Inspection on 18/01/07 for Chard Manor

This inspection was carried out on 18th January 2007.

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

Other inspections for this house

Chard Manor 31/01/06

Chard Manor 01/11/05

Chard Manor 09/11/04

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 Chard Manor Tatworth Road Chard Somerset TA20 2DP Lead Inspector Pippa Greed Unannounced Inspection 18th January 2007 09:15 Chard Manor DS0000060801.V325172.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 Chard Manor DS0000060801.V325172.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. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chard Manor Address Tatworth Road Chard Somerset TA20 2DP 01460 261016 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) Milbury /Voyage South Ltd Mr Gary Bush Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two places are permitted for named individuals aged between 16 and 17 years 31st January 2006 Date of last inspection Brief Description of the Service: Chard Manor Farm is an attractive listed building. The house has been purchased, renovated and refurbished by Voyage Ltd, to a good standard. It provides personal and supportive care for up to ten people with a learning disability age 18-65. The home also has a service user presently placed in category 16-17 years. The home is not far from the town centre, off the Axminster Road, close to the Church. It is accessed by a private drive, shared by other properties nearby. It is surrounded by gardens that are partitioned to provide two separate enclosed, safe areas and other, more open garden facilities. There are ten single rooms, all with en-suite baths. Some rooms have also been fitted with shower facilities. There are two spacious living rooms, a large sunroom and a dining room next to the kitchen. The home also has en-suite facilities for staff on sleep-in duties. The current scale of charges is £1,232 to £1,806. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection was conducted over one day (7hrs) by CSCI Regulation Inspector Pippa Greed. On the day of the inspection: - five support workers, two senior support workers and the manager were on duty and during the evening there were four support workers. There were two waking night staff and one sleep in duty rostered for that evening. The registered manager Mr. Gary Bush was available to assist the inspector during the unannounced visit. On the day of the inspection nine service users were at home initially. Five service users left to attend a drama session at college. The atmosphere was relaxed and informal. Staff were seen to work professionally and demonstrated good rapport with the service users. The inspector viewed all communal areas and five service users rooms and one unoccupied room. The inspector met with and engaged with five service users. One service user commented on staff ‘Yeah they’re okay (smiling)’. The inspector sat with and had lunch with the service users and staff and also observed daily routines within the home. The inspector spoke privately with one staff member. A selection of records was examined. These included three service users care plan and two staff recruitment files. CSCI sent out feedback cards for five service users, three relatives, seven staff, two social workers and three General Practitioners. Three service users surveys have been received, which were completed with advocated support from parents. These reflected positive comments. One parent wrote ‘Chard Manor is an absolutely wonderful set up. Whoever I speak to on the phone or in person is enthusiastic, helpful and friendly – I could not wish for a better place for my daughter.’ This is positive outcome for the service users who live at the home. Four care staff comment cards were received, which confirmed that they receive regular supervision and training updates. Two staff stated that they have not received manual handling training and three staff confirmed that they have had to deal with situations they felt unprepared for at times. However, they did not specify what these were. One service users survey was completed by a social worker, which was overall satisfactory. The social worker wrote that the service does well with individualised daytime support, liaison with families and ‘positive’ approach. The social worker also wrote that the service could improve communication Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 6 with the funding authority regarding significant issues affecting service user and improve on risk assessment. The inspector would like to thank the service users, staff, and manager for their time and hospitality shown to the inspector during her visit. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? The manager has developed a shift system designed to meet the service users social needs during the evenings. This was implemented during the summer. The staff team have been pro-active in supporting one service user’s specific hobby (Carnival Club) in recent months. The manager has implemented a new recording system in the staff handover record. All details relating to service users are maintained and used in accordance with the Data Protection Act. This ensures that the service users’ confidentiality is maintained. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 7 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. Chard Manor DS0000060801.V325172.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 Chard Manor DS0000060801.V325172.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose, and service user guide that clearly sets out the objectives and philosophy of the service. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. EVIDENCE: The service user is provided with a Statement of Purpose and a Service User’s Guide. The Statement of Purpose outline criteria for admission. Initial referrals may come from either a parent/ carer or from a social worker. A written profile and detailed assessment is obtained from the social worker, which would allow for Voyage’s Operations Manager to assess the suitability for placement. There is no set timescale as each case is judged on the service user’s needs. The Service User’s Guide is written in simple, easy to understand English supported by pictorial images (Change Picture Bank). The guide explains what the prospective service user can expect from Chard Manor. This enables the Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 10 service user and their family to make an informed choice. The Service User’s Guides are kept in service user’s bedrooms. Contracts are kept at head office. Copies of these should be made available in the home. One service user’s survey confirmed that he had a say in choice of home with parent’s support. The service user also confirmed that his family were provided with enough information about the home. One care plan sampled evidenced a Voyage pre-admission assessment pack, which was detailed. There is one vacancy at present. Chard Manor DS0000060801.V325172.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): 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 and well-written care plan for each service user. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: The inspector sampled three service users care plans. Care plans are well maintained for each service user. The Care Plan outlined details relating to health, medication, dental and optical care, diet, self help skills, daily living skills, activities, social, communication, and behaviour summary. The care plan file also included records of review meetings, visits to health care professionals, and contact with families. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 12 All three files sampled demonstrated that the manager has updated the care plan on a regular basis and review meetings were held in recent months. Behaviour Management guidelines were in place for one care plan sampled. This detailed possible triggers and how best to prevent these, displayed behaviour, management strategies and how staff would de-escalate the behaviour. It is recommended that the guidelines are reviewed, signed and dated. The inspector discussed with the manager the use of photograph identification on the care plan file. The manager plans to implement a personal planning book. It has pictorial images, which makes the care plan more accessible. This should include a photograph of the service user. This will form part of a person centred planning approach. Individual risk assessments have been completed for each service user. Risk assessments seen have been reviewed and updated. Service users are encouraged to exercise choice. This is done through individual communication system. The inspector observed staff interaction with service users during the inspection process. Staff were seen and heard to offer service user choices of activities and snacks. There was a strong feeling of caring rapport seen between staff and service users. One service user was enabled to exercise choice of preferred staff to sit with her at mealtime. Staff demonstrated their knowledge and understanding of service user’s moods, vocalisation, facial expression or body language, which indicated their chosen preference. Another service user was actively encouraged to complete daily living activity such as returning their plate after a meal and making a choice of dessert. The manager informed the inspector that service user’s meetings take place on a monthly basis. This provides service users and their key-worker opportunities to reflect and review their needs. Other examples of quality assurance monitoring are offered through monthly visits (regulation 26), staff meetings, service audits and annual review. The last service user’s meeting was held at Christmas time. Service users were consulted on colour scheme for the hallway and two lounges. The home keeps individual day to day records that detail the activities and choices that have been made by service users. Financial records were seen for two service users. One staff signature supported all entries and checked by manager or senior on a regular basis. The entries were correct for expenditures and tallied with the balance. It is recommended as good practice that two staff signatures are recorded for each transaction. All records relating to service users are stored securely and recorded appropriately including the staff handover book. Chard Manor DS0000060801.V325172.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home supports the service user with personal development. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users are supported with friendship and family contact. Service users rights and responsibilities are respected. Service users are offered a choice of menu, and the options are developed around their preferences and dietary needs. EVIDENCE: On the day of the inspection, service users were accessing a range of activities, some of which were attending college drama session, exploring tactile toys, also arts and crafts activity. