Inspection on 24/10/06 for Dunraven Lodge

This inspection was carried out on 24th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dunraven Lodge 03/02/06

Dunraven Lodge 30/09/05

Dunraven Lodge 07/12/04

Dunraven Lodge 22/06/04

Dunraven Lodge 13/01/04

Similar services:

Fairfields Country Rest Home

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Fairfax House

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

CARE HOME ADULTS 18-65 Dunraven Lodge 8 - 10 Bourne Avenue Salisbury Wiltshire SP1 1LP Lead Inspector Thomas Webber Unannounced Inspection 24th October 2006 09:30 DS0000028277.V316075.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 DS0000028277.V316075.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. DS0000028277.V316075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunraven Lodge Address 8 - 10 Bourne Avenue Salisbury Wiltshire SP1 1LP 01722 321055 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) Mrs Brigid O`Connor Mrs Eileen O`Connor-Marsh Care Home 20 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (20), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (4) DS0000028277.V316075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: Dunraven Lodge is a privately owned care home which offers accommodation and personal care to a maximum of twenty service users. These are primarily younger adults with a mental disorder. However, the home could accommodate two with dementia and four over the age of sixty five with a mental disorder within this maximum. Dunraven Lodge is one of three registered care homes operated by Mrs O’Connor and Mrs O’Connor-Marsh in the Salisbury area which have been in operation since the 1980s. Dunraven Lodge is a large detached Victorian house, which is located next door to one of its sister homes: Dunraven House. The location of the home is convenient for residents who make use of the facilities and amenities of Salisbury. The administration of all the homes is centred at Dunraven House and staffing is also organised centrally for all three homes. The premises provide ten single and five shared bedrooms for residents’ use. Two of the single bedrooms are provided with en-suite facilities. Most of the residents’ bedrooms are located on upper floors, which are accessed by use of a staircase. The home’s fees charged to residents for the care and accommodation range from £375 to £550 per week. The registered provider/manager is Mrs O’Connor-Marsh. Information about the care and services provided is available from the home, in written form, by way of its service users’ guide. CSCI inspection reports can also be seen in the home and interested people can download these directly from the CSCI website. DS0000028277.V316075.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 conducted over a period of two days on 24th and 25th October 2006 from 09:30 to 16:15 and 10:15 to 13:00 respectively. The judgements contained in this report have been made from evidence gathered before and during the inspection, which included a tour of the premises and takes into account the views and experiences of twelve of the twenty residents, which were sought on an individual and group basis. The views of two members of staff were also sought. The records of the most recent resident admitted were also checked in greater detail to ensure that they are being appropriately maintained and that his care needs are being suitably met. Thirty one of the forty three Standards were also assessed on this occasion which included the examination of records, staffing, care practices, systems, policies and procedures. Feedback was provided throughout the inspection. What the service does well: Residents are assessed by the home, prior to admission, to ensure that it can meet prospective resident’ needs. Copies of all relevant assessment documentation are also obtained from social services before offering a placement at the home. Prospective residents and their families are provided with the opportunity to visit and assess the quality, facilities and suitability of the home. Residents are provided with either a copy of the home’s written contract or placing authority’s terms and conditions so that they are aware of the services being provided to them. The home is run and managed by a person who is appropriately qualified and has considerable experience within the care setting. The home creates an atmosphere where residents and staff can express and contribute to the running of the home. The home ensures that there are sufficient numbers of staff on duty to meet the needs of the residents. The staff team reflects the gender composition of the residents and residents who were spoken with commented very positively about the care provided by staff. Residents benefit and are supported by a staff team who continue to receive ongoing training, feel well supported and who are appropriately supervised. Residents are also supported and protected by the home’s recruitment practices. Residents live in a comfortable, safe and well-maintained environment, which meets their individual and collective needs. The home is kept clean and tidy and provides sufficient communal space together with adequate bath, shower and toilet facilities. Residents have personalised their bedrooms to varying degrees and to their individual wishes. Residents who were spoken with commented positively about the level of accommodation provided and they confirmed that their bedrooms are kept clean and tidy. Adequate laundry facilities are in place to meet the needs of the residents and staff tend to DS0000028277.V316075.R01.S.doc Version 5.2 Page 6 undertake these duties. Residents who were spoken with commented that they were happy with the laundry arrangements in place stating that their clothing is suitably returned. All residents are provided with a care plan which identifies their strengths, needs, preferences and aims and objectives. Residents are supported to take risks within a risk management framework. Residents are encouraged and supported to achieve their greatest level of independence and control over their lives, which includes the right to make their