Inspection on 22/07/08 for Court View

This inspection was carried out on 22nd July 2008.

CSCI found this care home to be providing an Adequate service.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Court View 18/09/07

Court View 28/12/06

Court View 28/02/06

Court View 30/09/05

Court View 17/03/05

Court View 05/10/04

Court View 12/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Court View 23 Parkfield Road Pucklechurch South Glos BS16 9PN Lead Inspector Odette Coveney Unannounced Inspection 22nd July 2008 09:30 Court View DS0000003382.V365020.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 Court View DS0000003382.V365020.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. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Court View Address 23 Parkfield Road Pucklechurch South Glos BS16 9PN 0117 937 4021 0117 9709301 debb@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 18 - 64 years of age Date of last inspection 18th September 2007 Brief Description of the Service: 23 Parkfield Road, Pucklechurch, known as Court View provides accommodation for five service users with learning disabilities aged between 19 and 64 years. It is one of the homes operated by the Aspects & Milestones Trust formally known as Frenchay and Southmead Care Trust. The house is a detached dormer bungalow with a large rear garden. The ample front garden is also used as parking space; there is a large, well-established garden to the rear. The accommodation consists of 5 single bedrooms, 2 bathrooms, dining room, kitchen, and lounge. The house is within walking distance of a public house and local shops. There is a bus service to the centre of Bristol and the house is within easy access of the motorway system. The mission statement of the organisation is: To enable people with learning difficulties, mental health needs and physical disabilities to develop a fulfilling life in the community and to continually seek to improve and be responsive to the changing needs and wishes of the people we support. Fees range from £1,027 - £1,174 per week and are based on individuals assessed needs. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key standard site visit, it was carried out in one day over a 7 -hour period by one inspector for the Commission. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to visit an Annual Quality Assurance Assessment had been completed which allows the service to describe what the home does well, what has improved over the past 12 months and the areas for improvement that have been identified. This assessment was comprehensively completed and provided clear information about the home and the future development plans and areas raised within this document were verified during the visit. A number of comment cards were received prior to the site visit, one was received from a relative of someone living at the home, and four had been completed by the people who live at the home. Comments within these were reviewed during the site visit and were shared with the assistant team leader, maintaining confidentiality. Some of the comments raised are included within the main body of this report. It was evident that there had been efforts made to address some of the outstanding areas identified at previous inspection visits, however there are issues which remain outstanding in respect of the management of the service and also the unkempt front garden, further information can be found within the main body of this report. What the service does well: There has been a consistent staff team at Courtview, these staff members know the people who live at the home well and have a sound understanding of their needs and wishes. Staff have developed effective methods of communication and ensure that individuals are consulted with choices and decisions about their life. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Court View DS0000003382.V365020.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 Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to use the service and their families are given good information in written and verbal form about the home. Licence Agreements/Terms and Conditions of the service contain all of the required information. EVIDENCE: Courtview is a care home registered with the Commission for Social Care Inspection to provide personal care and accommodation for up to five persons aged 19 years and over. Courtview is owned and operated by the Aspects and Milestones Trust. The home is one of a variety of care services operated by the Trust focussing on services for adults who require support to live in the community. There are currently four individuals living at the home with no imminent plans to fill the vacancy. As there have been no new admissions to the home for a number of years and the current group of people living at the home is settled. The admissions processes for the home were not reviewed during this site visit. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 9 At our previous visit to the service in September 2007 we reviewed the statement of purpose for Courtview and recorded that this document provided information about who could be supported at the home, the accommodation, the process for admission into the home and how individuals would be supported to make a complaint. At this visit we saw that home had reviewed and updated this document in February 2008 and now included staff shift patterns and had been written in a more person centred way, however, we did note that no mention was made of the homes admission procedure and this information seemed to have been omitted. Following our visit we spoke with the area manager for the service Deb Stevenson and she arranged for the relevant document to be forwarded to us, this met the required standards and regulations and contained full detailed information. All the people living at the home have standard Trust terms and conditions and licence agreements. The contracts reviewed as part of our review and monitoring exercise were signed and contained information about fees and the obligations of the provider and person who lives at the home. The contract terms and conditions were clear and understandable. There was evidence to show that the home had discussed these contracts with individuals and they had signed their contract, as had the staff at the home. Court View DS0000003382.V365020.