skills in caring for people with individualised complex needs. The inspector spoke individually with a staff member who said they are very happy within their role at the home and said that they felt well supported both by the management and the organisation, this member of staff knew who to speak with if they were unhappy. This member of staff was fully conversant with the in depth and complex nature of the support that individuals require at the home and gave sound examples of how individuals are given choices and how their rights are promoted and how individuals are treated as adults. There are four staff members who completed the NVQ level III in promoting independence and there are a further three staff who are currently undertaking this award. All staff have received training in signalong, which was developed to provide staff with skills to communicate with individuals who do not use language as their method of communication. The recruitment and selection documents for five members of staff were reviewed at this inspection; these staff files evidenced that full and robust practices are adhered to at the home to ensure that those appointed have the qualities and skills to work within this care environment. Appropriate adult protection checks are taken to ensure the protection and safety of service users. It was recommended at the site visit undertaken to the home undertaken in August 2006, that in order to provide clear information on that staff training that audits be completed, the home have obtained this information from their training department and information was clearer on what training staff had undertaken. Comment cards received from relatives of those who live at Byways, prior to the visit recorded that; ‘we have always found that our relative gets the full support they need’, ‘The staff make us feel welcome when we visit, we are very pleased with the way staff have enabled and supported our relative’. During this site visit the inspector sat in during a staff meeting; a variety of appropriate topics were covered to ensure that activities are carried out effectively and efficiently. It was clear that staff put service users living at Byways ‘central’ to decision making processes, there was a fair exchange of ideas and allocation of duties, routines and practices were discussed and future plans outlined. Staff were listened to and responded to appropriately. Byways DS0000003400.V351900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from a well run home, however, long term arrangements must be made for the management of the home. Health and safety within the home is well managed this would be improved if manual handling risk assessments were in place. EVIDENCE: The current registered manager of the service Jeff Parry has been seconded to work as an area manager within the trust and the deputy manager Maggie Webb has taken up the role of ‘acting’ temporary manager. It is required that in order that service users and staff have stability and continuity within the management team that an application is forwarded to the Commission in order that there is a permanent registered manager for the service. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 23 Ms Webb has extensive management experience and her background is supporting and working with individuals who have a learning disability. Ms Webb has completed a NVQ at level four in care management. The temporary manager has a very “hands-on” approach and is very involved with the day-to-day care of the service users and working alongside the staff team. Staff meetings are held on a regular basis and there was evidence that everyone is encouraged to make suggestions about how the run is run and what happens, staff spoken with also confirmed this. From talking with staff it was evident that they felt supported in their role by the manager. Ms Webb had a good understanding of the care needs of the individuals. Positive relationships were observed between the manager, staff and the service users. Staff stated that the manager is approachable and operates an open door policy. There are clear equal opportunities policies within the home and all staff are given copies of these. Staff meetings are held regularly and there are also other strategies for enabling staff, service users and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, client review meetings, quality assurance, and an open and approachable management approach. It was also reported that the representative of the responsible individual visits the home on a regular basis, spends time with service users, staff and the manager and oversees the service provided at the home. Two service users were involved with drawing up the business plan for 2007/2008 and their ideas were incorporated within the plan. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment. The annual quality assurance assessment (AQAA), this is a new process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the Registered Manager was fully completed and detailed. The home are currently in the process of issuing quality assurance questionnaires to relatives of those who live at the home, this audit asks about areas of satisfaction such as the house, the staff, and the support that their friend or relative receives. Maggie Webb confirmed that once all of the surveys have been returned the information contained within these would be evaluated and used to improve the service if required. Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 24 A requirement was made during the last site visit to the home that records of fire instruction to be better maintained, this requirement was found to have been met. The fire logbook for the home was viewed at this visit and it was found that the home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. The inspector saw the fire panel in working order. There were no concerns in respect of health and safety identified during this site visit, and incidents and accidents had been well recorded and dealt with effectively, however in order to ensure that individuals are supported in line with their assessed needs it is required that manual handling assessments are developed. Byways DS0000003400.V351900.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 3 2 X 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 3 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 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 3 X X 2 X Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 26 No 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. 2. 3. 4. Standard YA37 YA30 YA42 YA24 23(2) b Regulation 8 (1) a 13 (4) a 13 (5) Requirement Arrangements are made for the registration of a permanent manager of the service. Arrangements to be made for the cleaning of the fan in the first floor bathroom. Manual handling assessments to be completed for service users. The ceiling on the top landing of the stairs to be re painted. Timescale for action 08/01/08 08/12/07 08/01/08 08/01/08 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 YA28 Good Practice Recommendations Consideration to be given for the redecoration of the kitchen. Consideration to be given to the replacement of the carpet in the entrance hall of the home. Consideration to be given to the re decoration of the ground floor toilet area. 2. 3. YA24 YA27 Byways DS0000003400.V351900.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Byways DS0000003400.V351900.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. 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