Inspection on 27/07/07 for Dalvington

This inspection was carried out on 27th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dalvington 03/07/06

Dalvington 16/12/05

Dalvington 20/05/05

Dalvington 06/12/04

Dalvington 16/06/04

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 Dalvington 146 Lower Howsell Road Malvern Worcestershire WR14 1DL Lead Inspector Dianne Thompson Key Unannounced Inspection 27th July, 1 August and 14th August 2007 10:00 st Dalvington DS0000018646.V341504.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 Dalvington DS0000018646.V341504.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. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dalvington Address 146 Lower Howsell Road Malvern Worcestershire WR14 1DL 01886 833424 01886 833684 malvernservices@efitzroy.org.uk www.efitzroy.org.uk Elizabeth Fitzroy Support 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) Sandra Hibbert Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This service is primarily for people with a learning disability but may accommodate people who also have an additional physical disability 3rd July 2006 Date of last inspection Brief Description of the Service: The registered provider of this home is the charity Elizabeth Fitzroy Support (EFS). A service is offered to a maximum of fifteen adults who have learning disabilities and some people may have a physical disability. Accommodation is divided into three units. Dalvington is the main unit. All facilities are on the ground floor and seven people with moderate to higher dependency needs can be accommodated. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. The Oaks is a separate house and can accommodate six people who are less dependent than those in Dalvington and more dependent than those in The Willows. The entire complex is registered as one establishment called Dalvington. A manager Sandra Hibbert has been in post for approximately six months and has recently applied to the Commission for Social Care to become the registered Manager. The operations manager visits Dalvington monthly, on behalf of EFS. Mr Neil Taggart is the Director of Operations and the responsible individual. The current weekly fee ranges from £800 - £1600 and there are additional charges for transport, hairdressing, chiropody, papers and some outings. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that included two visits to the service. Surveys and Relatives comment cards were sent out. Time was spent with people who use the service and staff on duty. The main purpose of this inspection was to see what the service at Dalvington was like for the people who live there. Records for people who use the service were checked, and a tour of the building was also carried out. Other information gathered by the Commission for Social Care Inspection (CSCI) since the previous inspection is included in this report. What the service does well: What has improved since the last inspection? Medication is now stored properly and safely. Staff follow information that tells them how to give medication safely. Dalvington now has ways to monitor and check that everyone is happy with the service they receive. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 6 Information to say that the alterations to the home have been done safely is now available in the home. Safety checks are being done in the home and on equipment to make sure everyone is kept safe. 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. Dalvington DS0000018646.V341504.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 Dalvington DS0000018646.V341504.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, 2, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are given information about the services offered at the home. This helps them make an informed choice about whether they would like to live at Dalvington and whether the home will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide provides information about the home to help people decide if they wish to live at Dalvington. The Statement of Purpose is to be updated to reflect the change of manager and changes within the staff team. Copies of information are available to all, including visitors to the home. Surveys from families confirmed that information about the home is shared, and that they are kept up to date with important issues. Evidence shows that full assessments were completed for everyone who uses the service prior to their moving into Dalvington. The home has an admissions policy and procedure in place. The assessment process is very detailed and care records show that the home receives full information about people, their background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 9 a range of sources such as other relevant professionals, visits to previous homes or schools, and discussions with family members. Introductory visits and stays are arranged at the home prior to admission. Everyone is given a copy of relevant information prior to moving into the home, and information is offered in preferred formats, such as symbols, pictures, audio and large print. Survey responses confirm that visits to the home were completed to make sure that the home was suitable. There have been two admissions to the home since the last inspection. The files for these two people were examined and evidence was seen to show that the home’s policies and procedures had been followed. Information held on files includes copies of the licence agreement, contract, residents charter, the home’s mission statement and a photo consent form. Dalvington DS0000018646.V341504.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 adequate This judgement has been made using available evidence including a visit to this service. Care plans provide staff with information about individual’s assessed needs. They include risk assessments to show how risks are to be reduced and how to promote independence. People who use the service are supported to make choices and decisions in their daily lives and routines. EVIDENCE: Individual care plans provide information about the care support each person needs. Staff have information to make sure that all care is provided in a preferred way. Individual likes and dislikes are recorded. Files for four people who use the service were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 11 The home has in place a pen picture file which provides easily accessible information for new or agency staff to access. Each person is allocated a key worker to oversee his or her care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs. The information held on individual files is