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): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning documentation at the home contains clear detailed information to enable those who live at the home to have their personal, emotional and health needs well met, with individuals being supported and encouraged to make decisions that affect their life. EVIDENCE: At this visit we looked in detail at the care and all associated records for all four of the people who live at Courtview. We saw that the care documentation written about those who live at Courtview is well written. It is clearly evident that care plans have been developed with, and owned by, the individual, based on a full and up to date holistic assessment. The care plans seen are person centred and focus on the individual’s strengths and personal preferences. The care plans seen record individual’s life experiences and set out in detail how all their current requirements and aspirations are met through positive individualised support. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 11 Through review of care documents it was clear that staff have a good understanding of the needs of those who live at Courtview and had recorded how individuals should be supported in areas such as personal, physical, emotional and healthcare support. Information seen recorded specific details of individual’s likes, dislikes, allergies and healthcare support and provided guidance for staff in order that they support those who live at Courtview in a way they prefer. The attitude and approach of the staff team promoted independence and supported people, where able, to make decisions about lifestyles and daily routines. Each person was offered the support of a named key worker; this is a member of the staff team with specific responsibilities towards supporting them. Monthly meetings are held on a one to one basis with individuals in order that their views can be obtained and action plans developed. Four comment cards were received; prior to our visit from people who live at the home. All were supported, due to their communication needs, with the completion of this form by care staff that are employed at the home. All responded that generally they can do what they want during the day, evening and weekends. All knew who to speak with if they were unhappy. All responded that staff always treat them well and that staff listen and act upon what they said. No concerns or issues were raised in any of these questionnaires or during the visit. We met two of the people living at Courtview on the day of our visit and no concerns were raised to us by them, they indicated that they were happy and well cared for when we asked them. Written feedback we obtained prior to our visit to the home from a relative of a person who lives at Courtview was “I am very happy with the service provided for my relative at Courtview”. We saw that the home had completed risk assessments for activities in which individuals were involved with and these covered areas such as being supported to maintain independence in areas such as cooking and making hot drinks, all risk assessments seen were well written, detailed and kept under review and ammended should individuals needs change. Care and associated documentation showed that all people are treated as individuals with differing wishes and choices, individuals cultural diversity is also well respected and supported. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given opportunities to take part in appropriate activities, individuals are supported to maintain relationships with others with their rights and responsibilities recognised as part of daily life. EVIDENCE: Upon arrival at the home two people were already out for the day participating in day care activities and during our visit a third person went out for a meal, the fourth person was supported at the home and they appeared to be relaxed and at ease, they we seen in the lounge, dining room and in their room. We spoke with the assistant team leader and staff on duty about the activities that people are involved with and were told that each person is consulted activities they participate in are of their choosing. We saw in support files and daily diaries that individuals regularly attend church; attend collage, clubs, bingo, and hydrotherapy, visit places of interest and meals out. Individuals Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 13 socialise with relatives and friends and go shopping. One of the people who live at Courtview are very interested in drama and recently took part in a ‘pod cast’ where they were interviewed and broadcast on the radio, this is an area this person enjoys very much and they are supported and encouraged with this. Two people at the home are supported to maintain a job for which they are paid, both individuals appear to enjoy their work and are asked regularly if this is the case. We also saw that holidays have been planed with individuals based on their likes and choice, these will be happening later in the summer. One person has already been away to Puerto Rico earlier this year. There is an activities board on display in the entrance area to the home, this is completed on a daily basis and individuals can make choices through the pictures and symbols available, staff told us that this board was successful and individuals had approach staff and shown them what they wanted to do. We saw in monthly key worker support meetings that those living at the home had discussed their forthcoming plans for their holiday and had also sighed these, as had the staff member involved. A survey we received prior to our visit from a relative of someone who lives at the home they had written, “My relative receives a good quality of live at Courtview” and had also said “The staff are always helpful and friendly, a weight has been lifted from me knowing that my relative is at Courtview, I cannot praise the staff who work there highly enough”. We saw that individuals are offered a varied and interesting diet with their likes and dislikes forming the basis for menu planning at the home, individuals go shopping with staff and prepare themselves drinks and snacks when wanted. It is further noted that the home obtained a ‘five star’ food hygiene award issued by South Gloucestershire Environmental Health Officers who undertook an inspection at the home earlier this year. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported with their personal care in the way they prefer. Individual’s physical and emotional needs are well met and individuals are supported with their medication, however improvements are needed with the recording of medication taken from stock and medication given ‘as and when required’. EVIDENCE: Thorough examination of care documentation evidenced that individuals are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. Records showed that where there had been concerns about individual’s health the home had made prompt contact with the GP or other services that have been needed, such as blood monitoring by the district nursing service, hospital appointments and specialist services like the dietician for individual dietary advice. We saw that all individuals are seen by a clinical psychologist on an annual basis that the medication and the wellbeing of the individual are reviewed, other professionals are consulted and Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 15 an action plan is set for the continuing support of the person, this support plan is tailored to the needs of the individual and changes are prompt if needed to ensure peoples emotional needs are met. We saw within care records that each person had recorded information about what was important and essential to them, information was clear about how individuals were to be supported with their personal care and what areas they were able to retain a level of independence with. Daily records and review of these care plans showed that staff had listened and respected people’s wishes and that these are monitored and reviewed on a regular basis. Procedures for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monitored dosage system. A check of the medication packs, plus discussion with a member of staff, indicated that medication had been administered as recorded, however, it was found that medication had been given yet staff had not signed to confirm this on records, also in order that all medication can be audited it is required that stock held medication must be better recorded. We also saw that some individuals had medication to be given ‘when required’ and some discussion took place with staff about what this means and also how individuals ‘anxiety’ be interpreted differently for different people. In order for clarity and continuity for individuals it is recommended that clear protocols should be in place in respect of medication that is given ‘as and when required’. All medication seen was stored securely. Waste medication is recorded and disposed of via the supplying pharmacy. During the visit we observed the staff talking and assisting individuals. This was always done in a sensitive, caring and respectful manner. The atmosphere in the home on the day of the visit was relaxed. Staff, the assistant team leader and those living at the home were observed to have good relationships. Staff responded to the needs of people in a polite and professional manner. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has procedures in place enabling individuals to make a complaint and voice their views about the service they receive and know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible those living at the home are protected from harm by having policies and procedures, however, training must be provided for staff about the Protection of Vulnerable Adults. EVIDENCE: Aspects and Milestones Trust continue to have an established complaints procedure that details actions taken if concerns are raised, within set down realistic timescales. All the people living at the home have access to a copy of the organisation’s complaints procedures, which include the contact details of the Commission and of the Trust officers. It was noted that care plans files contained a copy of the proceedure for making a complaint with evidence to show that this had been discussed with individuals. Comment cards received from those who live at the home recorded that individuals knew who to speak with if they had any concerns. There is a pictorial version of the complaint procedure. It is unlikely that individuals could or would make use of formal procedures and in general would Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 17 rely upon staff or other significant people advocating on their behalf. We were told by the assistant team leader, and staff that they had recently undergone training about the Mental Capacity Act in order to gain a better understanding of the legal responsibilities on this area. There is a policy titled “Doing the right thing” which encourages staff to report bad practice without fear of being discriminated against. There are staff working at the home that have either achieved or are undertaking a National Vocational Qualification in Care, (Health and Social Care, Level 3) and this has a core unit that incorporates adult protection and staff responsibility should they have any suspicions or concerns. It was noted when reviewing staff training files that there are staff who have not completed training in the protection of vulnerable adults, furthermore some staff had undertook training in this area a number of years ago, this training is essential, see staffing section of this report for our view on this. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30. The quality outcome area is adequate This judgement has been made using available evidence including a visit to this service. Those who live at Courtview live in a home that is homely and comfortable with the internal of the home being well maintained, however improvements are needed to the front garden to ensure it is accessible and safe for all. EVIDENCE: During our visit to Courtview individuals were observed sitting in the lounge, the dining room and going into their rooms, looking very relaxed and comfortable in their environment. The home is ‘homely’ with soft furnishings such as plants, ornaments and pictures and photographs, all enhancing the areas within the home. Downstairs there is a small ‘domestic’ type kitchen, this was found to be clean and tidy and well maintained. Since our last visit to the service a storage area upstairs has been converted into a small kitchenette area for those living at the home to use, a velux window has been fitted and there are facilities for Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 19 washing up and making snacks. Staff told us that two individuals are supported to maintain their independence and that this area is used by the individuals on a