Inspection on 08/08/06 for Derwent Cottage

This inspection was carried out on 8th August 2006.

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

The inspector found 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

Derwent Cottage 16/07/08

Derwent Cottage 17/07/07

Derwent Cottage 11/10/05

Derwent Cottage 07/06/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Derwent Cottage 27 Eastgate Seamer Scarborough North Yorkshire YO12 4RB Lead Inspector David Blackburn Key Unannounced Inspection 8th August 2006 08:45 Derwent Cottage DS0000061996.V305533.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 Derwent Cottage DS0000061996.V305533.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. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent Cottage Address 27 Eastgate Seamer Scarborough North Yorkshire YO12 4RB 01723 866146 01723 866147 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) Milbury Care Services Limited Mrs Andrea Whitehall Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 4 service users in category LD or LD(E), some or all of whom may also have physical disabilities. 11th October 2005. Date of last inspection Brief Description of the Service: Derwent Cottage is a detached house situated in a small village approximately four miles from the town of Scarborough. The home is close to the village centre and local facilities and amenities. There is easy access to public transport to and from neighbouring towns and villages. The home provides accommodation for a maximum of four service users. Derwent Cottage is a two-storey building with one en-suite bedroom, communal areas and service facilities, for example kitchen, on the ground floor together with three en-suite bedrooms, a shower room and an activity room on the first floor. There is a passenger lift between floors. Specialist lifting, moving and safety equipment is provided as necessary. The home offers long term accommodation for adults with a learning disability and associated health and behavioural problems including some challenging behaviour. The staff seek to provide a holistic regime offering personal care, help, advice and guidance with daily living skills and activities, a catering service, a laundry service and domestic and cleaning services. Activities are offered both on and off site. Good support is offered to the staff team by the local Community Learning Disability Team. The property is owned by Milbury Care Services who also provide the care input. A Statement of Purpose and Service User Guide are available in the home. A copy of this report will be included when published. The fee level advised at the time of inspection was around £1760 per week depending on assessed needs and level of care required. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection on which this report is based was the first to be carried out in the inspection year 2006 to 2007. The site visit was carried out over one day with a total time at the home of eight hours. This was complemented by a number of hours preparation time off site. The focus of the inspection was on the key standards. A number of bedrooms, communal areas and services, for example the laundry facilities and kitchen were inspected. An examination was made of some service users’ care records, the home’s policies and procedures and other documents, for example staff records. Conversations were held with a number of service users. None was able to enter into any meaningful discussion and generally made signs or gestures. Discussions were undertaken with some relatives off site prior to the visit. A number of staff were spoken with at the time of the site visit. Some of these discussions were in confidence. Care managers, visiting health care professionals and relatives had been contacted for their written views before the site visit. The comments and observations received, together with those made during discussion, are included within the relevant sections of this report. What the service does well: Service users appeared happy and well cared for. Although none was able to enter into discussion, they were relaxed and enjoyed a good rapport with staff. One visitor said “I have been very happy with the progress my relative has made since admission to the home.” A care manager said “I am very pleased with the progress my client has made at Derwent Cottage.” Good assessment procedures were available should a placement be sought at the home. These procedures should ensure any prospective service user would have their personal needs, hopes and aspirations fully identified and understood. A well-defined care planning system was in operation that was easy to follow and understand. The information clearly showed staff service users’ needs and how they were to be met. Although none of the service users was able to verbalise their wishes, choices and preferences, good attention had been paid to the different forms of communication they used including gestures, facial expressions and sounds other than words. This meant good feedback was gained from service users and their agreement or otherwise given to any planned course of action. A relative said “I am very happy with the overall care. My relative is doing well and the improvements made are plain to see.” Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 6 The location of the premises enabled service users to make full use of community facilities and amenities both locally and, further a field through regular excursions in the minibus. Visitors were always welcomed and staff ensured good contact was maintained with families through letters and cards. A balanced and generally nutritious diet was offered with staff well aware of service users’ individual likes and dislikes. Specialist crockery and cutlery was readily available. Personal assistance was given quietly and discreetly. Service users appeared to enjoy their food. Service users were offered personal and health care in a manner that appeared to meet their requirements. The registered provider’s policies and procedures on medication were being followed to further promote service users’ overall wellbeing. A visiting healthcare professional said “Staff show a good understanding of the complex needs of service users.” Services users were assured of protection from harm through good policies and procedures designed for their safety. Staff’s understanding of adult protection issues further promoted services users’ safety. The premises were clean, warm and free from offensive odours. Proper attention was given to the maintenance of hygiene. This gave service users a pleasant environment in which to live. Although there had been some new staff appointments, service users were cared for by a competent and well-motivated staff team. The employment of known bank staff ensured services users had the required care input on a consistent basis. A relative said “Staff are helpful and friendly. They are always ready and able to help.” Appropriate attention had been given to matters of health and safety to ensure the home was a safe place in which to live and work. What has improved since the last inspection? What they could do better: Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 7 A relative raised concerns about what care, services and facilities the weekly fee covered and what extras, if any, had to be met by the service user. Service users and their representatives should be aware of what is, and is not, included in the weekly fees and the cost of any extras. The administration of any controlled drug should be recorded in a register designed specifically for that purpose. This would give added protection to service users taking such medication. The complaints procedure should be displayed in the home. This would give service users and visitors easy access to the procedure should they wish to raise any issue. A copy of the multi agency agreement on the protection of vulnerable adults should be available in the home. The registered provider must ensure staff have the required training to enable them to continue to offer care in the most appropriate manner. 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. Derwent Cottage DS0000061996.V305533.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 Derwent Cottage DS0000061996.V305533.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): 1, 2 and 5. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users could be assured that through good assessment procedures their individual needs would be known and met. EVIDENCE: A Statement of Purpose was readily available and found to be comprehensive in its detail and the information provided. It was supported by a Service User Guide with good use made of pictures, symbols and colour. The information clearly stated that discriminatory behaviour, in any form, by anyone, would not be tolerated. A contract and statement of terms and conditions of residence was on three of the four files examined. The fourth was awaiting the final details to be agreed between provider and purchaser. One relative raised concerns about the exact nature of the care, services and facilities the weekly fee covered. They said they were unaware of what the fees (paid by the funding authority) covered and what extras their relative was expected to pay. The comment was made “I have asked the care manager and the home on several occasions for the conditions relating to my relative’s stay but have had no response from either.” Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 10 The manager said a meeting had been arranged with this relative, representatives of the service purchasers (local authority) and the registered providers to address this issue. On all the case files examined an initial assessment and care plan were available. They had been drawn up by a care manager of the placing authority. The registered provider had devised an assessment pro forma that was being used in conjunction with this assessment. This pro forma was comprehensive and detailed in the information it sought about any prospective service user. The information once gathered would be scrutinised and a preliminary decision made as to whether or not the assessed needs of the prospective service user could be met. If it was felt needs could be met, then appropriate arrangements would be made for the introduction of the service user to the home. Details of the transition arrangements made on behalf of service users were on some of the files examined. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. There was a clear and consistent care planning system in place that provided staff with the information needed to appropriately meet service users’ needs. EVIDENCE: A number of case files and care plans were examined. They were well organised and easy to follow. The files seen contained the relevant information to enable staff to know, understand and be able to meet the needs of each service user. The actual care plan recorded strengths and needs with a plan of action and expected outcome. These were shown under six major headings, for example health and personal care, each with a number of subheadings, for example continence promotion and washing and dressing. Cultural and spiritual needs were recorded. Care plans had been regularly reviewed, updated and signed. A daily record of the care given and any other significant events affecting the individual service user were maintained. They were well detailed and written clearly and concisely providing an accurate reflection of the care given. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 12 A number of risk assessments were found on each file examined. These showed the risks associated with activities inside and outside the home. The assessments recorded the actions to be taken or the controls needed to minimise or eliminate any particular risk. In discussion with staff there was no evidence to suggest service users were denied access to any activity because an element of risk was present. Although the care plans recorded each service user’s likes and dislikes, choices and preferences for the activities of daily living, the profound nature of each individual’s disabilities severely affected their ability to make day-to-day choices and decisions. The manager said she was investigating the possibility of obtaining advocates for service users as part of a person centred planning approach to their care. Observation throughout the site visit showed staff’s good attention to detail and the understanding of each service user’s needs. They were able to discuss the meaning of gestures, movements, facial expressions and changes in demeanour of the service users. Staff responded quickly and appropriately to these indicators and were seen and heard to consult with service users at every opportunity. They continually involved service users in decisions about activities, food and drink and personal care. Service users appeared relaxed and comfortable in staff’s presence. Some money was held for safe keeping on behalf of service users. The arrangements for receipt, recording and return of this money were satisfactory. One relative had raised concerns about the management of their relative’s money but this was to be discussed at the meeting between them and representatives of the service purchaser and registered provider. None of the written responses received from relatives, visitors or visiting professionals raised any concerns about the care regime in operation at the home. Derwent Cottage DS0000061996.V305533.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 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 was good. This judgement has been made using available evidence including a visit to this service. Service users were able to undertake a number of activities in the home and at external locations that enhanced their life experiences. Service users were offered meals that met their likes and choices and catered for any special dietary needs. EVIDENCE: All service users suffered from a learning difficulty often with associated physical disabilities. None was able to undertake any form of employment. A number did attend day care placements. A variety of activities were available in the home and at external locations. A number of those provided in-house were seen during the site visit. Staff were usually involved with service users in one-to-one activities though occasionally those of a group nature were undertaken. Activities were age, sex and gender appropriate taking into account each service user’s specific abilities and capabilities. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 14 The location of the home gave good access to local facilities and amenities. The use of the home’s minibus and the provision of bus and rail passes ensured service users were able to make full use of wider community facilities and amenities. The staff rota was devised in such a way to try and ensure a driver and escorts were always available. One staff member was able to use their own vehicle for service user outings. Visitors were welcomed though the frequency varied depending on the ability and location of the family members. Staff made arrangements for service users to visit families where this was feasible. Key workers (staff members with particular responsibility for one or more service users) also wrote to families on a monthly basis on behalf of each service user. They also ensured any replies were read to the service user and that cards were sent for birthdays and other festivals. Those routines, rules and regulations in place were designed for the safety and overall welfare of the service user. The care plans showed each service user’s personal preferences and choices in terms of retiring and rising, personal care and freedom of movement. These were only compromised by the need to be ready for day care transport or to attend appointments. The menus were devised by the staff based on the recorded likes, dislikes, preferences and choices of service users. Observation by staff of a service user’s reaction to additions to the menu gave a clear indication as to whether or not a particular item was liked. A variety of food was offered and the staff felt they catered for every need. Staff were observed to assist with breakfast and lunch and with drinks during the morning and afternoon. Any assistance was given in a quiet, dignified and unobtrusive way. Special crockery and cutlery were readily available. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Personal support was offered in such a way as to protect service users’ privacy, dignity and independence. Service users’ health needs were well met with evidence of good multi-disciplinary working taking place. EVIDENCE: The pre-admission documentation and the case file detailed the personal and health care needs and manner in which they were to be met. Discussion with and observation of staff clearly demonstrated service users’ needs were at the forefront of their minds. They provided care with the accent clearly on the maintenance of each service user’s privacy, dignity and independence. All personal care was given behind closed doors. The purchase of clothing, toiletries, personal care products and hairdressing services were normally undertaken by service users supported by their key worker on a one-to-one basis. Health care needs were detailed on the care plan. The reason for referral and outcome were shown together with any follow-up. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 16 Good liaison was maintained with a variety of health care professionals including physiotherapists, occupational therapists, speech and language therapists and tissue viability nurses. The necessary specialist equipment to ensure service users could use all the services and facilities provided by the home was in place. A medication policy and procedure were available. Discussion with and observation of staff carrying out medication administration and recording showed these procedures were being properly followed. All staff who administered and recorded medication had completed an external training course. Errors in medication administration and recording had been recently discovered. Proper enquiries had been made by the registered provider and the matter satisfactorily resolved. It was noted that some Schedule 3 controlled drugs (Misuse of Drugs Act 1971 Schedule 3) were held in the home. These were properly stored. Recording of administration was on the medication administration record sheet (MAR sheet). While it is not mandatory that Schedule 3 drugs be recorded in a controlled drugs register it is seen as good practice. The registered manager agreed to make arrangements to obtain such a register. None of the written responses received from relatives, visitors or visiting professionals raised any concerns about the way personal and health care was offered. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives could be assured their concerns and worries would be listened to and acted upon. EVIDENCE: The registered provider had published a complaints procedure. This was complemented by procedures from the purchasing authorities. Service users had been given copies of “Contact Me” cards that were simplified versions of how to raise concerns. Although the responses from visitors showed they knew how to complain, it was recommended the registered provider’s complaints procedure be prominently displayed in the home. Two complaints had been recorded since the last inspection. One had been considered under the Protection of Vulnerable Adults procedures of the local authority. Neither complaint had been upheld. Both were recorded. The registered provider’s policy and procedures on adult protection were available. They clearly showed the procedures to be followed. Staff appeared confident in the actions to be taken should abuse be alleged or suspected. The registered manager had made arrangements for further training to take place on this subject in the following month. It was recommended that a copy of the revised multi-agency agreement on adult protection be obtained. The registered provider’s recruitment and selection procedure ensured the protection of service users through the obtaining of written references and enhanced disclosures from the Criminal Records Bureau. Derwent Cottage DS0000061996.V305533.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, 26, 27, 29 and 30. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users were provided with a homely and comfortable place in which to live. EVIDENCE: Derwent Cottage is an adapted property opened as a care home some years ago, originally for older people. Purchased by the present registered provider, it was further adapted and upgraded to offer accommodation to a maximum of four service users with learning and associated physical disabilities. The property is located near to the village centre and within easy travelling distance of the town of Scarborough. Public transport passes close to the house. The premises are set in their own secluded and private grounds with no external indication that the property forms a care home. Level access was achieved to each external door. Fixtures, fittings, fabrics and furnishings were all domestic in nature reflecting the registered provider’s wish to create a non-institutional environment. The premises were maintained in a good condition internally and externally. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 19 Bedrooms were for single occupancy and furnished in a simple but adequate manner. They all showed evidence of personalisation according to the wishes of the occupant. All bedrooms had an en-suite bathroom. They were of a good size with the layouts giving easy access for service users and space for staff to assist as necessary. Specialist equipment was available including hi-lo baths, ceiling tracking and mobile hoists, beds and wheelchairs. A wet floor shower and separate toilet had been installed. Corridors were wide and communal areas spacious. A sensory room was available on the first floor. The premises were clean, tidy and odour free. There was a laundry area fitted with commercial machines. The walls and floors were readily cleanable. Suitable arrangements were in place for the laundering of linen, bedding, towels and personal clothing. Relatives and visitors were complimentary in their comments about the physical features of the home. They all felt it was maintained to a very high standard. Derwent Cottage DS0000061996.V305533.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 was adequate. This judgement has been made using available evidence including a visit to this service. While cared for by a competent and well-motivated staff team, relevant training must continue to ensure service users’ overall safety and wellbeing. EVIDENCE: The numbers and skill mix of the staff group met service users’ needs. Male and female staff were employed of different ages and backgrounds. Bank staff were used, all employed by the registered provider. The registered manager said bank staff knew the home and the service users. She was confident consistency of care was maintained. Staff said they enjoyed their work, had time to address service users’ needs, usually working on a one-to-one basis and felt the standard of service given was very good. Staff appeared clear about their roles and what was expected of them. They spoke confidently and knowledgeably about the people in their care. Staff showed an understanding of the actions needed to meet and promote equality and diversity. The Regulation 26 reports completed by a representative of the registered provider regularly noted the very good standard of service provided in the home to service users. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 21 Of the 11 permanent staff and 5 bank staff currently employed, 6 had achieved a National Vocational Qualification in care to at least level 2. Some had achieved this award to level 3 and others had gained further care related certificates. The registered provider was aware of the need for at least 50 of their staff to have achieved a National Vocational Qualification. All staff recruitment and selection was done through the published procedures of the registered provider. A number of staff files were examined including those of the last two permanent staff to be employed. They contained an application form, two references and the necessary clearances required prior to employment, for example enhanced disclosures from the Criminal Records Bureau. There was an in-house induction programme complemented by attendance on LDAF courses (Learning Disability Award Framework) and National Vocational Qualifications awards. A training plan had been developed to ensure training was provided to staff throughout the year. This training would include specialist subjects such as epilepsy, as well as the mandatory training to meet service users’ basic needs, such as manual handling and health and safety. There was however a measure of uncertainty among staff as to if and when original or updated training in these matters had been or was to be given. Some said they had completed a number of LDAF units but not all while others had yet to start. A number were keen to begin or to improve National Vocational Qualifications. The registered provider must ensure staff have a clear training programme that addresses their needs and ensures they have the required abilities to continue to meet service users’ assessed needs. The registered manager discussed her proposal to introduce an in-house training initiative based on staff assessment around the relevant care standards. She saw this as a means of directly addressing the most important areas of care. Responses from visiting professionals described staff as “enthusiastic” and “ready to follow recommendations.” Another said “I make regular unannounced visits and am always met by polite and efficient staff.” A relative said “I keep in regular by telephone and occasionally visit. The staff have created a well organised and stimulating environment.” Derwent Cottage DS0000061996.V305533.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 was good. This judgement has been made using available evidence including a visit to this service. Service users lived in a well-managed and safe environment with the registered manager providing clear leadership and staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The registered manager has been employed at the home for 15 months. She came to the appointment with experience of people with learning difficulties in a number of settings. She has achieved a National Vocational Qualification in care to level 4 and a Certificate in Care following a local university course. She has applied to undertake the Registered Managers (Adults) NVQ4 award. She has completed further training with specific regard to the service user group including autism, challenging behaviour and was, together with other staff, undertaking a course in speech and language development. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 23 Staff described her as committed and fair with the meeting of all service users’ needs as her primary aim. Some staff said she came to the post at a difficult time but had resolutely worked through the difficulties to provide a well managed home with a very good level of care offered to all service users. A service review was taking place at the time of the site visit. This involved service users, families and other interested parties in the process of reviewing the service performance. Copies of their replies were seen. A very high level of satisfaction had been recorded by visiting professionals and families. A development plan would be produced that was seen as crucial to the service development in line with the registered provider’s principle of continuous improvement. It was stated that the outcome would be published in October to allow the necessary resources to be linked to budget setting. Proper attention was being given to matters of health and safety. A number of safety reports and certificates were examined. All were relevant and up-todate. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 24 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 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 3 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 X 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 X 3 X X 3 X Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 25 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 YA35 Regulation 18(a)(c) Requirement The registered provider must ensure staff receive the appropriate training to enable them to continue to meet service users’ assessed needs. Timescale for action 30/09/06 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 2 3 4 Refer to Standard YA5 YA20 YA22 YA23 Good Practice Recommendations Service users and their representative should be clear about what care, services and facilities are included in the weekly fees. The administration of Schedule 3 controlled drugs should be recorded in a register specifically designed for that purpose. The complaints procedure should be displayed in the home. A copy of the revised multi agency agreement on the protection of vulnerable adults should be available in the home. Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Derwent Cottage DS0000061996.V305533.R01.S.doc Version 5.2 Page 27 - 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. 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