Inspection on 11/06/07 for Chippings

This inspection was carried out on 11th June 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 found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chippings 24/04/06

Chippings 12/01/06

Chippings 07/07/05

Chippings 23/11/04

Chippings 04/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Chippings Chippings 28 Russells Crescent Horley Surrey RH6 7DN Lead Inspector Susan McBriarty Unannounced Inspection 11th June 2007 09:50 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 Chippings DS0000013601.V342909.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. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chippings Address Chippings 28 Russells Crescent Horley Surrey RH6 7DN 01293 775350 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) chippings@gccare.co.uk Gresham Care Timothy Hurst Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2006 Brief Description of the Service: The Chippings is a detached property located in a residential area in Horley, Surrey and provides accommodation for six service users with a learning disability. The property is close to public amenities and accommodation is on two floors accessed by stairs. The facilities on offer include six single bedrooms, lounge, a dining area, kitchen, bathrooms, toilets, showers, utility room and a sensory room. The home has a large garden that is private, secure and easily accessible. A sturdy climbing frame and small summerhouse are available for use in the garden. Limited private parking is available to the front of the property. As at 11th June 2007 the fee levels ranged from £961.51 per week to £2,546 per week and were based on individual assessments. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over six and a half (6.5) hours, commencing at 09:50am and ending at 4:20pm. Ms Susan McBriarty, Regulation Inspector, carried out the visit. The manager was available throughout the inspection and the deputy manager also assisted the commission. The inspection took into account the records held at the home including residents’ files, staff personnel files, training records, medication administration and care records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents and staff. Three comment cards were received from health and social care professionals, relatives and residents. The Annual Quality Assurance Audit (AQAA) had not been completed by the 25th May 2007 as required by the commission and the manager was advised to make sure the completed document was returned to the commission by the 18th June 2007, the AQAA was received on the 15th June 2007. What the service does well: What has improved since the last inspection? The requirements and recommendation made during the inspection of the 24th March 2006 had been met. Risk assessments had been carried out ensuring that the people who use the service could continue to take risks as part of their lifestyle. The home had asked a dietician to assist in making sure that a varied wholesome diet could continue to be provided by the home. The downstairs hall and corridor had been repainted. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 6 The supervision of staff was in hand and documents were available for use to record all supervision sessions. The manager had completed a successful application for registration with the commission as manager of the home. A copy of the local authorities 2005 safeguarding guidelines was now available within the home. 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. Chippings DS0000013601.V342909.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 Chippings DS0000013601.V342909.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): Standards 1 and 2 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some work is needed to make sure that all the information necessary to make a decision about moving into the home is provided. People who wish to use the service can be confident that their needs will be assessed before they move in. EVIDENCE: The people who use the service have a learning disability and used a variety of methods to communicate with others. The methods of communication used included speech, Makaton and other non-verbal means of communication including facial expression. The commission would need a lot of support from members of staff to assist in asking residents their views of the service. The manager said a meeting had been held with the residents and they had completed three (3) surveys with staff support. The surveys were given to the commission during the visit. The commission looked at the Statement of Purpose and Service User Guide and talked about the content with the manager. The Statement of Purpose had been reviewed in June 2007 and the manager’s experience and qualifications had been included as required during the inspection of 24th March 2006. The documents needed further work to make sure all the information needed was available, for example care staff qualifications and Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 9 experience and more information about the accommodation provided. The Service User Guide was in an easy read format using pictures and simple sentences. The Service User Guide included information about what would happen before anyone could move in. A requirement is made to ensure that the Statement of Purpose and Service User Guide have all the information as set out in The National Minimum Standards for Young Adults and The Care Homes Regulations 2001. Feedback from people who use the service said that they had been asked if they wanted to move to the home and that they had received enough information about the home before they moved in. The AQAA received on the 15th June 2007 stated that the home makes sure that they look at providing the right staff to support residents to assist with individual and lifestyle choice. The organisation had a policy for new admissions to the home. The policy said that new residents must have day services available to them before they move in. Please see the Lifestyle section of this report. A number of files about the people who use the service were looked at. No new residents had moved in for almost three years. Information had been recorded in the files that confirmed assessments had been completed before people moved into the home including a copy of a letter to a local authority and minutes of a staff meeting showing that a discussion had taken place about the person wanting to move to the home. Only one file had a copy of the original assessment completed by the home. A recommendation is made that all the files hold a copy of the original assessment completed by the home as this would assist with assessing the changing needs of the people who use the service. Chippings DS0000013601.V342909.