own choices and decisions. Residents are supported and encouraged to access and take part in a range of activities both within the home and within the wider community. Residents maintain contact with their families and friends in accordance with their preferences and their rights are respected by staff. Residents receive a varied and satisfactory diet. Residents who were spoken with commented very favourably about the quality and quantity of food provided, stating that they receive plenty. Residents’ physical, emotional, personal support and health care needs are being suitably met. Staff, in line with the home’s practice, administer residents’ medication and appropriate systems are in place. Information is provided to residents on how to complain should they wish to do so. Residents who were spoken with commented that they had no complaints/concerns. However, they also felt confident that they could discuss any concerns with the management and staff of the home. Appropriate procedures are in place to protect the residents from abuse. The health, safety and welfare of the residents and staff are promoted and protected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000028277.V316075.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 DS0000028277.V316075.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): 2, 4 and 5 This judgement has been made using available evidence including a visit to this service. Residents are assessed by the home, prior to admission, to ensure that it can meet their needs. Prospective residents and their families are provided with the opportunity to visit and assess the quality, facilities and suitability of the home. Residents are provided with a copy of the home’s written contract or placing authority’s terms and conditions so that they are aware of the services being provided to them. Quality in this outcome area is excellent. EVIDENCE: The home, as part of its admission process, always undertakes its own assessment in respect to any prospective resident admitted to the home. Copies of other relevant information including copies of the care programme approach, client history and management plan/risk assessment completed by social services are also obtained, prior to admission. Since the last inspection, only one resident had been admitted and evidence was available to confirm that the home’s pre-assessment/ dependency profile had been completed in respect to the resident. In addition copies of the care programme approach and previous risk assessment reviews completed by the mental health team and other relevant information had been obtained. Evidence was also available to show that the home had confirmed in writing that the home could meet the resident’s needs based on their assessment and were happy to offer him a place. DS0000028277.V316075.R01.S.doc Version 5.2 Page 9 Prospective residents and their families can make as many introductory visits to the home, as they wish, to assess the quality, facilities and suitability of the home. This process is evident in the home’s admissions policy. The resident who was spoken with confirmed that he had made a pre-visit to the home with his community psychiatric nurse. Evidence was also available to confirm that his family had visited the home on another occasion prior to his admission. Residents who are privately funded are provided with a copy of the home’s contract. However, where residents are funded by social services, they would be provided with a copy of the relevant local authority’s statement of terms and conditions. Evidence was available to confirm that a signed contract had been established for the resident recently admitted. Contracts have also been established for all other residents admitted to the home. DS0000028277.V316075.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 and 9 This judgement has been made using available evidence including a visit to this service. All residents are provided with a care plan to ensure that their care needs are being appropriately met. Residents are supported to take risks within a risk management framework and are encouraged to achieve their greatest level of independence. Quality in this outcome area is good. EVIDENCE: All residents are provided with a long term assessment and care plan which identifies their strengths, needs, preferences and aims and objectives. Residents’ care plans are initially reviewed within the first month of admission, which provides the basis for the future development of the care plans. Shortterm plans have also been established which identifies specific goals that the home and resident are working towards. Residents’ care plans are signed and dated by them which confirms their involvement in this process. Residents receive a psychiatric review every six months. Written evidence was available to confirm that the new resident’s placement had been reviewed since he had been admitted and this involved all relevant parties. DS0000028277.V316075.R01.S.doc Version 5.2 Page 11 Residents are encouraged and supported to achieve their greatest level of independence and control over their lives, which includes the right to make their own choices and decisions. The home has an understanding of the rights of residents. The residents can come and go without restriction and opt in and out of any activities. Mealtimes can be made flexible to accommodate this. Residents can, within reason, get up and go to bed when they want within a structured environment. Residents who were spoken with confirmed that they are expected to get up for breakfast, they can come and go without restriction, choose how and where to spend their time, but are expected to be in their bedrooms by 22:30 where they can watch television if they want. Residents commented that they were happy with these arrangements. Risk assessments are completed as part of residents’ care plans. However, a “risk screen” is also completed on admission in respect to all residents and these are reviewed at least yearly. As stated in Standard 2, the home also obtains a copy of the management plan/risk assessment prior to admission where a prospective resident is known to exhibit behaviour problems. As also stated in Standard 7, residents are encouraged and supported to achieve their greatest level of independence and come and go as they wish. DS0000028277.V316075.