Inspection on 18/04/06 for Cottage Farm

This inspection was carried out on 18th April 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cottage Farm 19/12/08

Cottage Farm 20/06/08

Cottage Farm 20/06/07

Cottage Farm 25/11/05

Cottage Farm 04/05/05

Cottage Farm 07/12/04

Cottage Farm 20/07/04

Cottage Farm 07/01/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Cottage Farm Southampton Road Hythe Hampshire SO45 5TA Lead Inspector Patricia Hibberd Unannounced Inspection 18th April 2006 09:00 Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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 Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cottage Farm Address Southampton Road Hythe Hampshire SO45 5TA 023 8084 0661 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) www.macintyrecharity.org MacIntyre Care Bridget Prescott Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 named service users may be accommodated in the LD (E) category Date of last inspection 2nd March 2006 Brief Description of the Service: Cottage Farm is registered to provide accommodation to five younger adults with a learning disability, physical disability or sensory impairment, although the home currently accommodates three residents over the age of 65. The home is a large spacious bungalow in a semi-rural setting, on the outskirts of Hythe town centre and the New Forest. Accommodation is provided within individual rooms, with communal facilities including a large, comfortable sitting room, spacious kitchen / dining room, one assisted bathroom, walk in shower room, separate WC and utility room. At the front of the property is a large parking area, with the garden area at the rear mainly laid to lawn, with small shrubs, a patio area and an adjacent fruit orchard. MacIntyre Care provides a Day Support Service to service users living in the home, enabling 1:1 support to access community facilities, and individual activities. The Home has a copy of the statement of purpose and recent inspection report Home to inform prospective service users. As of 18/04/2006 weekly fees are £967.60. There are additional charges for hairdressing/chiropody/toiletries/holidays/activities and magazines. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the 2006/2007-inspection programme and took place over four hours. All of the core standards were inspected during this visit. Since the last inspection in November 2005 the manager Bridget Prescott has successfully completed her registration with the commission. A visit was also made to the service in March 2006 in relation to a statutory notice issued on the 28th December 2005 following two outstanding requirements from previous inspections dating back to 2003. The visit concluded that the requirements were being addressed. During this inspection a tour of the premises took place and care and other records were inspected. The inspector met and had some discussion with all of the service users, and observed their interaction with staff. A pre inspection questionnaire completed by the manager was given to the inspector during the visit of which information provided contributed to this report. Discussions were held with four staff and two visiting community nurses. A letter from a relative expressing their views as to the service provided was given to the inspector and will also contribute to the findings of the inspection. What the service does well: The home provides service users with a comfortable, homely environment. The home has a core staff team, many of whom have worked with the service users for a number of years, and have built up positive relationships. All five of the service users appeared relaxed and settled in their home. The manager is providing clear direction and leadership and endeavouring to ensure the service users diversity of needs are being addressed of which further details can be found in the body of the report. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Staff recruitment files must contain details of checks undertaken prior to employment, to ensure the safety of service users. This requirement is outstanding from the last inspection in November 2005 with a time scale for completion of 31/1/2006. A system needs to be put in place to ensure food temperature records are being completed on a consistent basis, opened food is labelled in the fridge and, some areas of the kitchen are cleaned as required. A reassessment of one-service users’ needs must take place in conjunction with relevant professionals to ensure their specific needs are met. Any training Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 7 needs/environmental changes identified as a consequence must be undertaken. Risk assessments of individual needs in the event of a fire evacuation must be undertaken and kept under review. Menus must be devised in a format appropriate to all service users’ accommodated. 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. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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 Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The pre admission assessment process is undertaken by people competent to do so ensuring prospective service users needs can be met in the home. EVIDENCE: The home has not admitted any new service users for some time with the five individuals having lived in the home together for a number of years. However, the manager indicated that there is a pre admission process that she would undertake with a prospective service user. Relatives/representatives/advocate and relevant professionals would also be involved as appropriate prior to admission to ensure the home could meet the individuals’ needs. Service users currently accommodated would be fully involved in the process. A care management assessment would be obtained if the individual were referred through Social Services. In the event of a self-funding arrangement the process of assessment in conjunction with all relevant parties would take place. Due to the diversity of needs of service users – one of whom has a visual impairment DVD’s in a sound/visual format have been produced for each individual to inform them of their home. This work has been undertaken by a member of staff and is an innovative piece of work and an area of good practice. The inspector viewed one of the DVD’s and sat with the service user Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 10 who demonstrated an understanding of the content of the DVD that was also backed by their favourite music. From observations of service users during the inspection it was evident that information collated on the DVD’s was compatible to their current lifestyles. The manager explained that the DVD’s would be shown to new staff as a part of their induction to the home and to gain an understanding of the individual service users needs and, life at Cottage Farm .One new staff member was able to confirm how useful the DVD’s had been as a visual and informative example of service users’ lives in the home. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” With the exception of one service user individuals’ needs are generally being met with choices being offered within a risk management framework. EVIDENCE: Two service users’ files were viewed which contained a range of information relevant to the individuals. The files are now indexed and organised to ensure they remain current.Care management reviews were held in both files. Where able service users have been involved in their care plans although due to individual and diverse needs including one having a visual impairment some areas of the care plans would need to be determined with appropriate professionals. The manager further advised that there is now an independent advocate visiting the home monthly who is building relationships with service users and staff. This was seen as an area of good practice. Person centred plans (PCP’S)are being developed, and some good work has been undertaken; with service users at the centre of these plans. One staff member explained how the recent PCP training had enabled her to consider each service user as an individual with individual needs. They further Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 12 considered the relevance of an individual’s history and impact on their current lifestyle. The manager informed the inspector that some of the service users have lived in long stay hospitals prior to moving into the home and, as a consequence collating information regarding their past including any friends or relatives they may have is acknowledged to be a huge piece of work However, during the inspection a community nurse had researched one service users history and had found a range of information relating to the individual that the manager indicated would contribute to their PCP. Action plans have been developed for each file, to ensure that progress continues, and specialist assessment outcomes are now being integrated into care plans. Guidance has been put in place to identify to staff the support each service user requires from the time they get up to retiring at night. These are regularly reviewed. Evidence seen during the inspection confirms that staff have a good understanding of peoples needs with staff indicating that the recent training which includes communication, epilepsy awareness, continence, mental health and a positive approach to “challenging behaviour” having been of much support to their daily practice. Support staff were observed offering service users choices and enabling them to make decisions about their daily life. Risk assessments are now being undertaken or completed with the manager indicating that they are being kept under review. However, two requirements were identified in relation to fire risk assessments being undertaken of all service users’ needs in the event of a fire evacuation and a review of one service user’s needs in relation to his visual impairment. These must be shared with staff and kept under review. A visiting community nurse confirmed that she will be commencing a reassessment of the service users needs with relevant professionals being consulted as to the environmental changes needed in the home and staff training. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The rights and diverse needs of service users are generally being met with their aspirations to live ordinary and meaningful lives being recognised and supported by staff trained to do so. Friends and famililes are encouraged to visit the home. A healthy diet is provided although menus are not in an appropriate format for all individuals accommodated. EVIDENCE: Additional one to one day services support is provided for each service user to facilitate a wide range of activities, and up to date information is displayed on the notice board, to advise of community events and activities. Further in house activities are available. One service user was able to indicate their enjoyment of looking at books whilst another was observed relaxing and listening to music. The PCP’s being developed are further informing the home as to individuals aspirations and interests. An example being of one service user who used to attend church on a regular basis but has not attended for a number of years. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 14 The church he used to attend has now been identified and, the manager indicated that plans would be put into place for the individual to visit the church and be supported to attend a service if they chose to do so. Families and friends are welcome to the home with the individuals consent. Staff indicated that they would be aware if a service user was unhappy with a visitor through their behaviour.An independent advocate as previously stated visits the home monthly. One service user indicated that they receive regular visits from a relative. The PCP has identified that they would like to contact other relatives and this is being explored. Family contact for other service users is being incorporated into PCP’s circles of support. The manager was able to explain how routines within the home are changing, to reflect each individual’s rights and responsibilities, and to promote independence. An example being of times service users get up in the morning and go to bed, when they choose to eat their meals and, having unrestricted access to the home and garden with support as needed.Routines observed around the home and discussions held with service users and staff further supported this practice. One service user was being supported by a community support worker to go out into the community and by their facial expression and gestures appeared to be looking forward to the outing. The community support worker spoken to appeared to have a good understanding of the individuals needs. As detailed in the previous section however, the needs of one individual with a visual impairment need to be ascertained to ensure they are leading a fulfilling and meaningful life. Menus were viewed which were displayed in a written format on the wall in the kitchen. The menus are compiled on a Sunday with service users. Whilst they appeared to offer a varied and healthy diet it was evident from discussions held with three service users that they had no understanding of what they were to have for their lunch on the day of the inspection. When asked how the service user with a visual impairment would be informed as to what they were having for lunch a staff member explained that they would prepare the meal and place it in front of them and explain what was on their plate. Should they not wish to eat the meal an alternative would be offered. However, the manager showed the inspector the work that was commencing in devising a menu in a pictorial format that will be followed up at the next inspection. A separate piece of work will need to be undertaken for the individual with a visual impairment to ensure they can be informed as to what is available One service user has a soft diet that is detailed in their care plan. Staff spoken to were aware of the need for the individual to avoid toast and bread to prevent them choking. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has systems in place which ensure that the service users’ personal and healthcare support and medication needs are met. EVIDENCE: From two files viewed, discussions held with service users and observations of staff support it was evident that staff were providing sensitive and flexible support maximising privacy, dignity and independence for individuals. For example files provided detailed guidance to staff concerning service users’ morning and evening routines, preferences, likes and dislikes and health care visits of which staff spoken to were able to describe and have a full awareness and, as how to transfer into their practice. Another example related to the DVD’s produced for individuals of which one service user was able to demonstrate they enjoyed their bath that they found relaxing. The key worker system in the home appears to be working positively; with staff meetings held on a monthly basis (in addition to daily communication) endeavouring to ensure needs of individuals are known by all of the staff team. The home is supported by the local learning Disability Health Team. During the inspection a discussion was held with two nurses who had much praise for the Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 16 support staff give to meet the diverse needs of service users accommodated. Particular reference was made to one service user who has mental health needs. The nurse advised that the staff had undertaken a complex piece of work with the individual monitoring their daily mental health that had subsequently informed the Consultant Psychiatrist and Community team as to specific needs/medication requirements. All staff (with the exception of a newly appointed staff member and one who has recently returned from long term sick leave) has now received training in the safe administration of medication. This meets the requirement of previous inspections with the manager confirming that the two staff that had not received the training would do so shortly. This will be followed up at the next inspection. The practice of an un prescribed laxative chocolate being given to one service user on alternative days is no longer taking place. The manager further indicated that only medication prescribed by a GP is administered to service users. Medication records were seen to be up to date and signed for. Medication was securely locked in a cupboard in the office. Support staff were observed offering appropriate, caring support as required by individuals accommodated. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are safe from abuse and neglect. The complaints procedure is in a format that is appropriate to most of the service user’s accommodated. EVIDENCE: There is a complaints procedure, and a pictorial version has been developed, which is displayed in the kitchen/diner. However, there needs to be further work undertaken with the individual with a visual impairment to ensure the complaints procedure is in a format which enables them to express their views/concerns.. The manager indicated that she has ensured that the procedure is available to relatives, and that people feel able to use it. Two complaints were recorded as being received from service users and had been appropriately dealt with by the manager. This was a positive indication that service users felt able and were being supported to express any issues with services provided. Service users meetings held weekly are also a forum whereby views can be aired and discussed. Discussion with staff and management confirmed an awareness of issues of abuse, and the reporting procedures within the home. All staff with the exception of two have attended formal training in the protection of vulnerable adults. One complaint was received by the commission in December 2005. This was investigated by the Home and was concluded as being not upheld. An independent advocate is now working with service users as previously mentioned. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 18 Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in maintenance has provided a comfortable and homely environment for service users although further improvement may be necessary to meet the specific needs of one service user. The Home was clean although a system needs to be in place to ensure the cleanliness of parts of the kitchen are maintained and food is appropriately stored. EVIDENCE: Since the last inspection a number of issues have been addressed including carpets being regularly cleaned, the lock on the lounge door to the patio being fully operational, nail holes in walls being appropriately filled in corridor areas, and the bathroom decorated. Decorating and garden equipment was securely stored away and a recent visit by environmental health identified no issues. The home was free of odours, was bright and airy with ample washing facilities available. Paper towel dispensers were waiting to be installed in bathrooms of which the manager confirmed would be undertaken shortly. The laundry area was clean with service users laundry separately washed. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 20 Bedrooms viewed had all been personalised to suit the service user. New items have been purchased replacing broken and worn furniture found at the last inspection. Two service users showed the inspector their bedrooms indicating they were happy with the facilities provided. There is a planned maintenance programme in place that is monitored by the manager. One service user with mobility difficulties indicated that they could access the garden via ramps from both their bedroom, the lounge and front door. A requirement made at previous inspections requested the provision of a call alarm system, to allow staff to summon help in an emergency. This was once again discussed with the manager, who advised that risk assessments had further supported there being no requirement for the system to be reinstated. Policies and procedures are in place for the control of infection. Clinical waste is collected on a weekly basis. A new member of staff confirmed that they had been given the policies and procedures to read and would be discussing further with the manager as part of her induction. Following the reassessment of a service user who has a visual impairment the manager indicated that any environmental changes identified would be carried out. Discussions were held with the manager relating to a need for a system to be put in place to monitor cleaning programmes and to ensure food is appropriately stored and food temperature recording is consistent. The kettle was seen to be dirty and a probe used to test the temperature of hot food was also dirty. Food opened in the fridge had not been labelled and temperatures of hot food not consistently recorded. This will be followed up at the next inspection. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by an effective,sufficient, competent and trained staff team ensuring their needs are met. Information in staff files held in the Home do not ensure the protection of service users. Staff training is generally appropriate to the diverse needs of service users. EVIDENCE: A statutory notice was sent to the Organisation in December 2005 in relation to staff training that had been required at previous inspections over a period of two years. A follow up visit in March 2006 confirmed that a comprehensive training plan was in place with staff having attended the following training: food hygiene,/moving and handling,/Control Of Substances Hazardous Health,/health and safety,/First aid,/medication,/ communication,/Person Centred Planning,/Fire,/value base,/continence,/behaviour management,/epilepsy awareness,/ administration of rectal diazepam and mental health awareness. Three of the ten members of the Homes staff team have achieved National Vocational Qualifications (NVQ) and three are working towards the award. Discussions with one staff member confirmed that they had found the training beneficial and, that it had enabled them to transfer new skills to their practice. There was also a new member of staff undertaking their induction. They confirmed that they were receiving the support they needed to gain knowledge Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 22 and information of the service users needs and were reading the health and safety policies and procedures for the home. The home has a core staff team, which has worked with the service users for a number of years, and have built up good relationships. Interaction observed between staff and service users was appropriate, and demonstrated positive relationships built. The staff rota sampled identified that two or three members of staff are on morning shift, two on afternoon shift with two overnight. From observation during the day, staffing was at an adequate level to meet service users’ needs, particularly in view of the additional day services support. The existing staff team covers relief hours. However, the manager indicated that the practice of some staff working fourteen-hour shifts and upwards of fifty hours per week on a regular basis has now ceased. This was evident from rotas viewed. At the last inspection in December 2005 staff files sampled were incomplete, and did not demonstrate that appropriate checks had been undertaken prior to employment. For example one file contained only an application form, all had proof of identity but no references or photographs were available nor was there confirmation of criminal records bureau checks having been undertaken. A requirement was made to ensure that the required documentation is in place to demonstrate that all appropriate checks are undertaken prior to employment. All information was held at the head office of the organisation. During this inspection the manager informed the inspector that they remained incomplete. The requirement is therefore brought forward in that the required documentation must be in place to demonstrate that all appropriate checks are undertaken prior to employment and safe guarding service users. Discussions with a recently appointed member of staff indicated that they had undertaken a thorough recruitment process prior to being employed in the home. Their paper work held in the Home was also incomplete. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is giving clear leadership, direction and ensuring the quality of the service is monitored for the benefit of service users. Procedures in place are ensuring the health, safety and welfare of service users. EVIDENCE: Staff spoken with said that the home is benefiting from the leadership and direction of the manager, and practices within the home are continuing to change to ensure the service is run for the benefit of service users. Service users were seen to respond positively to the manager who demonstrated a good knowledge of individual needs. The manager indicated that she receives regular supervision and has a job description and contract of employment. A statutory notice was issued following the last inspection in December 2005 in relation for a consistent failure to have a quality assurance system. A follow up visit in March 2006 indicated that link worker and resident meetings are being Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 24 held on a regular basis, and arrangements had been made for an advocate to visit the home on a monthly basis to ensure the residents have every opportunity to contribute to the running of the service. During this inspection a newsletter was viewed of which contributions had been made by service users and staff. This had been distributed to relatives and other interested parties. A letter received from a relative had much praise for the newsletter considering it to be informative and “ an excellent idea”. Questionnaires have also been sent to relatives and service users’ representatives. The manager continues to develop a service plan and indicated that systems and practices in the home are ensuring the health and safety of service users and staff. A pre inspection questionnaire received during the inspection indicated that regular checks are being undertaken of appliances and fire checks are being carried out weekly. One staff member was able to explain the fire evacuation procedures for the home and, what action she would take to ensure the safety of service users in the event of a fire. However, she was not aware of individual risk assessments having been completed for service users. The certificate of employer’s liability, displayed in the reception area, was up to date. Details of training undertaken and relevant to safe practices can be found in the staffing section of this report. Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 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 X 2 3 3 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement A reassessment of one-service users’ needs must take place in conjunction with relevant professionals to ensure their specific needs are met. Any training needs/environmental changes identified must be undertaken. Risk assessments of individual needs in the event of a fire evacuation must be undertaken and kept under review. All staff files must contain the required documentation listed in Schedule 2 of The Care Homes Regulations 2001. This requirement is outstanding from the last inspection in November 2005 when a timescale for action was 31/01/2006. Timescale for action 18/05/06 2. YA9 12 18/04/06 3. YA34 19 02/05/06 Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cottage Farm DS0000012379.V288914.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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