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): Standards 6,7 and 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their assessed and changing needs can be met and they are able to make decisions and take risks as part of their lifestyle. EVIDENCE: A number of care plans were sampled. The care plans set out the needs of the people who use the service including their likes and dislikes. Those areas identified as needing care and or support had documented risk assessments for each area of risk. The care plans and risk assessments were dated and also identified when they would next be due for review. On looking at the risk assessments the commission saw that the home also made sure that changing needs had been identified and an additional risk assessment carried out. The requirement made during the inspection of the 24th March 2006 had been met. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 11 The home used a daily log to show what happened each day including those areas of the care plan that had been identified as a goal or target for the resident to meet. The form provided by the home asked the members of staff completing them to state yes or no when filling in that section of the log. A number of entries had been ticked and sometimes not all the goals identified had been ticked. This was discussed with the manager who said that he would discuss this with the staff team to make sure the information asked for was provided and confirm the needs identified had been met. The people who use the service were encouraged, where possible, to make decisions about their lives. Documents and records seen by the commission included the minutes of a one to one meeting with a resident talking about how they wanted their bedroom decorated. The minutes were in easy read format using pictures and simple sentences. The completed AQAA received by the commission said that the home listens to residents and acts on what they say. The commission made observations during the visit that confirmed that members of staff treat the people who use the service with respect and call the residents by their given name. Observations were made where a resident changed their minds about what they wanted. The request was responded to positively and members of staff encouraged the resident to take part in the changed activity. Feedback from three (3) people who use the service said they were treated with respect. In some instances choices were not available as property and personal belongings might be damaged. Please see the Environment section of this report. Chippings DS0000013601.V342909.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): Standards 12,13,15,16 and 17 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service have a range of social, leisure and recreational activities that meet their assessed needs and ensures where possible family contact and friendships. Meals are varied and enjoyable. EVIDENCE: As noted in the Choice of Home part of this report the organisation’s policy said that people moving into the service must have day services provided. In discussion with the manager the commission asked about choice and the right of prospective resident or resident to say no. The manager said that residents do have the right to make choices about not going to an activity and evidence was seen where a resident had made the decision not to go a record had been made. The manager said the home encourage people to have an activity programme that they would enjoy and would seek to change any programme that was no longer wanted by a resident. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 13 A timetable of activities had been set out showing that each resident had a variety of activities provided throughout the week and that these were different for each person. The minutes of a residents meeting were seen that showed that the people who use the service were asked about what they wanted to do including during college breaks. The activities provided included swimming, attending college, working as a volunteer in local shops and attending a dance night. Where families had remained involved records were kept of visits to the family home. The faith of each resident, where identified, was documented, as was whether the person practiced his religion or not. Those records sampled by the commission showed that people had chosen not to practice their faith. Where specific needs had been assessed about a resident’s sexuality risk assessments were in place to ensure that members of staff dealt with these matters sensitively. Feedback from three (3) people who use the service said that they could choose what they wanted to do during the week. Observations made during the visit showed that the home could be very busy with visitors from other services coming and going and residents sharing chosen activities. The AQAA received by the commission said that the home was good at providing independent living, maintaining family links and providing good communication. During the inspection of the 24th March 2006 a requirement was made for the home to talk to a dietician to make sure that the people who use the service have a good varied diet that meets their needs. The manager showed the commission evidence of the visit by the dietician. No specific recommendations were made to change the range of food available and information about healthy eating was given. The daily log completed by members of staff set out what each resident had to eat that day and what activities he had taken part in. Chippings DS0000013601.V342909.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): Standards 18,19 and 20 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical and emotional needs of people who use the service are met in a way they prefer and require and the policy and practice of the home for the giving of medication needs further work to make sure that the training provided supports and protects residents. EVIDENCE: The care plans and risk assessments sampled made clear the assessed needs of the people who use the service including their likes and dislikes. One sampled showed that work to install specific equipment in the home was carried out before the resident moved in. The work was agreed with an Occupational Therapist, a specialist worker who assesses peoples physical needs. The AQAA received by the commission said that the home supports the people who use the service to make choices about their appearance and that the records and documents kept by the home confirm this. Observations made during the visit confirmed that clothing was appropriate to the age of the residents. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 15 Records and documents held in the files of the people who use the service showed that appointments were made with specialist health care providers including the provision of specific mobility items. Other appointments had been made to ensure that residents’ health care needs were met including dentists, opticians, doctors and an annual health check The home had a policy and procedure for the giving of medication. Information had also been provided about side effects of some medicines and about giving painkillers including when to contact the doctor if the member of staff was worried. A new monthly record about giving medication had just been started and the commission did not view the previously filed records. Members of staff had received training to give medication and the manager said that a member of the staff team carried out the training and the pharmacist checked the outcomes. The member of staff doing the training was booked on an advanced course about medication for July 2007. Separate training was given to ensure members of staff were able to give more intimate medication such as suppositories. A requirement was made for the home to make sure that the member of staff has been assessed by an appropriate specialist as competent to carry out the training in giving medication. All the people who use the service needed or would need support to make sure they took the right medication. Chippings DS0000013601.V342909.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): Standards 22 and 23 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives can be confident that their concerns and complaints are listened to and acted upon. Further work is needed to make sure residents are protected from abuse by the policy and practice of the home. EVIDENCE: The home had a complaints policy and procedure in an easy read format that set out how to make a complaint and when a reply could be expected. The manager was aware that the address of the commission needed to be changed following the commission’s move to a new address. The manager said that no complaints had been received by the home. The commission had not received any complaints since the last inspection. Feedback from three (3) people who use the service said they would know who to speak to if they were unhappy and how to make a complaint. The AQAA received by the commission confirmed the information about complaints found during the visit by the commission. No comment had been made about safeguarding matters. The home had a policy and procedure to protect adults (safeguarding). The policy states that all allegations would be investigated by the manager and report sent to the local authority. The policy and procedure had been reviewed in August 2005 and was due for review again in August 2007. Policies and procedures were also in place for whistle blowing, bullying, financial abuse, race and sexual harassment and client-to-client abuse. The Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 17 client-to-client abuse stated that members of staff were to report the matter to the manager, document, monitor, and record and discuss at next staff meeting. A copy of the local authorities guidelines dated February 2005 was held in the office of the home as recommended during the inspection of the 24th March 2006. A Requirement is made to make sure that the safeguarding policy and procedure supports the guidelines provided by the local authority to ensure members of staff know what to do if an allegation is made. A further requirement is made to make sure that a statement is added to all safeguarding policies and procedures setting out what the home will do if an allegation of abuse to a resident is made. The policies and procedures include whistle blowing, financial abuse, bullying, client-to-client abuse and race and sexual harassment and any other safeguarding policies and procedures held by the home. This will ensure that people who use the service are safeguarded from abuse, neglect and self-harm. No safeguarding referrals have been made since the last inspection of the 24th March 2006. Chippings DS0000013601.V342909.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): Standards 24 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a well maintained home that is kept clean. Some work was needed to make sure that the home was kept safe for the residents. EVIDENCE: A tour of the home took place. All of the bedrooms and communal areas including the garden were seen. The requirement made during the last inspection to redecorate the downstairs hallway and corridor had been met. Where possible and taking into account the assessed needs of the people who use the service the bedrooms had been personalised. Some bedrooms had very little furniture provided as was preferred by the residents. In some bedrooms televisions and music systems had been placed in inaccessible cupboards to reduce the risk of destruction or to assist the resident to use reasonably and still get some sleep. The manager was able to inform the commission about each of the residents’ needs and how they affected the furniture and personal items placed in the bedrooms. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 19 Two of the bedrooms were discussed with the manager in more detail. The commission talked about the privacy needs of one resident and asked the manager to give further thought to privacy needs as the evening became dark. The trees outside the home affected the available light in the second bedroom. The manager said he was considering how to address this matter and had made enquiries about how to cut the trees back. The commission also noted that the window had been painted a dark colour and that a lighter colour may also assist in improving the light available. The laundry and shower area on the ground floor contained chemicals for washing clothes, shampoos and sprays for personal use. The manager told the commission that none of the residents would go into those areas and misuse the items. A requirement was made to risk assess the potential hazard of leaving the items accessible in the laundry and shower area to make sure that the residents were safe from self-harm or the possibility of harming others. The risk assessment to take into account the information provided in the care plans for example eating non food stuff and biting objects. One bathroom had a communal towel provided. The manager said that when members of staff were assisting with personal care individual towels were taken to the bathroom. A communal towel was also provided in the staff toilet. A requirement is made to risk assess the possibility of cross infection taking into account residents assessed needs and members of staff dealing with food. A repairs book was kept by the home that identified what repairs or redecoration were needed in the home and a signature when completed. An area was provided to put the date for completion, not all had been filled out. It would benefit the home to make sure that the date of completion was made clear. The AQAA received by the commission confirmed the use of the repairs book and that nine (9) members of staff had received training about infection control. The home was clean and fresh and the garden was well laid out and accessible to the people who use the service throughout the day. Chippings DS0000013601.V342909.