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to access and take part in a range of activities both within the home and within the wider community. Residents maintain contact with their families and friends in accordance with their preferences and their rights are respected by staff. Residents receive a varied and satisfactory diet. Quality in this outcome area is good. EVIDENCE: Opportunities are available for residents to continue to take part in activities engaged in prior to entering the home or establish new ones where they have changed localities. Most residents have valued daytime occupation and attend the Salisbury Industrial Therapy Unit for various days of the week. Two residents attend the Shaw Trust Gardening Centre one day a week and another two residents undertake voluntary work. Residents come and go as they wish and there is no restrictions placed on them attending any activities of their choice. Residents use a variety of means of transport, which includes buses (with them having their own bus passes), DS0000028277.V316075.R01.S.doc Version 5.2 Page 13 taxis and walking. The range of activities now available to the residents has increased both within the home and externally. Organised activities are arranged which include swimming, bowling, snooker and riding for the disabled. Residents attend the drop in centre (Elizabeth House) and access the various activities and social events on offer. Small groups of residents also attend TABS which provides free to learn courses. Residents have the opportunity to pursue their own hobbies and interests and are encouraged to do so. Some residents also attend the church of their preference. Staff duties cover attending and supporting residents in activities and appointments. The home has an open policy on visiting hours and residents can choose whom and where to see any visitors, either in their bedrooms or in the quiet area within the dining room. Residents have the opportunities to meet and make friends with people of their choice. Staff will involve and assist residents to undertake some tidying of their bedrooms. Although currently locks have not been fitted to the residents’ bedroom doors, these can be fitted on request. Staff respect residents’ private areas and knock before entering their bedrooms. This practice was evident during the inspection. Residents can choose how and where to spend their time and again this was observed and confirmed by those residents who were spoken with during the course of the inspection. Residents have unrestricted access to the home and grounds. Smoking is restricted to the rear garden and “Chalet”, which is located at the bottom of the garden. Residents’ incoming mail is given directly to them unopened, although staff would assist residents to understand the contents of their mail, if required. A phone is available within the home for residents to receive any calls. The provider reported that a number of residents have their own mobile phones to make outgoing calls. Alternatively, residents can use the public call box located in close proximately to the home. A satisfactory and varied menu is in operation which provides a choice at all mealtimes, including a cooked breakfast at weekends. A cook is employed to undertake the main cooking duties. There are various dining areas within the home and there is an expectation that residents will eat their meals within these. Drinks are also available for residents at other set times of the day and staff would facilitate this. Residents who were spoken with commented very favourably about the quality and quantity of food provided, stating that they receive plenty. DS0000028277.V316075.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 This judgement has been made using available evidence including a visit to this service. Residents’ physical, emotional, personal support and health care needs are being suitably met. Staff, in line with the home’s practice, administer residents’ medication. Quality in this outcome area is excellent. EVIDENCE: None of the residents require assistance with regard to personal/intimate care, although a number of them need support and prompting. A policy has been established which states that male staff will not provide intimate care to female residents. Some flexibility exists in respect to the times for residents to get up, go to bed, have a bath and eat their meals. Residents are reported to choose their own clothes, although support would be provided if required. Residents are registered with one of seven surgeries within the Salisbury area and have a choice of General Practitioners. Where residents are admittedly locally, they would maintain their own GP unless they choose otherwise. Residents can independently access these or any other health care services. Residents normally attend the surgery for any appointments, either on their own or with the support of staff. The community psychiatric nurse visits weekly to provide depot injections and counselling as well as monitor blood levels. As part of these visits the community psychiatric nurse would liaise DS0000028277.V316075.R01.S.doc Version 5.2 Page 15 with the psychiatrist and home if she has any concerns. The psychiatrist visits the home every three months to primarily review any residents by appointment, although other residents would also be seen where the home has any concerns. The district nurse provides any nursing treatment as and when required. The home’s policy is for staff to maintain control and administer all residents’ medication unless agreed otherwise with the resident’s care manager. Evidence was available to confirm that three residents were partly selfmedicating and this related to personal use of inhalers. The home uses the Boots monitored dosage system and examination of residents’ drug sheets showed that these are being appropriately initialled for medication administered. Appropriate systems are also in place for the receipt and return of unwanted medicines. Staff do not administer medication unless they have achieved appropriate training for this. Evidence was also available to confirm that a large proportion of staff have achieved such training. Management also stated that there are always two members of staff involved in the process of medication administration. DS0000028277.V316075.