muddled and confusing. Information that is no longer relevant should be archived to make sure that current information is easily accessible and not conflicting. Care plans need to be reviewed and updated. Individual profiles provide a summary of information to advise staff, but some profiles have not been updated since 2005. All files for people who use the service are now kept in locked cupboards in each of the units. Time was spent with the manager during the second visit to the home. The manager said that some work has started on archiving information and up dating the files for people who use the service. It was pleasing to see evidence of the work that had commenced following the first visit to the home. The information on the file is much improved, with information more accessible. Arrangements to update and review care plans are being made. These reviews are important and must be completed with some urgency, particularly as previous inspection reports indicate that progress has been very slow in the past to achieve the required standard of care plans and review system. Planning and development meetings are being arranged for person centred care planning (PCP) process to begin. The Organisation has a PCP Taskforce who will be involved in developing this system within the home. They will also be providing input and support as PCP’s are implemented. Additionally, as part of individual staff supervision the manager said she will monitor and review progress with individual key workers. The home completes risk assessments to promote safety and independence for people who use the service. There are guidelines in place to provide information on how risks can be avoided. Risk assessments and guidelines should be developed to provide responses in the event control measures fail, such as the risk of choking. This was discussed with the manager and assistant manager. Plans include information about the ways that people who use the service communicate and understand information. The speech and language therapist has developed these plans to make sure staff are consistent in their approach. Examples of the different methods used include audiotapes, and objects of reference. Staff training in communication methods needs to be maintained. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 12 All files for people who use the service are now kept in locked cupboards in each of the units, and this meets the requirement of the previous inspection. Family surveys confirmed that care given is what they expected or agreed with the home. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. People receive help and encouragement to lead active and interesting lives and are supported to access facilities within the community. People are also supported to maintain links with their families and to develop friendships. The menu is varied and people can choose their meals and snacks, although people should be encouraged to eat a healthy and balanced diet. EVIDENCE: People who live in The Oaks were out for lunch at the time of the inspection. People who live at The Willows were out at their respective day centres. A birthday celebration was taking place in Dalvington. Time was spent with two people who were at home at the time of the first inspection visit and the assistant manager of The Oaks. Dalvington provides a range of activities for people who use the service, both in-house and within the local community. All activities are organised to take Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 14 into account individual needs and preferences, making sure that everyone has the opportunity to take part. People who use the service are supported to attend Service User Forum meetings that take place every two months. Opportunities are discussed regularly with people who use the service through their monthly meetings. Planning activities and any other issues within the home are discussed in these meetings and the minutes are included for discussion in staff team meetings. Individual engagement profiles are completed and provide guidelines for staff to support people with activities such as clearing the table after meals, making their bed, or personal laundry. Dalvington employs activity co-ordinators to plan and support daily activities with people who use the service. Activities include grocery shopping, places of interest, lunch out, countryside centre visits, Eastnor Castle, household tasks, personal shopping, hydrotherapy, Snoezelen and music therapy. A state registered music therapist provides music sessions. Some people attend a local college. There is also quality 1:1 time built into activity plans. One person likes to help out in the office, opening the post. Since the installation of the new office building other people have visited to see what is going on there. The plans for the proposed IT room within the office block are gaining momentum. The manager said that funds are now available for the equipment needed. Staff have visited the Naidex exhibition as part of their research into suitable equipment. Advice is also being sought from the local Social Education Centre (SEC). A programme called sensory world will help people who use the service to choose their menus and possibly become involved in on-line food shopping. Survey comments stated that ‘ key workers know their individual clients very well and seek to make every aspect of their lives suitable – accommodation, food, clothes, activities excursions and holidays’. Holidays are planned each year. One person indicated they are looking forward to the holiday planned in July to a cottage in Wales. Some people went to Devon in May and are looking to arrange another holiday towards the end of the season. Dalvington has had a new vehicle. People who use the service were involved in choosing the colour and testing the vehicle for suitability. Choosing a vehicle that people could get in and out of easily was very important and this formed part of the selection process. Evidence shows that regular contact with friends and family is supported. People who use the service are supported to keep in touch with people they Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 15 have known in their past and with people who used to live at the home who have since moved to another home. Survey responses indicate that families visit their relative at the home on a regular basis. Survey results show that people are satisfied with the care provided. One parent commented that their relative ‘always seems happy. Has a lovely room and is given plenty of opportunities to go out to different activities’. Dalvington provides a varied menu although some improvement could be made to the nutritional value of some of the meals. On one of the visits tins of spaghetti were being served for lunch. This was discussed with the manager who said that dietary and nutritional training is planned and a referral for dietary advice has been sought. The copies of the menus supplied illustrate the use of convenience foods. There should be more emphasis on homemade foods and fresh fruit and vegetables. The manager said there are plans to encourage people to be more involved in menus and food shopping which will promote healthier and alternative meals. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 16 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. Personal and healthcare needs are identified in care plans. The plans provide information and promote consistency of care and support for people who use the service in a way that takes into account their preferences. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of everyone who uses the service and staff. EVIDENCE: Individual care records and plans provide information about physical and mental health and the support needed from staff to maintain good hygiene and health. Care plans sampled contain information about preferred personal care routines. Throughout the visits it was apparent through reading a sample of the service user plans, discussion with the managers, staff and observation that people who use the service are offered appropriate support with their personal and health care needs. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 17 Staff make sure that the safety and privacy of people was kept when they provided assistance. Personal support was observed being given in a discreet manner and staff knew how to assist each person and how to use the equipment. Staff said they are able to communicate with people who use the service verbally and, in certain cases, with the additional use of objects of reference. Some people who were at home at the time of the visit were unable to communicate, but they appeared to be comfortable, fully involved and at home in their environment. People who use the service are well supported by medical services, which include GP’s, speech and language therapists, dentist, chiropodist, psychologist, psychiatrist and the community learning disability team. Dalvington purchases the services of a physiotherapist on a regular basis to provide support for people to maintain their mobility. This is helped by the production of guidelines in pictures and diagrams to make sure that good practice and support is maintained. Records of all physical checks are completed where people have particular health related issues such as weight and physical functions. In this way the home is able to closely monitor and respond to changes or obtain appropriate medical input whenever necessary. There are gaps in some of the charts, and medical information had not been transferred to appropriate sections within the files. In another example, there is no record to show that follow up appointments such as dentists and opticians have been attended. Annual ‘Ok Health Checks’ are completed for everyone who lives at Dalvington. Health Action Plans (HAP) were completed in May 2004 and reviewed in July 2007, but they are not being used effectively. This was discussed with the assistant manager who was advised a more effective use of the HAP’s to avoid duplication, make information more accessible and keep records up to date. Dalvington has a medication policy and procedure in place. The organisations policies and procedures provide guidelines to follow should any medication error occur. Additionally procedures advise that errors are to be reported to the CSCI. Medication in Dalvington is kept in the small room that was previously used as an office. A monitored dosage system (MDS) of dispensing medication is used. Medication Administration (MARS) record sheets were checked. Photographs of everyone who is prescribed medication should be included in these files. A specimen signature sheet for all staff has been completed and is held on the file. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 18 First aid supplies are currently stored in containers on the windowsill. The assistant manager was advised to reconsider the location, as strong sunlight and heat can adversely affect some of the first aid supplies. Evidence shows that some medication reviews are taking place although the records are inconsistent. Record sheets are duplicated and information is unclear. There is lack of follow up information, for example correspondence from a GP suggests that further information can be obtained from a given website address. There is no evidence to indicate that this research has been completed, and no further information is available on the file examined. Support plans should be retyped and dated when amendments are made to make sure information is clear. Staff signatures to indicate that guidelines have been read should be obtained according to the procedure. There should be one up to date copy of support plans for staff to follow, not several copies of different plans. This is confusing and poses a risk to people who use the service. It was pleasing to find that work had commenced on the files following the first visit and files were available for the second inspection visit to demonstrate some progress. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 19 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 adequate This judgement has been made using available evidence including a visit to this service. People who use the service are protected by easy to understand information about how to complain, and appropriate information for staff is provided. Staff support people to express their views and any concerns they may have. EVIDENCE: Dalvington has a suitable complaints policy and procedure in place. The complaints procedure is available in alternative formats where appropriate. No complaints have been made to Dalvington and no complaints have been received by the CSCI since the previous inspection. Relatives commented that they have ‘never needed to have any concerns’. The assistant manager said that compliments had been received within the feedback from the quality review questionnaires. People who use the service are encouraged to speak to staff if they are unhappy. The home’s complaints procedure is available in the home and everyone has a copy. Survey comments state that people would ‘talk to staff if they were unhappy’ and that staff ‘would provide support’. There are suitable policies and procedures in place to support staff in keeping people who use the service safe. Staff complete training in relation to abuse and protection during their induction and through specific training courses, although not all staff have completed specific training on abuse. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 20 Dalvington has relevant financial policies and procedures in place to make sure that money is kept safe for each person. The provider conducts both in house and regular financial audits. The manager said that the service is looking to support people to become more involved in managing their own money, having their own bank accounts and support to access their money from their bank. Any incident of abuse must be reported immediately to the CSCI and the Worcestershire Adult Protection Team. This was discussed with the management team and they appear to be aware of the procedures to follow should an allegation be made. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 21 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, 25, 27, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Dalvington provides accommodation that meets the needs of people who use the service, and offers a spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained. EVIDENCE: A tour of the home was conducted. Dalvington is located in a residential part of Malvern with shops and amenities nearby. Accommodation is divided into three units with Dalvington being the main unit. All facilities in Dalvington are on the ground floor and accommodation is provided for seven people with high dependency and mobility needs. All units have separate communal rooms lounge, dining room, kitchen, laundry, bathrooms and toilets. Some of the people who use the service were happy to show their bedrooms. All rooms were clean, tidy and well presented. The bedrooms are a good size, suitably furnished and personalised by people living Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 22 at the home. There is a call system for all units. The sensory room is very well equipped and a useful resource for everyone to use. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. A new kitchen has been installed with new flooring. New carpets have been fitted to the lounge and bedrooms since the last inspection. The Willows has a separate entrance and a separate garden. The Oaks is a separate bungalow and can accommodate six people who are less dependent than those in Dalvington and more dependent than those in The Willows. The kitchen has recently been refurbished in the Oaks, and has been very tastefully done. The dining room, hall and lounge are scheduled for redecoration and this is to include new furniture. The office and small toilet has been converted into a separate laundry room, so the home no longer shares facilities. The assistant manager said that it is proposed for the bathroom to be replaced with a wet room particularly for people who prefer to take showers. In Dalvington a replacement bath is on order as the existing one is leaking. The spare room (which was previously one of the offices) is being converted into a family or visitors room. The previous office is now a wet room and provides spacious shower facilities. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available. All cleaning materials are stored in locked cupboards in the laundry rooms. Staff were observed wearing appropriate protective wear for the work they were doing. Some members of the staff team have completed training in infection control, with further training arranged. This meets the requirement of the previous inspection. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 23 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. Staffing levels are being maintained and the staff team understand their responsibilities. Staff are well supported and work together to provide people who use the service with consistent care. Staff receive training to help them meet the needs of people who use the service. It would be beneficial to people who use the service if more staff were qualified. The home’s recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at Dalvington. EVIDENCE: Dalvington has a committed and stable staff team. Staff training is provided although this appears to be inconsistent and fragmented. Mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults is to be provided. There is evidence to show that previously raised issues and practices have not been addressed within specific timescales, and have been repeated throughout Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 24 inspection reports. There is inconsistency within staff training in that some staff have yet to complete required or specific training while other staff are due to complete refresher courses. Training is organised through the organisations regional office. One member of staff has recently completed NVQ level 2 in care and two other members of staff are currently completing NVQ level 2. The organisation is currently looking to obtain external providers for further NVQ training, as the service does not meet the required level of qualified staff. The manager said she is developing a staff-training matrix to provide a clear overview of staff training needs. Although staff training is organised regionally, the organisations training policy does specify that records should be maintained at a local level. The manager said that training for all staff is being coordinated. One member of the management team has now qualified to provide moving and handling training for all staff on a regular basis. This will meet the requirement of the previous inspection. The recruitment policy and procedures for EFS ensure that everyone completes an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. Although it ahs been agreed between EFS and CSCI that some personnel records are kept at the regional office, individual staff files retained in the home should contain documents listed in Schedule 2 of NMS, in relation to regulation 7, 9 and 19. This was discussed and agreed with the manager. All staff are required to work a probationary period at the home. All newly employed staff complete an Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the home, people who use the service and safety matters. Surveys indicate that staffing levels, recruitment and staff training has been a concern. The manager and one of the assistant managers said that staffing levels and recruitment have been addressed. Dalvington is almost fully staffed with one part time post remaining. The assistant manager said there are plans to combine two part time posts to fill those hours. There are now sufficient staff on duty at weekends to support people to take part in activities in and out of the home. Staff are now more flexible to meet these needs and day activities hours are now allocated to the weekends to facilitate more activities. Senior staff also work weekend shifts to provide support and direction as necessary. This meets the requirement of the previous inspection. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 25 Survey results from professionals indicate that the homes response to training is slow and actions are not always fully established The managers say the home is well supported by the organisation, and with the committed and consistent staff team. The manager said that staff had been very responsive and supportive to the needs of the people living at the home during the recent flooding in the area. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 26 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, 39, 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is managed in an open and positive way. Elizabeth Fitzroy Support monitors the home in various ways to make sure that the service continues to develop as people want and that the home remains a safe place to live and work in. EVIDENCE: The manager Sandra Hibbert has been in post for over 6 months. Sandra has recently applied for and has been successful in regard to her application to CSCI as registered manager for the home. Sandra has many years experience working with people who have a learning disability, mainly in managing day services. Sandra is qualified to Certificate in Management Studies and NVQ level 3 in care, promoting independence. She is currently seeking to access Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 27 NVQ level 4 in care and the Registered Managers Award (RMA). Sandra completes training relevant to her position including Fire Training for Managers, Infection Control and Communication. Training in equality and diversity is being sought. Two assistant managers support the manager. Time was spent with the manager and one of the assistant managers. The new format for reports, the Annual Quality Assurance Assessment (AQAA) and Legal Requirements was discussed. Staff confirmed that the manager is approachable and supportive. Staff said they are able to talk to members of the management team at any time. In respect of management support from the provider, EFS has Training and Human Resource Officers who are available to advise and support the home. The provider’s monthly visits are one of the ways that EFS monitors the service and how the home is being run. These visits include interviews with staff and people who use the service. An audit of relevant aspects of the service, including records, environment, complaints received, finance and safety is completed. Any actions that may be needed to address shortfalls are specified. The REACH quality assurance system has been adopted by the organisation to help with the evaluation of the service. The manager has recently sent out questionnaires to relatives as part of the quality assurance review. This provides the opportunity for the newly appointed manager to review the service and develop an action plan. The feedback from the questionnaires has identified amendments to the questionnaire format that would provide more information about people’s views of the service. The quality assurance system is to be reviewed in January of each year and will determine the planning for the forthcoming year. The home is looking to develop this further to include the involvement of local advocates and the ‘speak up for yourself’ group which meets in Malvern. This meets the requirement of the previous inspection. Evidence was seen which shows that matters of Health and Safety are well managed. Approval for the completion of the alterations to the premises has been obtained from Building Control and an industry-accredited electrician. This meets the requirements of the previous inspection. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking mandatory health and safety training topics. Generic risk assessments are in place. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 28 Fire records were checked. Fire drills are well practiced and well documented, which is an example of good practice. The name of everyone present during the fire drills is recorded. All other safety and equipment checks are completed regularly. The fire risk assessment was updated on the 28/11/06 and meets the requirement of the previous inspection. Although Fire training is taking place for all staff to the required level per year, the information will be easier to monitor when the manager has completed the training matrix. Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 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 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes 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 12 and 15 Requirement All service user plans must be kept up to date and reviewed with service users and their representatives every six months or when needs change. This will ensure that the health and welfare for everyone who uses the service is maintained. The CSCI is to be notified when this is completed, and within the timescale given. Timescale for action 30/11/07 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 YA1 Good Practice Recommendations The Statement of Purpose needs to be revised and in a suitable format for sending out to interested parties. The updated statement should be available to the service users and their representatives and a copy sent to CSCI. The organisation acting as appointee for all service users should be reviewed. DS0000018646.V341504.R01.S.doc Version 5.2 Page 31 2. YA7 Dalvington 3. 4. YA9 YA17 Risk assessments and guidelines should be developed to provide responses in the event control measures fail There should be more emphasis on homemade meals using fresh fruit and vegetables on the menu. People should be more involved in menus and food shopping with healthier and alternative meals promoted. Health Action Plans should be used more effectively to avoid duplication, make information more accessible and keep records up to date. The home should have a training programme based on the in the individual training and development assessments for each member of staff. All staff should receive training in communication methods. The manager should complete training, as agreed at registration. 5. YA19 6. YA35 7. 8. YA35 YA37 Dalvington DS0000018646.V341504.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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