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): Standards 32, 34,35 and 36 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Significant improvement is necessary to make sure the recruitment policy and practice within the home supports and protects people who use the service. Some work was needed to make sure that all members of staff received the training they needed to do their job and ensure the assessed needs of the people who use the service were met. EVIDENCE: The home had a total of twelve members of staff. The members of staff reflect both genders, all the residents are male. An equal opportunities policy was in place. The AQAA received by the commission said of the twelve members of staff eight (8) were white British and four (4) were Black African. Two of the most recent members of staff personnel files were looked at. One had started work before a PoVA first check had been completed, the second had been working for some months and a Criminal Records Bureau (CRB) check had not been applied for. This meant that a PoVA first check could not be completed. The PoVA check makes sure that a check is made against a list of people who should not work with vulnerable adults. The manager said that they had been informed by the organisation that it was alright for staff to work Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 21 without a PoVA check as long as they were always supervised by another member of staff and this member of staff was always supervised by another. An immediate requirement was made to make sure that no member of staff started work at the home without an application being made for a satisfactory CRB check and a satisfactory PoVA first check received. The references received were also looked at and one had not used their last employer as a reference and another had a reference from a person that had not been originally nominated in the application form. A requirement is made for the home to review all their staff files to make sure that appropriate references have been received. The review to make clear why the member of staff’s last employer was not used and or why the nominated referee was not used. Where this is not possible that the reason for this is made clear. In addition one person had not signed the rehabilitation of offenders’ part of the application form; the reason for this had not been recorded. A requirement is made to make sure that the home check all application forms to make sure that all the information required is provided including appropriate referees and a full employment history with a reason for any gaps in employment and the form is completed in the way required by the organisation. The AQAA received by the commission on the 15th June 2007 made no comment about the recruitment practice of the home. Each member of staff had a record of training completed held in their personnel file. The training provided included nail cutting, food hygiene, health and safety, protection of adults and epilepsy. The manager said that in- house training was provided about how to record information in reports and documents. As noted earlier in this report the people who use the service have a variety of communication methods. The manager told the commission that the home is looking at using objects of reference for some of the residents to further assist in communication. Four (4) of the residents use Makaton a lot and three (3) of the twelve (12) staff have received training in basic Makaton. The risk assessments viewed said that regular training was provided to members of staff in using Makaton, this was not correct. The AQAA received by the commission stated that none of the people who use the service had specialist communication needs. A requirement has been made to include training in communication. Three (3) of the twelve (12) members of staff including the manager had a qualification; National Vocational (NVQ) training. The deputy manager was expecting to begin his NVQ Level 4 training soon although a start date was not available during this visit. The AQAA received by the commission saw Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 22 qualifying training as an area for improvement by the home. Additional management training was seen by the home as an area for improvement. It would benefit the home to keep a separate record of training showing what training had been provided to whom and when and when refresher training was due. This would help to make sure that members of staff training needs were kept up to date. The commission looked at some of the supervision records that had been completed. The management of the home were aware of the levels of supervision needed each year and said that this was in hand. A document was available showing who had received supervision and when. The management team in the home confirmed with the commission that formal training to provide supervision had not been received. The requirement made during the inspection of the 20th March 2006 had been met. One member of staff spoken with confirmed supervision and appraisal took place and they felt supported by the management of the home. A requirement is made for the home to review the training provided including Makaton, other communication methods as needed, supervision and qualifying training. This will assist in further improving the knowledge, skills and communication in the home. Please also see the Personal and Healthcare section of this report regarding training to give medication. Chippings DS0000013601.V342909.