Inspection on 19/10/06 for Dairy Close

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dairy Close 02/06/08

Dairy Close 09/02/06

Dairy Close 05/04/05

Dairy Close 29/11/04

Dairy Close 08/07/04

Dairy Close 15/03/04

Dairy Close 07/10/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Dairy Close 20 Dairy Close Leek Staffordshire ST13 6LT Lead Inspector Irene Wilkes Key Unannounced Inspection 19 October 2006 10:00 Dairy Close DS0000041908.V312402.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 Dairy Close DS0000041908.V312402.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. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dairy Close Address 20 Dairy Close Leek Staffordshire ST13 6LT O1538 386762 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) Choices Housing Association Limited Mrs Donna Collyer Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Dairy Close is situated in a residential area of Leek. It is registered with the Commission as a care home for four younger adults with a learning disability. The Beth Johnson Housing Association owns the property and is responsible for all building maintenance. Choices Housing Association is the care provider. At present there are four men permanently living at Dairy Close. The property is a bungalow situated in a cul-de-sac with good access to the front and rear of the building. It is of a domestic design presenting the same as the other properties around it, and therefore not standing out as a care setting. The home is within walking distance of the town centre and public transport is accessible, although in addition the home has access to a shared car for private transport. The gardens are spacious, secure and well maintained; there is a patio area with seating, tables, a barbeque and greenhouse. The inside of the property is very well maintained, homely and domestic in character. All four single bedrooms are large, airy, personalised and attractively decorated. Bathrooms and toilets are appropriately located throughout the home. The care charges range from £928 minimum to a maximum of £956 per week. These are 2006/07-year prices. Residents pay for their own personal toiletries and magazines. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key (main) inspection and was unannounced and undertaken by 1 inspector in mid October 2006. There were no requirements or recommendations made at the last visit to the home, and only the core standards as required for a key inspection were looked at during the visit. The home is registered for 4 people with a learning disability. The home is currently full, comprising of four younger adult men who have lived at the home for some time. All 4 men were at home at the inspection. Each is able to verbally communicate to varying degrees, and they were happy to chat throughout the visit. 2 survey forms had also been returned by residents. The inspection also relied on observation, examination of residents’ records and support from staff to gain an insight into how the home was meeting people’s needs. Two, increasing to three staff were on duty during the visit, with a ‘change over’ of staff taking place in early afternoon. All staff were spoken with during the inspection and one newer staff member was asked about the recruitment process, induction and other training, and the support received from the manager and the wider staff team. Two comment cards were returned from relatives. No relatives visited during the inspection. The records of three residents were looked at in detail, and the files of three staff, staff rotas, medication, staff training, menus and records relating to health and safety issues were inspected. The manager of the home was on duty throughout the visit. What the service does well: The service does everything well. In particular: It is recognised at Dairy Close that each resident is different, with individual wishes and needs. All of the activity of the home is therefore geared to meeting these needs and wishes. To do this the home finds out from the resident and all relevant others who can help in the process everything about them, including how they want to spend their day, how they wish to be supported, what their health needs are, what they want from life in the future, and makes sure that there are plans in place towards achieving these outcomes. The plans are well written so that they are clear to everyone, and are reviewed monthly by the resident and their key worker, and every six months relatives and any health professionals who may be involved are invited to the review. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 6 The residents are encouraged to change their plans, just like all of us do, and the reviews take account of this and amend the plans accordingly. Personal and healthcare support needs are met. Each person has a Health Action Plan in place that they have helped to write and this shows what support is required to help the men to remain healthy. It was also clear that all health related appointments are kept, and any actions recommended to meet health needs are put into action. Residents said that they were happy at the home. ‘I like living here’ was how one summed it up. They said that they liked the staff. Relatives were also positive about the service. ‘The staff are brilliant – couldn’t wish for anything better’ ‘Social needs are met which I feel is very important. I’m always invited to reviews.’ An excellent manager, who has an open management style, is in charge of the home, and she has formed good relationships with the residents and staff alike. Her approach is calm and always resident centred. She ensures that the home is well run, is safe for the residents, and she leads a committed and enthusiastic team of staff who are well trained, so that the health, safety and welfare of the residents is promoted. What has improved since the last inspection? What they could do better: All services should continually strive to improve and the home is recommended to explore ways in which this can be achieved. In particular the manager and staff are asked to explore further areas where information for residents is provided in a way which best suits their communication needs. While the person centred plans, health action plans and review formats are provided in simple English and picture form, this could perhaps be extended to care plans and risk assessment records if this is the style that residents best understand. New fire regulations came into effect on 1 October 2006. The manager is aware of the new regulations and was working on the individual fire risk assessments that are now needed. A requirement has been made that these are completed. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 7 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. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are thoroughly assessed before they are offered a place in the home. In this way they and their relatives can be confident that the home will be able to meet their needs. EVIDENCE: There have been no new residents at the home since the last inspection. Previous inspection has evidenced that a thorough assessment of the individual’s needs is normally undertaken prior to them moving into the home. A discussion with the manager evidenced that such an assessment would always take place in the future to ensure that the home could meet the person’s individual needs and to ensure compatibility with the current residents. The assessment paperwork was also seen that confirmed the areas that would be assessed prior to admission. Dairy Close DS0000041908.V312402.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 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents are involved in decisions about their lives and play an active role in planning the care and support that they receive. EVIDENCE: The records of 3 of the residents were inspected. The records showed excellent attention to the detail required by staff to support the residents in a positive way. Each file had excellent recording of the 24-hour support required by each individual. Reading these records gave a clear account of both the support required and the individual choices of each person in relation to rising, retiring, mealtimes and the general procedure of their day, and how these choices should be observed by staff to promote independence and positive behaviours of the resident. There were also care plans, well thought through risk assessments, and detailed and informative person centred plans in place showing the desired outcomes, and the plans in place to achieve these outcomes for each person. Each record identified any specialist input required by the resident. For example records showed where the community nurse and psychological therapist was involved to draw up a consistent approach by staff to supporting Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 11 a resident. There were individualised procedures in place focusing on positive behaviour for residents who had the potential to become aggressive. The resident and other professionals had been involved in drawing up the procedures. The plans are reviewed overall on a six monthly basis, with relatives and where relevant, other professionals invited to the review. In addition to this the key worker also meets monthly with the resident to assess the progress made towards achieving the desired outcomes. The person centred plan is provided in pictorial/simple printed English to aid the resident’s understanding. As a positive service development the home is now at a stage where it may be possible to provide other elements of the plan in a format that the residents can understand, and the manager is asked to consider this service development. At Dairy Close the staff most definitely respect the right of the residents to make decisions. This was not only evidenced in all of the records seen where the choices of individuals were clearly documented, but also in the practice of staff in their approach to the residents that was seen and heard during the visit. Records showed how the staff team provide information, assistance and communication support so that residents can make decisions about their own lives. In the day-to-day activities at the visit residents were seen to be ‘doing their own thing’ and where they did not want to do something at a particular time there was no pressure to conform. Three men were all, in a limited way when asked, able to respond to the commission that they make their own choices about their lives. There was a communication plan in place for each resident. This showed that staff had studied when a resident said a particular phrase and what they thought from experience of reactions, what it really meant. For example, for one resident when they say the phrase ‘It’s up to you’ had been realised to really mean ‘I don’t want to do what you are saying’ and now staff respond accordingly. There were relevant individual risk assessments in place in each of the files seen. All of the assessments were thoughtfully considered and any restrictions were in the best interests of the resident concerned. Risk assessments for the management of actual and potential aggression (MAPA) had the signed agreement of a multi professional team. The residents had also signed the risk assessments where this was possible. Dairy Close DS0000041908.V312402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The wishes and choices of residents are at the heart of service provision and the home is operated to achieve these goals. EVIDENCE: There was evidence in the files seen that the home had supported one resident in the search for paid work via sheltered employment. Although this had not happened as yet he had decided to continue with his college course for woodwork, at which he is excellent, and had now completed a literacy course, receiving a certificate for its completion, and had moved on to a numeracy option. Another man attends day services on two days per week. All of the men are integrated into the local community by pursuing social activities linked to their particular interests, as documented in their individual plans. They visit variously the pub, cafes, the library, bowling, theatre, activities linked to various forms of transport for one man, and enjoy rambling as part of a rambling group. They enjoy a variety of day trips based on their interests. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 13 The manager ensures that the key workers monitor the activity programmes monthly to ensure that community presence and social inclusion is maintained. A relative wrote in a satisfaction survey form sent out and returned to the home ‘Social needs are met which I feel is very important.’ Records showed that the residents are supported to maintain family links and friendships. This is by way of exchange visits to relatives, and one man keeps in contact with friends at the home where he used to live. There was evidence to show that relatives and/or significant others are invited to review meetings. Two satisfaction survey forms that the home had sent out each highlighted that they were always made very welcome by all of the staff at the home. The daily routines of the home promote independence, choice and freedom. This is a particular strength of this home. The atmosphere at the visit was one of mutual respect shown between staff and residents with all that was going on clearly geared to residents’ individual wishes and preferred choices. The right to privacy was clearly promoted. At the visit the home was having new carpets fitted and this disruption was managed with residents still being able to spend the day as they chose with the staff supporting them in a calm and relaxed manner. Given the mental health dependency levels of the residents this particularly impressed. One of the residents said that the four men choose the meals that they have. A member of staff later explained that they choose between them on a weekly basis, with staff support to encourage a health diet. During the visit there was bacon omelette for lunch, followed by fresh fruit, and braised steak, chips and vegetables for tea. One of the residents assisted with lunch preparation, at his choosing. The meal was taken in the spacious dining area and was a relaxed occasion. None of the men has particular dietary needs and no one needs assistance with eating. The menu book was seen and this showed that a varied and balanced diet is provided. One of the residents said that he enjoyed all of his meals in the home. Dairy Close DS0000041908.V312402.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 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 excellent. This judgement has been made using available evidence including a visit to this service. Principles of respect, dignity and privacy are at the forefront of the approach of the service when meeting the personal and healthcare needs of the residents. EVIDENCE: The 24-hour plans generally show that residents can bath or shower unaided, but risk assessments were in place regarding this. One resident was recently referred to an occupational therapist as he has become a little unsteady and a bath seat has been issued. Staff are supporting him to access this currently until his confidence improves, and there were full records available. The plans also show what support or prompting is required for shaving and other aspects of personal care. Where anyone required support with personal care during the visit this was attended to promptly and discreetly. The residents said when asked that they choose their own clothes and hairstyles. There are male workers on the staff team at the home, ensuring that if any of the men would prefer a male member of staff as their key worker, this is possible. The healthcare needs of the residents are well met. There were records showing daily monitoring of health, and records for all health appointments were documented, with follow up action required appropriately recorded. There were individualised records for nutritional needs, epilepsy and mental health. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 15 Each man has a Health Action Plan that addresses all aspects of their individual health needs, including medical and family history and treatment consent. The plan is monitored on a monthly basis. The home has sound medication procedures in place. The manager and deputy manager are qualified nurses but all staff are trained to administer medication. The staff have in the past all received accredited training from a pharmacist with internal training being provided by the manager. The organisation is looking for a new external trainer, as the previous provider no longer provides training. The manager was confident, however, that the training received by the staff meets the commission’s professional advice as contained in the document ‘Training care workers to safely administer medicines in care homes.’ Nevertheless she said that for the newer workers she would still also wish to access some external training to ensure best practice. The home uses the Nomad cassette system for medication. None of the residents self-administer medication. There were safe procedures for the receipt, recording, storage, handling, administration and disposal of medication. A sample of MAR (Medication Administration Record) charts were inspected and these had no gaps in recording. The day’s medication was matched against the MAR chart and there were no errors. There are no controlled drugs used in the home. The residents’ consent to medication was recorded in their care plans. There was an authorised staff signature list, a ‘dropped tablet’ protocol, a homely remedies list agreed by the GP, and stock control sheets and PRN (as and when required) protocols in place, for medication authorised by the consultant psychiatrist. The home has access to an on-call management team to authorise the provision of PRN medication when a registered nurse is not on duty. Dairy Close DS0000041908.V312402.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 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 good. This judgement has been made using available evidence including a visit to this service. Residents are given opportunities to freely express any concerns and these are quickly responded to. They are protected from abuse and their human rights are promoted. EVIDENCE: The organisation has recently improved its Complaints Procedure with the provision of a new leaflet designed for use by residents. The leaflet was on display in the home. Two residents who were asked said that the staff had talked to them about their right to complain. One resident had made two complaints about another resident, which had been appropriately recorded. These were about day-to-day living issues and had been appropriately investigated by the manager. Residents are also aware of advocacy services that are available. Survey forms had been distributed by the home to relatives as part of their quality