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 This judgement has been made using available evidence including a visit to this service. Residents are confident that any complaints/concerns raised by them will be suitably dealt with and appropriate procedures are in place to protect the residents from abuse. Quality in this outcome area is good. EVIDENCE: The home has established an appropriate written complaints procedure and each resident has been provided with a copy. Residents who were spoken with commented that they had no complaints/concerns but felt confident that they could discuss any concerns with the management and staff of the home. Management reported that no complaints have been received by the home since the last inspection. The home has robust procedures in place for responding to suspicion or evidence of abuse and these include a Whistle Blowing procedure. Copies of the shortened version of the Swindon and Wiltshire Vulnerable Adults Procedures, which are in line with the Department of Health guidance “No Secrets”, have been distributed to all staff. Some staff who were spoken with confirmed that they have received training in this area. The issue of abuse is also covered during the induction of new staff. DS0000028277.V316075.R01.S.doc Version 5.2 Page 17 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, 26, 27, 28 and 30 This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, safe and well-maintained environment, which meets their individual and collective needs. The home is kept clean and tidy and provides sufficient communal space together with adequate bath, shower and toilet facilities. Residents have personalised their bedrooms to varying degrees and to their individual wishes. Adequate laundry facilities are in place to meet the needs of the residents. Quality in this outcome area is good. EVIDENCE: The location of the home is convenient for residents who make use of the facilities and amenities of Salisbury. The property is in keeping with its surroundings and the residential neighbourhood, although the design and layout of the home is not suitable for wheelchair users. The premises provide sufficient lighting and ventilation with furnishings, fittings and decoration being maintained to a good standard. The level of heating to the top floor of one part of the building has been resolved since the last inspection and a suitable temperature is now being maintained. In addition, redecoration has also been carried out to some residents’ bedrooms. Management reported that there are DS0000028277.V316075.R01.S.doc Version 5.2 Page 18 plans to convert one of the kitchens to provide additional dining space but will retain a small kitchenette. They also intend to create a doorway through to the adjoining property on the ground floor. The premises provide ten single and five shared bedrooms for residents’ use. Two of the single bedrooms are provided with en-suite facilities. Residents’ bedrooms located on the first and second floor levels are accessed by use of a staircase with one bedroom located on the ground floor. Residents’ bedrooms are suitably furnished and they can bring limited items of furniture and personal possessions to make their bedrooms more homely. Residents have personalised their bedrooms to varying degrees but to their individual wishes. Residents’ bedroom doors are not provided with locks but management reported that locks could be fitted at the request of the residents. This policy was reinforced at a recent residents’ meeting. Residents are provided with a lockable storage space within their bedrooms. Residents who were spoken with commented positively about the level of accommodation provided and they confirmed that their bedrooms are kept clean and tidy. The home provides adequate bath and toilet facilities to meet the needs of the residents accommodated. These facilities consist of three bathrooms, two of which have shower facilities, two separate shower rooms together with ten toilets, five being separate from the bath and shower facilities. All bathroom and toilet doors are fitted with suitable locks. The communal space consists of two lounges, two dining rooms and a dining area within the kitchen. These facilities are comfortable and suitably decorated and furnished. A chalet is located at the rear of a well-maintained garden, which has been designated as the smoking area for the home thus providing a smoke free zone to all other parts of the environment. The home continues to be maintained to a satisfactory standard being clean and tidy. Residents are encouraged and supported by staff to keep their bedrooms tidy. The laundry room is located on the ground floor and attached to the building of Dunraven House, which provides adequate facilities to meet the needs of both homes. A smaller washing machine is available for those residents who wish to undertake their own washing, however, staff tend to undertake the laundry duties. Residents who were spoken with commented that they were happy with the laundry arrangements in place stating that their clothing is suitably returned. DS0000028277.V316075.