Inspection on 28/06/06 for Elcot Close (5)

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elcot Close (5) 21/12/05

Elcot Close (5) 15/07/05

Elcot Close (5) 10/02/05

Elcot Close (5) 12/10/04

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

CARE HOME ADULTS 18-65 Elcot Close (5) Marlborough Wiltshire SN8 2BB Lead Inspector Pauline Lintern Key Unannounced Inspection 28th June 2006 10:00 Elcot Close (5) DS0000028533.V302101.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 Elcot Close (5) DS0000028533.V302101.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. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elcot Close (5) Address Marlborough Wiltshire SN8 2BB 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) 01672 516320 White Horse Care Trust Mrs Christine Messenger Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (2) of places Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated in the home at any one time is 5 No more than two service users admitted as younger adults with a learning disability may be accommodated after attaining their 65th birthday. 21st December 2005 Date of last inspection Brief Description of the Service: 5 Elcot Close is a spacious detached well-maintained property situated on the outskirts of Marlborough town centre. The home is registered to provide residential care for up to five people who have a learning disability. It is managed by the White Horse Care Trust and is one of a number of care homes run by them. The house, which is in a quiet cul-de-sac, has a pleasant enclosed garden to the rear of the property and an open planned garden at the front. The home provides single bedroom accommodation for three service users and a shared room for two. The home has its own transport so service users can access the wider community and attend a range of health care provision. Typically the home provides a minimum 2 staff on duty during the day. At busy times extra staff may be deployed. There is no awake staff at night, support staff take it in turns to sleep in so as to be available to respond to any night time needs as they arise. Additionally there is an on call system in operation so extra help can be summonsed in an emergency. The home encourages and enables service users to maintain their independence. The philosophy of care is in line with the principles of John OBriens five accomplishments. The Registered Manager is Christine Messenger. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over four and a half hours. The manager was there on arrival but had a previous engagement so left the deputy to assist the inspector. The inspector met two service users and was able to obtain their views on the service. The commission sent out surveys to relatives, GP’s, service users and staff. The inspector toured the building, which is in the process of having alterations made to it, to provide another bedroom downstairs, a bathroom and a new kitchen. Documents sampled included care plans, risk assessments, health and safety, recruitment, training and complaints. All key standards were inspected during this visit. The fees charged at 5 Elcot close start at £957.00p per week. Additional costs, which are met by the service users include; hairdressers, toiletries, books, magazines, holidays and social outings. What the service does well: What has improved since the last inspection? The review process of risk assessments has improved. The fire risk assessment has been reviewed. Medication records show that medication is being recorded when it is administered to service users. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 6 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. Elcot Close (5) DS0000028533.V302101.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 Elcot Close (5) DS0000028533.V302101.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Service users are provided with some information in their service user guide to enable them to decide if they wish to live at the home. Service user’s needs are assessed prior to being offered a service. Quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Each service user has a copy of the service user guide. However during examination there was some information missing. This was passed on to the deputy who confirmed that she would ensure that this is rectified. Service user surveys confirmed that they were asked if they wished to move into the home. One service user added ‘ I like the home very much’. Service users said that they were given enough information on the home to enable them to decide if it was the right place for them. Assessments are carried out to ensure that the home can meet the needs of the service users. The three files sampled show that the Trust complete assessments regularly to identify any changes needed. Assessments cover religious beliefs, personal support requirements, social contact, health care needs, risk assessments and communication. Each service user has a contract, which outlines the cost of the service and the terms and conditions. There is also a pictorial format to assist understanding for service users who may not be able to read. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 9 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, 7and 9 Care plans are in place and reviewed regularly to ensure that the person’s needs are being met. Staff support service users to make decisions about how they wish to live their lives. To enable service users to live as independently as possible risk assessments are in place. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: During the inspection three service user’s care plans were examined. Each person has a review calendar in the front of the file, which shows the reader when reviews are due. As well as a care plan review each person has a support plan, which is also regularly reviewed. The manager reported that the key workers ensure that support plans are reviewed three monthly. Sampling of the files demonstrates that staff use them as a means of monitoring progress and change. The care plans include information on mobility, healthcare, confidentiality, communication, pen profile, activities, likes and dislikes. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 10 One service user’s care plan states that they can make choices verbally about all aspects of their life. The daily notes provided an example of a service user being asked if they needed help by staff and them choosing not to take it. The manager explained that although the home holds service users personal allowances, when individuals are going to the resource centre or out on a trip they are provided with their own purse and spending money so they are empowered to manage that money. Discussion with the deputy demonstrates that when there are concerns over service users behaviours, procedures and protocols are put into place with specialist guidance. All staff receive training in physical intervention. The deputy confirmed that staff had recently completed refresher training in this subject. One service user who spoke to the inspector said that she enjoyed going shopping and that she always chooses her own clothes. All care plans have a statement informing the service user that the file belongs to them. Risk assessments have improved since the last inspection. Observation of the risk assessments demonstrated that they have all been reviewed recently (05/01/06. All staff sign to confirm that they have read and understood the contents. The staff have developed person centred ‘life’ books for each service user. One service user said that they enjoyed looking at photographs of families, friends and celebrations. The books belong to the service users and are located where they are easily accessible for them. The deputy reported that the service users spend a lot of time looking through their ‘life’ books with the staff. The ‘life’ book and the care plans are both separate sources of information and do not confuse the reader as to their purpose. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16 and 17 Evidence indicates that service users have the opportunity to take part in age appropriate activities. Many activities are available for service users in both the local community and further a field. Contact with family and friends are encouraged. Service users rights are respected. Meals are balanced and varied. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: All of the service users living at Elcot close attend the Wyvern College during the week. At the college they do various activities for example sports, IT, literacy, numeracy and communication. During the inspection one person told the inspector that they enjoyed going to ‘work’. There is also provision for the service users to attend the Marlborough resource centre. One service users attends the ‘New Road group’, which is a charity drop in centre. One service users has been awarded certificates for ’skills for life’, ‘learning to choose staff’ and ‘towards independence’. The manager explained that three service users wished to ‘earn’ some money. It was agreed that the trust would pay the national minimum hourly rate to the Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 12 service users for doing some domestic chores around the house. One service user appeared pleased to be able to earn some money and reported to the inspector that she liked to spend it on sweets, clothes and makeup. The focus on accessing the community and leisure activities rates very high at the home. The activities timetable indicates they access many facilities. There is evidence of trips to the pub, walks, bowling and attending birthday parties of friends and service users in some of the Trusts’ other homes. The Trust holds a regular ‘crafty club’ and the venue alternated between the various homes. This enables service users to form friendships with people other than those they share a home with. The ‘life’ books show many photographs of celebrations, day trips, theatre trips and holidays. Service users confirm that they have holiday arrangements planned for this year, which they are looking forward to. The staff explained that they are on many mailing lists now and receive flyers on forthcoming events and shows. These are then distributed to the service users and they have the opportunity to pick where they wish to go. Pantomimes and shows look to be among the favourites by the amount of programmes and souvenirs that are kept in the ‘life’ books. In house activities include the karaoke machine, which the staff say is very popular and also, knitting, TV, videos and music. Staff confirmed that some service users enjoy going to one person’s bedroom and they all chat and listen to music or watch DVD’s together. If the person whose bedroom it is does not want company staff reports that she will say so. There is a pet cat that belongs to one service user and appears to be pampered by its owner. Service users are able to maintain relationships with families and friends. One service user was looking forward to a trip home at the weekend to stay with their parents. Staff report that families are involved in the planning of care and most attend the meetings. The deputy reported that when service users relatives visit they have the opportunity to see their family member in private if they wish. However generally everyone joins in for a chat in the lounge. There are guidelines to ensure a safe environment for all service users. Only one service user actually uses their bedroom door key, the others choose not to. A risk assessment is in place that underpins this decision. All service users have the opportunity to attend a church of their choice if they wish. At the time of the inspection only one service user attends a local church. Staff confirm that they accompany them to the church and then collect them when the service is over. The Trust holds regular ‘resident’s consultation meetings’, where service users can meet up with people from other Trust homes and staff and share their views and discuss issues. The minutes from the last meeting (13th April) indicate that three service users from Elcot close attended. The deputy reported that one service user attended the meeting once, however on their return they informed the staff that they ‘did not like it and did not want to go again’. The deputy agreed that this was their choice. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 13 The deputy confirmed that service users are handed their mail if they are at home when it arrives. All correspondence is listed and reviewed at the three monthly support meeting. At election times all of the service users have a voting slip come through the post. The deputy confirmed that staff have explained what it was all about but no one chose to vote. Observation of staff members during the visit demonstrated that staff talk and interact with services users, not exclusively with each other. The home has a pleasant relaxed atmosphere and the service users appear to enjoy the friendly ‘banter’. Due to the home undergoing building work, there are parts of the garden that are not so easy to access at the moment due to scaffolding and building tools. The deputy confirmed that they are managing the situation by going into the community and avoiding the garden where possible. She commented that the people living in the house do not generally access the garden much anyway. There were some pretty plant pots, which one service user had taken responsibility for. At the time of the inspection the kitchen was temporarily out of use. Staff have made provision for this by ensuring that the meals planned for can be cooked in either a slow cooker, microwave or alternative device. On the day of the inspection the manager confirmed that she was going to buy an electric rice cooker for the home. Service users confirmed that they enjoy a take away and salads and so these will also be on the menu. One service user told the inspector that their favourite is sweet and sour pork balls. According to the deputy this is everyone’s favourite Chinese dish in the house. One service user said that the ‘food here is good’ and they ‘love carrots, cabbage and Sunday roast’; another service user agreed that the Sunday roast was a favourite along with potatoes. The menu was examined and it was varied and nutritional. The deputy confirmed that at the weekly service user meetings, service users have the opportunity to choose the meals for the following week form a book of menus and pictures. At the time of the inspection service users were observed being given a choice of sandwiches for lunch and the option of where they chose to eat them. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Service users are able to state how they wish their personal care to be delivered. Policies and procedures for medication protect service users where possible. Service users physical and emotional health needs are met. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: One service user who spoke to the inspector said ‘staff help me pick what to wear’. They added that the staff had helped them to loose a lot of weight and that their family was pleased as it is healthier for them. They explained that it was a combination of diet, using the exercise bike and walking. Documents show that service users inform the staff of their preferred method of bathing, whether it is a shower or preferring to relax in the bath. All personal care is delivered in privacy, either in the bathroom or in their bedroom. One service user reported that they like to buy their own clothes and make up and enjoy wearing jewellery, which reflects their personality. The services appear to enjoy shopping trips together. The home has a key worker system and they strive to ensure this remains consistent to enable good relationships. All service users have access to an annual OK health check. General health is monitored by the GP. Files show that other health care facilities are accessed Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 15 as required for example dentist, diabetic nurse, psychiatrists and opticians. Staff support individuals to attend any appointments. The recording of medication administration has improved since the last inspection. The storage of the medicines is secure. The administration of ‘as required’ (PRN) medication is recorded on a different coloured sheet to reduce the possibility of mistakes. Service users or their representatives have signed to confirm they agree to staff administering their medication. Training is given before staff is allowed to administer medication. Staff were observed being respectful and not rushing them, when offering to help someone do their hair. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users feel that they can express their concerns and that they will be taken seriously. Where possible policy and procedures protect service users from any form of abuse, neglect or self-harm. Quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There have been no complaints since the last inspection. The complaints log was examined and it demonstrated that any complaints are recorded and acted upon within the 28-day timescale. There is a complaints policy and procedure, which was reviewed on 1/06/06. Service users confirm that they knew how to make a complaint and who to speak to. The Trust provides service users with pre-addressed postcards to enable them to raise issues with the regional manager. The deputy informed the inspector that at the weekly resident’s meeting, they are always asked if they have any worries or concerns. One service user commented that they would ‘talk to staff or their mum’ if they needed to. Another forum where service users are able to raise concerns is at the resident’s consultation meetings. Policies and procedures are in place to protect service users where possible from any form of abuse. Staff receive training in abuse awareness. One staff member told the inspector that they knew the procedure for safeguarding adults and that they would have no qualms in reporting a colleague if necessary. The home has a ‘whistle blowing’ policy, which was reviewed in April 06. Staff confirmed that they have a copy of Swindon and Wiltshire’s guidance ‘No Secrets’. A copy is available in the dining room of the home also. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 17 The deputy confirmed that all relatives of service users have a copy of the complaints procedure. There was a discussion with the manager with regard to the ethos /culture of the home. Due to many long standing relationships between some staff members and some service users the manager has developed individual statements for each service user’s care plan to explain that sometimes the communication exchange could be perceived as over familiar with the use of ‘nicknames’. We agreed that the home has recognised the diversity of the service users and are ensuring that they are also safeguarding the individuals by putting down clear protocols. The inspector suggested that at the next care review the manager should raise this subject and ensure that all parties are in agreement with the arrangements. This should then be recorded and closely monitored. Observation of the communication between staff and service users during the inspection indicated that service users really enjoy the ‘playful’ banter. Elcot Close (5) DS0000028533.V302101.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, 25 and 30 Staff are ensuring that the home is as safe as possible whilst the building work in progress. Bedrooms are individual to suit each service user’s needs. The home is clean and hygienic. Quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: At the time of the inspection the home was in a slight state of disarray due to the building work taking place. However the remainder of the home was homely and comfortable. The new bedroom will enable one of the service users to enjoy their own room instead of sharing. There will be a new bathroom next door to the bedroom. The deputy confirmed that the service user was asked if they wished to move to a single room and had said that they did. We discussed what measures would be put in place to alert the staff member who would be sleeping in on the first floor in the event of an emergency. The deputy reported that they would be looking at the options available. Once the alterations are completed the home will still be in keeping with the local community. The home has a vehicle to enable service users to access the wider community. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 19 Part of the inspection involved a tour of the home and, with their permission the inspector viewed some service user’s bedrooms. They were found to be cheery and full of personal possessions such as photographs, books, pictures, dolls and ornaments. Each person has their own television set with a video player and music systems and plenty of CD’s. The deputy reported that some service users enjoy watching videos in their bedroom also listening to music. The washing machine and tumble drier are presently located in the conservatory. The deputy explained that laundry is carried to the washing machines in laundry baskets. Staff support service users by doing their washing for them. One service user will do their own ironing, however whilst the building work is going on staff are completing the task for them. The inspector noticed that there was no paper towels available in the downstairs toilet and raised this with the deputy. She explained that the home had experienced problems with service users disposing of them down the toilet, which had resulted in the drains becoming blocked. The maintenance file showed that the drains were unblocked April 06. It is recommended that advice is sort from environmental health regarding safe hand drying facilities that do not compromise infection control. The deputy confirmed that the hand towel is laundered each evening. Each bathroom and toilet had antibacterial hand washing facilities available. During the inspection the home appeared clean and there was no offensive smelling odours. Elcot Close (5) DS0000028533.V302101.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, 35 and 36 It appears that staff have the skills and experience necessary for the tasks they are expected to do. The home’s recruitment policies and procedures protect service users where possible. Staff ensure that service users have the opportunity to share their views. Generally staff supervision takes place regularly. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: One staff member who spoke to the inspector explained that they are in the process of completing the last work book for their Learning Disabilities Award Framework (LDAF) which covered adult abuse. They explained that this is in preparation for their National Vocational Award (NVQ). The staff member explained that they had started at Elcot close in November 05 and their induction covered all mandatory training such as manual handling, first aid, health and safety, basic food hygiene. They have also attended training in John O’Brien principles, key worker role and abuse awareness. They confirmed that they receive regular 1-1 time with their line manager and that they find the team meetings useful and ‘have learnt a lot from them’. She confirmed that since working at Elcot close they feel well supported by the manager and the Trust. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 21 The deputy and the manager are both NVQ assessors. The deputy said that she has her NVQ level 3 is in the process of completing her NVQ level 4 and the manager has her Registered Manager’s award and is also an Internal Verifier for NVQ. The Trust supports the staff to complete their NVQ awards. Each staff member has a personal training file, which details course completed and when refreshers are due. Observation of the staff on the day of the inspection indicates that they are good listeners and communicators. Three staff supervision notes were sampled; only one showed that they had not had supervision since 23/01/06. It is a requirement that staff receive regular supervision to ensure that they meet the requirement of at least six times in one year. Three recruitment files were examined and demonstrated that the home’s recruitment procedure safeguards service users where possible. Checks with the Criminal Records Bureau (CRB’s) are completed before new staff commences employment. Two satisfactory references are also requested. Verbal references were also noted as being received. There is evidence that staff are given a Statement of particulars of employment and a job description. Staff receive yearly appraisals to monitor their progress and to support their own personal development. Elcot Close (5) DS0000028533.V302101.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, 41and 42 5 Elcot close appears to be well managed. There is the opportunity for service users and their families to comment on the service. Where possible the health and safety of service users is protected. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: The qualifications of the manager are referred to in the previous outcome group. The manager has overall responsibility for the day-to-day running of the home and is supported to do so by the Trust. The Trust sends out quality assurance surveys to all next of kin each year to obtain their views on the service that is being provided. The audit tool for 2006/7 has not yet been completed but is in place in preparation. The home has a training and development plan which runs alongside the quality audit. The home then receive a breakdown of the comments. Service users have their weekly resident’s meetings and resident’s consultation meetings to enable them to feedback. Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 23 Where possible the manager ensures that the health, safety and welfare of service users is catered for. Staff attend manual handling training during their induction period and then follow up with refresher courses. Following the last inspection the Fire risk assessments are now reviewed and a copy is in the fire log. They were last reviewed 18/10/05 The home has a fire representative who has attended Fire awareness training. Records indicate that Fire drills take place regularly, the last one being on 17/5/06. The records state that the one, which was due for 04/06/06, could not take place due to the builders being at the home. The fire alarms were last tested on 26/6/06 and the emergency lighting on 03/05/06. Fire fighting equipment was tested on 04/06/06. All chemicals hazardous to health are locked away in a cupboard. The deputy explained that due to the building work they have had to relocate the materials into a locked cupboard in the kitchen for the interim period. The home completes Infection control audits. All radiators are covered to ensure there is minimal risk of burning from hot surfaces. Water temperatures are checked and recorded. Fridge and freezer temperatures are taken daily and hot and cold food is probed to ensure it is stored and served at a safe temperature. The accident book was examined. All recording of information is in compliance with the Data Protection Act. Staff are aware of the procedure for Reporting of Injuries; Diseases and Dangerous Occurrences Regulations (RIDDOR). All electrical appliance checks are completed. Elcot Close (5) DS0000028533.V302101.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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 4 13 3 14 4 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 3 3 X Elcot Close (5) DS0000028533.V302101.R01.S.doc Version 5.2 Page 25 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. 1 Standard YA36 Regulation 2 Requirement Timescale for action 28/08/06 2 YA1 The registered manager must ensure that all staff receive regular recorded supervision at least six times a year. 5(1)(bcdef) The registered manager must ensure that the service user guide contains all relevant information as identified in the National Minimum Standards. 28/09/06 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 YA41 YA29 YA30 YA13 YA23 Elcot Close (5) Good Practice Recommendations It is recommended that leaving gaps between entries in daily notes and communication books be avoided where possible. It is recommended that consideration is given on possible equipment to be used for a call system located in the new ground floor bedroom. It is recommended that Environmental Health are consulted about safe hand drying facilities. It is recommended that the manager discusses cultural and communication diversity at the care reviews and recorded. DS0000028533.V302101.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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