assurance systems, and the two that had been returned showed that the relatives were aware of the complaints procedure and who to complain to. Choices has robust procedures in place for responding to suspicion or evidence of abuse or neglect that comply with the Public Interest Disclosure Act 1998, Department of Health Guidelines titled ‘No Secrets’ and Staffordshire’s multi agency procedures for the Protection of Vulnerable Adults. Staff receive training on abuse at induction and there is also a planned programme of internal courses across Choices organisation for more established staff. There have been no reported allegations or incidents of abuse. A member of staff and the manager were questioned about their Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 17 understanding of what constitutes abusive practice and the reporting responsibilities of staff and management. In each case there was a sound understanding of requirements. Staff working at the home receive an intensive course on MAPA (Management of Actual and Potential Aggression). There are occasions at the home when chemical or physical restraint has to be used. Records were closely inspected of violent incidents and restrictive interventions since April 2006. The records evidenced, and the discussion with the manager confirmed that the earlier part of the year had been difficult at the home to manage the behaviours of one resident in particular, as he is prone to violence and aggression. Further advice had been sought from other health professionals and revised care plans had been introduced, with the outcome that since July the incidents had considerably decreased. This good practice has resulted in much reduced chemical intervention through consistent approaches and diversionary tactics being used by the staff, and a calmer atmosphere in the home that benefits all of the residents. Dairy Close DS0000041908.V312402.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 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 good. This judgement has been made using available evidence including a visit to this service. Dairy Close provides a safe, well-maintained and comfortable home for the residents, with a layout that encourages independence. EVIDENCE: The property is a four-bedroom bungalow on a small housing development of similar properties. It is in a quiet road although the town of Leek is close by, as are a range of community facilities. There are large attractive gardens to the front and rear of the property and inside the home is maintained to a high standard, providing spacious and welldecorated accommodation with quality furniture and fittings throughout the communal areas. The bedrooms of two of the residents were seen at this visit, when the men were pleased to show this visitor around. They were both well personalised with their own television, a range of CD’s and videos, and the resident who is fascinated by transport had numerous model cars, helicopters, trains and planes on show. Both men said that they liked there bedroom and living at the home. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 19 There is a large bathroom with over bath shower and toilet, and a further bathroom with a walk in shower and toilet. Grab rails had been fitted when the home was first occupied. A bath seat has been provided for one resident who has become a little unsteady. Each of the three other men is completely mobile. A member of staff provided a tour of the home. Discussion evidenced that dirty linen and the disposal of incontinence waste was being dealt with appropriately, so ensuring that service users are not at risk from cross infection. The washing machine has a sluice facility. Disposable gloves and aprons were seen in use. The home was clean and hygienic. Dairy Close DS0000041908.V312402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an excellent team of staff employed; their commitment and enthusiasm is supported by good training opportunities which all mean that residents benefit from the staff that support them. EVIDENCE: There is a generally stable staff team at Dairy Close. This core team has been increased since the home opened and now there is a team of seven staff, plus the manager, providing 322.5 care hours per week. The home is fully staffed at the moment. There are 2 or 3 people on duty throughout the day, dependent on the men’s activities, with 1 sleep in member of staff. There is occasional use of agency staff, but on these occasions the same worker is used, allowing for continuity. The approach of the staff to the residents was discreetly observed or listened to throughout the visit. Staff have an excellent rapport with the men and treated them with respect. Consistent agreed approaches to behaviours were followed in a calm, supportive way. It was clear that staff, including the newer staff, had an excellent understanding of each of the residents’ needs. All of the staff that were on duty were spoken with during the day, some in more depth than others, but it was clear in every case that they were interested, motivated and committed to their work. This comes from effective Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 21 leadership and example. The men who were asked said they liked all of the staff. Two resident survey forms were returned to the commission and both were positive. ‘I like living here’ was how one had summed it up. Choices organisation has a history of providing good training for staff. They undertake a sound induction, followed by LDAF (Learning Disability Award Framework) training over a period of six months, and this is used as underpinning knowledge for progress towards NVQ. Once LDAF is completed staff are encouraged to undertake their NVQ 2. Two members of the staff team who were both recently recruited said independently of each other that they were very impressed with their induction and the training provided. Both had experience in working in care elsewhere and they regarded their training at Choices to be the best they had received. Training records were examined and these showed that all mandatory training was up to date for all staff. Induction includes equal opportunities training. Training needs are discussed during annual appraisal and follow up monitored via quarterly supervision. 