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 and 36 This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s recruitment practices. The home ensures that there are sufficient numbers of staff on duty to meet the needs of the residents. Residents benefit and are supported by a staff team who continue to receive ongoing training and who are appropriately supervised. Quality in this outcome area is good. EVIDENCE: The deployment of staff ensures that there is a minimum of three members of care staff on duty throughout the waking day with two care staff sleeping in each night. There are also four domestics employed who are deployed to work throughout all three homes, providing a full clean in each home once a week with additional cleaning undertaken daily by the care staff. The staff team reflects the gender composition of the residents and residents who were spoken with commented very positively about the care provided by staff. Four newly appointed staff files were checked and these showed that the home is following appropriate recruitment practices and these include obtaining a full employment history, two satisfactory written references and satisfactory Criminal Record Bureau enhanced checks. However, the home was advised to obtain a police check and a reference from the last employer in respect to the DS0000028277.V316075.R01.S.doc Version 5.2 Page 20 overseas member of staff via the employment agency. Where this documentation is already available, it must be translated into English. The advice was provided to further improve the existing good practice maintained by the home. Evidence was available in the staff files to confirm that the newly appointed members of staff had completed the home’s induction training programme, which is normally completed within six to eight weeks. On completion of this programme staff would be considered to undertake the National Vocational Qualification level 2 in Care as well as the various mandatory training courses. A training matrix has been established by the home for easy monitoring of training undertaken as well as training due to be completed by staff. A training plan has also been established for each member of staff which identifies the training already achieved and any future goals. At the time of the inspection, the home had achieved approximately 57 of staff being trained in NVQ. A further nine staff should achieved the NVQ level 2 in Care award by the end of March 2007 and a further seven in NVQ level 3 in Care by the same date. Clearly the home is working very hard to achieve a trained workforce by 2007. The home continues to ensure that staff attend and update their knowledge through training and this was confirmed by staff who were spoken with. There are a range of mechanisms in place for the proprietors to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include regular staff meetings, daily handover meetings and both formal and informal staff supervision. Staff who were spoken with confirmed that they receive formal supervision and they are happy with the level of support available. Staff files checked also confirmed that staff were in receipt of regular supervision. DS0000028277.V316075.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 42 This judgement has been made using available evidence including a visit to this service. The home is run and managed by a person who is appropriately qualified and has considerable experience within the care setting. The home creates an atmosphere where residents and staff can express their views and contribute to the running of the home. The health, safety and welfare of the residents and staff are promoted and protected. Quality in this outcome area is good. EVIDENCE: Mrs O’Connor-Marsh has primary management responsibility for this home and is qualified as a State Enrolled Nurse, has obtained the Certificate in Social Services which includes a Management component and is currently undertaking the Registered Managers’ Award. Mrs O’Connor-Marsh also has considerable experience in the care profession. She is supported by a deputy manager who has day to day responsibility for the care provided to the residents and is currently working towards achieving the NVQ 4 Registered Managers’ Award. DS0000028277.V316075.R01.S.doc Version 5.2 Page 22 Discussions with staff and residents indicated that there is an open, positive and inclusive atmosphere within the home where the proprietor/manager communicates with a clear sense of direction and leadership. Staff feel able to contribute ideas and suggestions pertaining to the running of the home. Regular staff meetings and daily hand over meetings have been established which ensure that staff are kept fully up to date. Staff commented that management are very approachable and they are happy with the level of support provided. Staff morale is good and staff commented that they work well as a team and they are happy with the training opportunities available to them. Likewise, residents feel able to discuss any issues or concerns with the management and/or staff and feel these would be suitably dealt with. Residents’ meetings have been established which are held every two months and provides them with a forum to discuss any issues pertaining to the running of the home. Residents also have the opportunity to discuss individual issues through the key worker system. Management ensures that there are safe working practices within the home and these comply with the relevant legislation. Risk assessments have been established to ensure a safe working environment. All bedroom windows from the first floor upwards are fitted with window restrictors. Written evidence was available to show that appropriate servicing, tests, checks, drills and instruction to staff are being carried out in respect to fire prevention. A tour of the premises did not identify any major health and safety issues. Staff continue to undertake the various mandatory training and a number of staff are due to undertake further training in health and safety and food hygiene later this year. DS0000028277.V316075.R01.S.doc Version 5.2 Page 23 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 4 3 X 4 4 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 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 3 X X X 3 X DS0000028277.V316075.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA34 Good Practice Recommendations The registered individuals should strongly consider obtaining a police check and a reference from the last employer in respect to the overseas member of staff recently employed. DS0000028277.V316075.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000028277.V316075.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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