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 14 The inspector engaged briefly with two service users using a bouncing space hopper and non-verbal communication. Normally the home would also arrange for lunch out and visit to National Trust for five service users but due to severe gales, this was postponed. An activity timetable listed trampolining, National Trust visit (voluntary work), massage, swimming, Headway, horse-riding, cookery at college, music session, sensory room session, gym, art session, drama at college, gardening at college, Independent Living at college, and ‘Look good & feel good’ at college. Service users access the local community, utilise services within other Voyage home and go out on environmental visits. They are able to pursue their personal hobbies and interest within the home. In-House activities include relaxing with sensory fibre optics, cookery, daily living skills, listening to music, massage, tactile exploration and games. One service user has recently joined the local carnival club. Service users at the home regularly attend a social club held monthly in Taunton and socialise with their peers. Service users have also enjoyed a Christmas party held in Bridgwater where a disco and buffet was provided. Two service users have enjoyed a successful long weekend break in London last October 2006. The service users requested to visit London and staff team arranged the trip. All service users enjoyed a caravan holiday in Sidmouth last summer 2006. This was arranged in two groups including two days trip over a period of time. It was planned around service users needs and provided quality one to one time. Staff spoken with stated that some service users have home visits. Regular contacts are maintained with families through weekly phone calls and visits to the family home. A service user was observed participating in an activity. Through the interaction and communication, it was evident that staff were supportive and clearly understood the service users needs. The inspector noted that the lunchtime routine was relaxed and unhurried. The meal prepared was appetising and freshly made. The home has a pleasant and spacious dining room that was comfortable to eat in. Fresh fruits were readily available. Staff understood non-verbal service user wishes and supported this. The manager informed the inspector that they plan to further improve the menu picture board with more pictorial symbols and install a protective Perspex cover. One service user told the inspector that she likes the staff and likes living at Chard Manor. Chard Manor DS0000060801.V325172.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has a detailed medication policy, which provides clear guidance. Medication records are managed safely. EVIDENCE: The home has appropriate aids and equipment to support service users mobility. The health and safety checks for these equipments are maintained regularly. The home provides en-suite bathrooms which promotes service users dignity with personal care. It was evident from the care plans through regular monitoring that any changes in the service users wellbeing or behaviour would be identified. The manager and staff team would then take pro-active steps to address and meet changing needs. This was evident in service users care plan that were Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 16 sampled. These included a multi disciplinary approach with medical professionals or support provided from Learning Disability psychiatrist. The care plans that were sampled contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, and optician. Records are kept of all visits and consultations. Service users have individual manual handling assessment, which were reviewed on 8th January 2007. Weight records were kept. However, the three care plans viewed showed that weight were recorded last August and September 2006. It is recommended that weight records are maintained regularly in order to provide up to date information relating to service users health. This would ensure that potential complications are identified and dealt with at an early stage. The home’s procedures for the management and administration of medication were examined at this inspection. Medications were handled and stored appropriately. The storage area was clean and tidy with clearly labelled boxes with service user’s photographs. The Medication Administration Record demonstrated that two senior staff sign and book in medication received by the home. The home has a detailed medication policy. Photographs of service users are stored on their medication care profile. Epilepsy protocols were prominent within the Medication Administration Record and provided clear procedures to follow. The home has an appropriate Controlled Drugs register in place. It is recommended that two staff signatures confirm all hand transcribed entries. It is also recommended that variable dosage is recorded appropriately on the Medication Administration Record sheet. At present the care plan does not contain details relating standard 21 in the care plans. Chard Manor DS0000060801.V325172.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place for the protection of vulnerable adults from abuse. The home has a complaints procedure and policy relating to the Protection of Vulnerable Adults in which the staff have knowledge of. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults (POVA), Whistle Blowing, Complaints policy, and Grievance policy. The home has a clear, easy to understand flow chart for whistle blowing procedure placed in the office. However, it is recommended that the CSCI and Social Services contact details be added to the flow chart. This also applies to the Complaint policy. The organisation’s Vulnerable Adult policy was sampled (section 4:4). It sets out the expectations of the alerter (staff) to report issues through organisational line management structure. If the issue of concern relates to the staffs immediate line manager the policy instructs the person to go directly to their managers manager, and so on. This may be a weakness in the procedure, as the member of staff may not wish to report to senior management their manager on suspicion alone. Stating in the policy that the staff member can go directly to any of the statutory agencies at any time to report their concerns Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 18 could rectify this. The Public Interest Disclosure Act 1998 provides clear ‘good practice’ guidance. Four staff comment cards were received. These confirmed they knew where Protection of Vulnerable Adults information was kept. They also stated that they understood how to report any concerns about poor care or allegations of abuse. POVA training has been offered to staff. The inspector met with a staff member and asked about their understanding of Safeguarding Adult procedures. The staff member knew of the policy, who to report to and confirmed that they have received POVA training. The home has a number of systems to safeguard vulnerable people, which include a recruitment policy. This means that new staff does not start work at the home until a satisfactory POVA check and an enhanced Criminal Records Bureau (CRB) clearance has been obtained. Two staff recruitment files were seen to be robust and contained records required in Schedule 2, Care Homes Regulations. The complaint log was sampled and provides appropriate recording tools if required. The manager informed the inspector that no complaints have been made. Similarly none have been reported directly to the Commission. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a high standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a good standard of cleanliness. EVIDENCE: Chard Manor is an attractive listed building with gardens to front and rear. The private rear garden is enclosed and has picnic tables/ benches. The home has ten single bedrooms, four of which are on the ground floor. All rooms have ensuite facilities. Communal area includes two lounges, dining room, a conservatory and kitchen. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 20 Service users are enabled to use a sectioned area of kitchen in order to encourage independence skills. Service users are able to make their own breakfast at a time of their own choosing, which promotes dignity. In the kitchen the inspector saw records of daily fridge and freezer temperatures. These were found to be within safe range. The prepared food stored in the fridge were date labelled. Food probe records were seen and maintained within appropriate range. The kitchen was considered clean and sufficiently equipped. The home has a good-sized laundry room, which houses an industrial washing machine and a tumble drier. It was found to be clean. However it was cluttered with lots of baskets thus making objects on shelves and windowsill difficult to reach. It would be appropriate to de-clutter the space for ease of access. The home offers smaller quiet communal space such as conservatory or the second lounge should a service user wish to spend time alone or be with families. The conservatory provides television, computer and telephone. The inspector viewed five service users bedrooms and one vacant room. Each service users bedroom was specifically decorated to their taste and interest. The bedrooms were filled with a range of décor such as rope lights, large framed photograph of friends and family, comfortable rocking chair, television, DVD player, CD collection, artwork, sensory light display, soft toys, furry throws, posters and personal memorabilia. The bedrooms are complemented by full en-suite facilities, which were also personalised in a bright and cheerful manner. The home also has en-suite facilities for staff on sleep-in duties. The manager informed the inspector that the hallway has been redecorated and that they plan to redecorate the two lounges. Through discussion held at service users meetings, it is anticipated that one lounge wall will be painted in a neutral colour and used to display service user’s art. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. Staff receive comprehensive induction and training updates. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are well maintained. On the day of the inspection, five support workers, two senior support workers and the manager were on duty and during the evening there were four support workers. There were two waking night staff and one sleep in duty rostered for that evening. Since the last key inspection, the manager has completed a recruitment drive and a full staff team is currently in place. The manager informed the inspector that the team work proactively to help meet service users evening activities. Day staff work to 8:30pm. This could be problematic should a service user wishes to make ad-hoc social arrangement. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 22 The manager and staff team have supported this with an altered shift pattern during the summer and degree of flexibility from staff during the winter months. Staff have recently supported one service user with an evening social pursuit. The manager has completed an analysis of staff training needs, to ensure that all staff are provided with appropriate training to undertake their role. Newly employed staff complete a thorough induction programme including POVA. The manager has registered nine staff to undertake National Vocational Qualification (NVQ). Staff are provided with regular opportunities to receive training, and have attended courses on First Aid, Food Hygiene, Health & Safety, Manual Handling, Non Violent Crisis Intervention (NVCI), Medication (Boots and distance learning), Learning Disability Award Framework (LDAF), Sexuality & Interpersonal Relationships, Management Development Programme, Total Communication and Intensive Interaction. Out of twentythree care staff employed (excluding the manager), four have obtained the NVQ level 2 or 3 qualification in care. As stated previously, two staff recruitment files were examined. These were maintained appropriately. Each was found to contain the documentation required within Schedule 2 of the Care Home Regulations 2001. The inspector viewed the records in relation to staff supervisions. The manager has an overview of all staff supervisions that have been conducted. Senior staff also provides supervision in order to maintain good frequency. The inspector noted that staff have been supervised recently. The inspector spoke with one staff member. Staff confirmed that the manager was approachable and that they would be able to raise any concerns. Staff felt well supported by the manager and staff team at Chard Manor. Staff informed the inspector that senior staff meeting takes place as well as staff meeting. This ensures regular communication and opportunity to identify care needs. Staff also confirmed that there was a wide variety of training available to enable them to develop the skills and experience necessary to provide a good quality of care for service users. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is very well run and benefits from a competent manager. There is a relaxed and inclusive atmosphere within the home. Health and Safety checks are well maintained and the service users welfare is protected. EVIDENCE: Gary has nine years experience of working with adults with complex needs and challenging behaviour within the Voyage organisation. Prior to being appointed as a manager at Chard Manor, Gary was joint manager for a larger home within the organisation. Gary has attained the National Vocational Qualification (NVQ) level 3 in Promoting Independence. Gary has qualified as an NVQ assessor and manual handling trainer. Gary is currently undergoing the Registered Managers Award (RMA) NVQ 4. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 24 He is supported by one deputy manager and three senior support workers. Staff at the home seek service users’ views on an individual basis, taking account of behaviours, verbal and non-verbal communication. There is a strong person centred focus and this was evident throughout the inspection process. The home has good systems in place that monitor the quality of care delivered to service users. These range from care plan reviews, service users meetings, staff meetings, staff training and supervision, monthly visits and detailed audits from operations manager. Staff spoken with confirmed that the manager was approachable and that they would be able to raise any concerns. Milbury/ Voyage has systems in place in relation to financial planning, budget monitoring, human resources, training and quality assurance monitoring. The home has appropriate policies and procedures in place to safeguard vulnerable service users. However, these should include the contact details of statutory agencies. All records relating to service users are stored securely in accordance with the Data Protection Act 1998 including the handover book. The home has a current Employers Liability insurance. The home operates a comprehensive system of health and safety audits. The portable appliances test (15.5.06), gas landlord register (19.5.06), water temperature (weekly), Lifting Operations, Lifting Equipment Regulation (LOLER) checks (18.10.06) wheelchair checks (weekly) was completed appropriately. Legionella external agency check was carried out in May 2006. All checks have been appropriately maintained. Accidents have been recorded and an analysis completed on a monthly basis. Accident figures appear low overall. The monthly analysis are complied by the manager and sent to Voyage Head Office for further audit. This is considered as good practice. Records are kept of daily fridge and freezer temperatures, food probes and hot water temperatures. These were maintained regularly. Chard Manor DS0000060801.V325172.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 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 3 3 3 2 2 3 Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA9 YA19 YA20 YA22 YA23 Good Practice Recommendations It is recommended that Behaviour Management Guidelines are dated and reviewed at an appropriate frequency in relation to the service user’s needs. It is recommended that weight records are regularly maintained in order to provide up to date information relating to service users health. It is recommended as good practice that two staff signatures support all hand transcribed entries. It is also recommended that variable dosage be recorded. It is recommended that the complaints policy include contact details of statutory agencies. The organisation may wish to consider its policy with regards to Safeguarding adults so that it empowers the staff member to contact either of the statutory agencies with their concerns. It is recommended that service user’s finance records is signed by two staff members in order to provide a clearer audit trail. DS0000060801.V325172.R01.S.doc Version 5.2 Page 27 6. YA40 Chard Manor 7. YA41 It is recommended that the manager provides photograph of service users on the service users care plan file as outlined in schedule 3 of the Care Home Regulations 2001. Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Chard Manor DS0000060801.V325172.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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