3 staff files were inspected. These showed that an appropriate recruitment procedure is followed that is based on equal opportunities. Each file had all of the information that is required including an application form, two written references, two had evidence that a Criminal Records Bureau (CRB) check had been completed, while the third had evidence that there was POVA First (Protection of Vulnerable Adults) clearance whilst the CRB return was awaited. This latter member of staff was being suitably supervised. Newly appointed staff are subject to a probationary period. The recruitment procedure that had been undertaken with her was discussed with a new member of staff. She confirmed that this was thorough and that all of the appropriate checks had been required before she had started at the home. She had been issued with the General Social Care Council Code of Conduct leaflet and had received a statement of terms and conditions. Dairy Close DS0000041908.V312402.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 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 excellent. This judgement has been made using available evidence including a visit to this service. The residents at Dairy Close are fortunate to have the current manager running the home. The way that it is operated places positive outcomes for them as the whole focus of the service, and there is a service development ethos clearly in place. EVIDENCE: The registered manager is a qualified nurse and she has also completed the Registered Managers Award. She was the Deputy Manager previously at the home, before becoming the manager in 2005. The manager has a very open management style and the staff spoken with all said that she provided excellent leadership. She is always readily available to support staff, gives clear instruction and is firm when necessary but very fair. The Commission was impressed throughout the visit by the approach of the manager to running the home. The day was a difficult one for the residents as carpet fitters had arrived at very short notice to fit new bedroom and hall carpets, and this was also an unannounced inspection. Unexpected events are Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 23 particularly an issue for one resident and the manager dealt with this and other concerns throughout the day in a calm, professional way that also provided a good role model for the staff team. Evidence throughout the inspection showed that the manager pays great attention to running the home to ensure that it complies with the Care Standards Act and Regulations, General Social Care Council Code of Practice, other legal requirements, and in the best interests of the residents. The manager has a clear focus on monitoring and review so that the service is continually developing to meet the needs of the residents. There are individual residents’ reviews held monthly when all aspects of their care and the accompanying records are reviewed. House meetings are held monthly when residents’ rights and choices are discussed with them and any issues that they raise are addressed. The manager distributes satisfaction survey forms to the relatives. 2 of these had been returned recently. The survey form asked relevant questions about the service received by their relative and about communication with them, and the comments received were positive: ‘The staff are brilliant – couldn’t wish for anything better’ ‘Social needs are met which I feel is very important. I’m always invited to reviews.’ All of the monitoring review that is undertaken is fed into an annual quality report produced by the manager. This was seen and it details the progress made throughout the year in improving the quality of the service for the residents. The manager discussed that she recognises that this can now be developed further by highlighting areas recognised for improvement in the coming year. A tour of the home was made and all areas appeared safe. The only aid used in the home is a bath seat for one resident as overall they are all mobile. The resident had been assessed for the bath seat by an occupational therapist and whilst the bath was not seen in use it was reported to be safe. The organisation charges each manager with complying with all internal policies and procedures to maintain safety in the home. There were risk assessments in place for moving and handling and appropriate food hygiene and infection control procedures are followed. COSHH (Control of Substances Hazardous to Health) substances were suitably stored in a locked cabinet. Records showed that all appliances had been PAT (Portable Appliance Testing) tested, and there was evidence of regular maintenance of electrical, gas, water and whole environment safety. Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 24 Fire safety was maintained by adherence to a programme of regular weekly and monthly checks of the fire alarm and fire fighting equipment. Quarterly fire drills are held and records showed that staff fire training was up to date. There are daily fire checks to maintain a safe environment. The manager was aware of the recent new fire legislation that came into effect on 1 October 2006. There was a fire risk assessment in place for the whole building, although the content of this was not inspected. The manager was in the process of considering the individual fire risk assessments for the four residents. It is required that these are completed for each individual in line with the new fire safety legislative requirements. Dairy Close DS0000041908.V312402.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 X 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 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 23 (4) Requirement Document in each care plan an individual fire risk assessment for each resident Timescale for action 19/12/06 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 YA6 Good Practice Recommendations As a further development of the care plan information, consider any additional areas, as well as the person centred plans, that may be suitable to be provided in other communication formats, suitable to the needs of each individual. i.e. visual, graphic, simple printed English, Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Dairy Close DS0000041908.V312402.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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