daily basis. This is a good facility, which enables people to maintain independence skill and make choices about when and what to eat. Also since our last visit we saw that the lounge had been redecorated and had benefited from new furniture, new patio doors had been fitted, the bathroom on the ground floor and three bedrooms had been redecorated and new flooring had been fitted in the hallway, lounge, stairs and the kitchenette area. At the time of our visit we saw that decoration was taking place of the hall, stairs and landing area and we look forward to seeing this completed at our next visit. The home has sufficient bathroom areas for individuals with both shower and bathing facilities in place; these are close to individual’s private rooms. During our last visit to the home in September 2007 an environmental health officer who agreed with us that attention to be given to the front garden accompanied us. We reported during our last visit due to rubbish and overgrown area to the front of the home a requirement was made at our site visit to the home in October 2006 that attention to be given to the front garden. Although it is acknowledged that staff and a group of students have cleared some of the area further work is needed to make this a safe and accessible area for people who live at the home. At this visit we were again told that staff, and students had cleared the front garden of overgrown bushes and shrubs however little evidence was in place of this as the area had again overgrown. During this visit we saw quotes given by contractors to clear and make good and safe this area. The day after our visit we received a call from the area manager for the service who confirmed to us that the quotes had been reviewed and a date has been set for the work to be completed. We will review this within the agreed timescales. The home was found to be clean, tidy and odour free. Court View DS0000003382.V365020.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): 32, 34, 35. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Those living at Courtview benefit from sufficient numbers and skill mix of competent staff to meet their needs. Training is provided in a variety of topics to ensure knowledgeable and competent staff for the safety and benefit of those living at the home, however protection of vulnerable adults and dementia awareness training is needed. EVIDENCE: There is a well-established staff team at the home. At the time of the visit there were sufficient numbers of staff on duty to meet the needs of those living at the home. The small staff team have developed good relationships with those who live at Courtview and have a sound understanding of their needs, wishes and aspirations to enable them to live a fulfilling life A sample of staff training files were examined, information seen showed that staff have undertaken core skills training such as fire safety, manual handling, first aid as well as National Vocational Qualification in care practice at levels 2 Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 21 & 3. We did note that there was a number of staff that have not completed abuse training and also noted that only one staff member has completed training about dementia. Training in dementia understanding is important as the home is supporting someone with this illness. It is required that specialist training in dementia awareness must be provided in order that staff have the knowledge, skills and understanding in order to support this person fully. Furthermore in order that staff aware fully aware of their role and responsibility in respect of adult protection it is also required that training in the protection of vulnerable adults is provided for all staff, including refresher training for those staff members who completed training in this area many years ago. Due to the manager not being on site and him being the only person with access to locked cabinets we were unable to review the recruitment and selection documents for staff. There has been no new staff employed at the home since our last visit and agency staff are not used at this home. We have had no concerns in the past and have previously found that the Trust undertake rigorous checks in respect of criminal records, obtaining references and full identification checks in order to protect the people living at the home, this are will be fully reviewed at our next visit to Courtview. During our visit we spoke individually to staff members on duty who said they are very happy within their role at the home and said that they felt well supported both by the management and the organisation, staff knew who to speak with if they were unhappy. Staff we spoke with were fully conversant with the in depth and complex nature of the support that individuals require at the home and gave sound examples of how individuals are given choices and how their rights are promoted and how individuals are treated as adults, such as key working and day care review meetings, daily consultation and recording individuals wishes and also the monitoring and recording how these are met by the home and other services. There were two staff members on duty when we arrived at the home with a third staff member who came on duty for the afternoon shift. It is noted that there is one staff member who sleeps on the premises at night, with another staff member being on call if needed. We discussed with staff the importance of monitoring the situation and should individuals support needs change this should be reviewed and staffing levels ammended accordingly. Staff were observed throughout our visit interacting with the people living in the home and each other in an informal, friendly and respectful manner. A relative had written in their survey form sent to us prior to our visit that, “The staff do an excellent job”. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. There are formal quality monitoring systems in place in order to measure the aims and objectives of the home. There are procedures and protocols in place in order to ensure the health, safety and welfare of those who live and work at the home. EVIDENCE: At our last visit to the service we reported that Ian Knowles was the temporary manager at the home; he works at the home part time and also at another home within the Trust. Staff told us that he is available and is supportive. In order for continuity and further development of the service it was required that long term permanent arrangements are made for the management of the home. Prior to our visit to Courtview we had spoke with the area manager for Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 23 the service who had kept us updated on the management situation at the home. A manager had been appointed by the Trust, however this person has since moved to another service. Following our visit the area manager confirmed that the post had been advertised externally in the hope of attracting a wider range of candidate and told us that a date had been set for interviews. Whilst the quality of care to those living at the service is good the service are reminded that they are in breach of the Care Standards Act by not having a permanent manager in post. We will review this outstanding requirement within the agreed timescale for action to be taken by the service. It should be noted that the assistant team leader assisted us at this visit. The assistant team leader has been employed by the Trust for many years and has worked at Courtview for over 6 years, this person has an NVQ at levels 2 and 3 and has also completed a chartered management institute course at level 2 aimed for team leaders. At all times the assistant team leader cooperated with our visit, was motivated and appeared to enjoy her role supporting those who live and work at the home. There was evidence that the home ensures, so far as is reasonably practicable, the health and safety of those who live and work at the home. There are procedures and protocols in place in order to ensure the health, safety and welfare of those who live and work at the home. These include staff training, fire and equipment checks, regular maintenance of equipment and health and safety audits, completed by both staff at the home and by visiting external auditors. We read the report of the last visit and saw that there were no issues/concerns recorded in this area. There are formal quality monitoring systems in place in order to measure the aims and objectives of the home. A representative of the Registered Provider for the Organisation had visited the home each month. These visits are used to ensure the home is being managed within the Organisation’s policies and procedures and included reviewing areas such as health and safety, the support, health and welfare of those who live at the home and monitoring of staff role and responsibility and the environment, these visit are recorded. Prior to the site visit the Commission received from the assistant team leader a completed annual quality assurance assessment. The annual quality assurance assessment (AQAA) is a new process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the assistant team leader was fully completed and detailed. Within the summary of what the service does well the AQAA had recorded “ service users choices, desires, wishes, respect and dignity are listened to and met, the home provides a homely comfortable environment and individuals are supported by well motivated staff”. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 24 During our last visit to Courtview we noted that the cupboard, which held individuals money for safekeeping had the keys in the lock for the whole of the time, we were there and this was left unattended. A requirement was made that monies held by the home for safekeeping be held securely. At this visit we checked some peoples money and we found clear records in place, which corresponded with money being held. The cupboard was kept locked at all times and we saw handover checks of money taking place. Staff spoken with were aware of security and their responsibility in this area. Policies and practice guidance are provided in the home. They have been reviewed and updated in the last three years, thus current good practice is contained within them to provide clear guidance on best practice provision for the benefit of residents. A lone working policy has been implemented for the safety and protection of those who live and work at the home. Information received indicated regular safety and fire checks are carried out. Information regarding certificates of safety checks, servicing of equipment and other required safety inspections was supplied. Staff spoken to confirmed that regular fire instruction and drills had taken place. The home have kept us informed of incidents which have affected the wellbeing of those who live at the home and have responded appropriately to each situation as and when it occurred, furthermore the home record accidents/incidents well. In order that the home is using the correct documentation to report incidences to us it is recommended that the home obtain a copy of the new CSCI Regulation 37 notification. The home displays a current certificate of Employer’s Liability Insurance. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X 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 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 2 3 3 X 3 X Court View DS0000003382.V365020.R01.S.doc Version 5.2 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 YA37 Regulation 8 Requirement Permanent arrangements must be made for there to be a Registered Manager at the home. (The service was notified of this since September 2007) Timescale for action 22/09/08 2. YA28 16 The service must make 22/09/08 arrangements to clear the front garden of rubbish and make this a safe accessible for service users. The service was notified of this in December 2006). The home must comply with the report completed by the Environmental Health Officer in respect of the overgrown front garden area. Training in the Protection of vulnerable adults training must be provided for staff in order that they are aware of their responsibilities in this area. Training in dementia awareness must be provided for staff in order to equip them with the skills and knowledge to support individuals in this area. 22/09/08 3. YA42 13 4. YA35 13 (6) 22/10/08 5. YA35 18(1) c (i) 22/10/08 Court View DS0000003382.V365020.R01.S.doc Version 5.2 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. 1. 2. Refer to Standard YA7 YA42 Good Practice Recommendations Photograph of the manager to be added to the staff photo board. The home to obtain a copy of the new regulation 37 notification form. Court View DS0000003382.V365020.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Court View DS0000003382.V365020.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!