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): Standards 37,39 and 42 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home takes into account the views of residents and their relatives. Improvement is necessary to make sure that the people who use the service can be confident that their safety and welfare are promoted and protected by the policy and practice of the home. EVIDENCE: The manager was clear about their role and the responsibility and accountability of being a registered manager and had completed qualifying training. The manager had completed application for registration as the manager of the home as required during the inspection of the 24th April 2006. The Annual Quality assurance Assessment (AQAA) had not been completed by the 25th May 2007 as required by the commission and the manager said that a number of priorities meant that he had not given priority to completing the Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 24 document. The commission advised the manager that the AQAA must be completed and returned to the commission by the 18th June 2007. The AQAA was received on the 15th June 2007. The information in the AQAA received did not cover all the key standards of The National Minimum Standards for young adults. The commission saw evidence of a quality assurance check carried out by the manager in 2006. As yet a quality assurance audit had not been completed for 2007. Questionnaires had been sent out to relatives and professionals during 2006 and their responses recorded. The document stated that the manager would take action regarding any issues raised by the quality assurance check. The actions taken and the outcomes had not been recorded and the home had not made those outcomes known to the people who took part. A requirement is made to make sure the quality assurance audits completed by the home show the outcomes and actions taken by the home are documented and made known to the people using the service, their relatives and other professionals. The commission sampled a number of safety checks carried out in the home. Legionella checks were carried out on 15th August 2006, Gas checks on 12th January 2007 and fire checks on 2nd May 2007. The fire safety officer last visited the home on 21st March 2007 and Environmental health on 17th November 2004. A policy and procedure for health and safety were in place and were due for review in August 2007. Matters raised in this report, including the late completion of the AQAA, recruitment checks and the safeguarding of adults, do not confirm that the safety of the people who use the service is promoted and protected. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 2 X Chippings DS0000013601.V342909.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. 1. Standard YA1 Regulation 4,5 Schedule 1 Requirement The Statement of Purpose and Service User Guide must be revised and updated to ensure that all the information as set out in The National Minimum Standards for young adults and The Care Homes Regulations is provided. This will make sure that prospective residents have all the information they need to make a decision about moving to the home. The home must confirm with the commission that the person carrying out the staff training for the administration of medication is trained and competent to do so. This will ensure that people who use the service are protected by the medication policy and practice of the home. The policies and procedures related to safeguarding adults, including adult protection, whistle blowing, financial abuse, race and DS0000013601.V342909.R01.S.doc Timescale for action 24/08/07 2. YA20 13(4)(c)(6) 20/07/07 3. YA23 13(6) 24/08/07 Chippings Version 5.2 Page 27 sexual harassment, client to client abuse must be reviewed and revised to make sure the referral process support the local authority multi-agency guidelines for the safeguarding of adults. This will ensure that residents are protected from abuse. 4. YA30 YA42 13(4)(a)(c) A risk assessment must be 13/07/07 carried out on the potential hazard of the storage of chemicals such as those used for laundry washing, shampoo and other chemicals in parts of the home. This will ensure that residents are protected from harm. A risk assessment must be carried out on the potential hazard of cross infection through the use of communal towels in parts of the home. This will ensure that residents and staff are protected from harm including infection. No member of staff can begin work at the home until such times as a Criminal Records Bureau application has been made and a satisfactory PoVA first check has been received and appropriate supervision by another member of staff is in place. This will make sure that residents are protected by the recruitment policy and practice of the home. 13/07/07 5. YA30 YA42 13(4) 6. YA34 19(9)(10)(11) 11/06/07 7. YA34 19(1)(3)(4)(5) The references for each member of staff must be reviewed and where it is not possible to gain a reference from a previous employer the reason must be made clear, DS0000013601.V342909.R01.S.doc 13/07/07 Chippings Version 5.2 Page 28 where the reference is from someone other than he or she nominated by the applicant in their application form, the reason must be made clear. This will make sure that residents are protected by the recruitment policy and practice of the home. 8. YA34 19(1)(a)(b) Schedule 2 The home must make sure that job applicants have completed the application form in full including a full employment history including the reason for any gaps in employment. This will make sure that residents are protected by the recruitment policy and practice of the home. A review of the training provided must be carried out to include Makaton, other communication methods as needed, qualifying training and supervision to ensure the people who use the service have their individual and joint needs met and further improve communication. The actions and outcomes from any quality assurance audits carried out by the home must be made known to the people who use the service, their relatives and other professionals. This will confirm that residents’ views underpin self monitoring, review and development by the home. 13/07/07 9. YA35 18(c) 27/07/07 10. YA39 24 13/07/07 Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 29 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 YA3 Good Practice Recommendations It is recommended that a copy of the original assessment for each resident be kept at the home to assist in identifying changing needs. Chippings DS0000013601.V342909.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate, Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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