Inspection on 29/01/07 for Evergreen Partnership

This inspection was carried out on 29th January 2007.

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

Evergreen Partnership 19/01/09

Evergreen Partnership 23/01/06

Evergreen Partnership 22/09/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Evergreen Partnership Maple House Woodmansterne Lane Wallington Surrey SM6 0SU Lead Inspector David Pennells Key Unannounced Inspection 29th January 2007 2:20pm Evergreen Partnership DS0000062089.V326909.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 Evergreen Partnership DS0000062089.V326909.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. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Partnership Address Maple House Woodmansterne Lane Wallington Surrey SM6 0SU 020 8254 9403 020 8254 9403 dan.maplehouse@btinternet.com 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) Jaqueline Cook Maureen Edith Collyer Daniel Royston Roberts Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Maple House (Evergreen Partnership) is a substantial house set on the southern outskirts of Wallington in Sutton borough, close to a bus stop, which can provide transport into the local Carshalton, Purley or Croydon areas. Being situated just off a roundabout, the entrance to the property can easily be missed, but once recognised, there is a driveway - which provides parking on site at the front of the house, for a number of vehicles. The house, which opened as a new service in mid-2005, is substantial; providing four good-sized bedrooms for service users, and plentiful communal space (a separate lounge / dining area / sun lounge), and adequate toilets and bathing facilities. There is a large rear garden area, with plans to use some of the garden - which is split into two - for growing vegetables, which ties in appropriately with the location, as Maple House is close to many market garden / garden centre outlets around the local area, which has an ‘agricultural’ / ‘countryside’ perspective to it. The service - a non-smoking facility - is designed to provide for up to four service users with learning disabilities and associated challenging behaviour, aiming to provide service users with: a range of opportunities to support and empower people…to enjoy a fully enhanced quality of life whilst supporting them to make informed decisions and choices about the way they would like to live…The focus will be on fun, choice, good health, enjoyment and comfort, providing people…the opportunity to expand their sphere of experiences and to develop their lives in creative and imaginative ways supported by a highly skilled and experienced staff team (extracts from the home’s Statement of Purpose). Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was conducted from early afternoon to early evening on a Monday (29th) and the morning of the subsequent Wednesday (31st) - both being ‘ordinary’ weekdays. The manager of the service, Danny Roberts, was available to assist the inspector on these two occasions, and other staff members and the two currently resident service users were available to meet the inspector and to add their opinions / perspective on the service provided. Questionnaire responses concerning the service were also received from the relatives of both service users, the GP, Care Managers, and the Clinical Psychologist and Consultant Psychiatrist working with the home - all reporting back a generally positive reaction. The inspector is grateful to service users, staff and the manager for their welcome, hospitality and cooperation throughout the inspection visit - and to all who contributed to the inspection process. What the service does well: What has improved since the last inspection? The service is now developing, thanks to the arrival of a second service user at the home, but the service is still looking towards providing a service for four, and the home certainly still feels underused. The staff team continues to grow - with the registered manager and deputy manager guaranteeing consistency of management input - and with staff training being generally promoted well. Since the last inspection visit, all requirements and recommendations set have been heeded and the home is better ‘primed’ for the more complex times ahead when staff will be supporting four service users with the demands that this will bring. Evergreen Partnership DS0000062089.V326909.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. The summary of this inspection report can be made available in other formats on request. Evergreen Partnership DS0000062089.V326909.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 Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be assured that sufficient information is available, for themselves and other interested parties, to assess the suitability of the service prior to admission - through the Statement of Purpose and other documentation. Service users can be confident that their needs and goals will be assessed using a comprehensive assessment tool, as well as the placing authority being required to provide adequate information. This leads to an accurate assessment of need, goals and aspirations - informing a decision as to whether the home is able to provide a suitable service to the applicant, and providing material for the consequent individual care plan. Service users can be assured that the process of introduction / familiarisation to the home will be taken seriously, and applied in the most suitable way to encourage induction / integration within the community at Maple House. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home has a good initial Statement of Purpose - describing the premises, the staffing, the aims and philosophy of care and itemising all areas to be addressed and described under Schedule 1 of the Care Homes Regulations 2001 and Standard 1 of the NMS. The documentation for the service users who were resident in the home was examined. The home has its own assessment tool, which had been used, alongside the funding local authority’s assessment of need - and a resultant full care plan and appropriate risk assessments were fully in place. All documents appeared to be authenticated by signature and dated - an important verification element. Now that two service users have been admitted, details of the admission process at the home have become clearer; the second service user’s placement was a useful tool to rehearse the process for the future, again. Staff members visited the newer service user in their previous placement in order to start familiarising themselves with them (and her with them) and to observe her routines. Due to the specific circumstances - and the distance of the service user away from Wallington - it had been agreed that visits to the house would not serve a useful purpose; the initial placement period served as the ‘introductory’ visit sequence to the home - which went very smoothly. Staff members from the previous placement have also visited - which has provided a sense of continuity. Documentation examined in the home showed that all necessary paperwork had been completed at the point of transfer, and the ongoing paperwork was in good order. Evergreen Partnership DS0000062089.V326909.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, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be involved in the home’s process of devising of their care plan – and will be encouraged to make informed decisions about their lifestyle through careful person-centred care planning. Service users can be assured that they will also be involved in all aspects of decision-making within the home as suits their capacity. Service users are well supported to take reasonable daily living risks; these areas being well documented and shared with the service user; the generic assessment format being used to consider all aspects of potential risk initially is backed up by a specific individual focus. Service users can be assured that information relating to them is kept safely and securely and within the parameters of best practice relating to data protection. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 11 EVIDENCE: The inspector found full care plans in place for both service users - this being related to the day-to-day recording, and alongside suitably pertinent risk assessments for both generic and any specific areas identified. Care plans evidenced service user involvement by their signatures - as appropriate clearly indicating their involvement with the planning / development process. Monthly summaries are maintained - reviewing the progress made by each service user - this being an excellent tool for when the formal reviews arise. Participation and consultation about life in the home - and the taking into account both current service users’ views and opinions have clearly been taken into account entirely along the way - and different strategies are in place to ‘consult’ each service user, due to their different ways of expressing themselves. The longer-term service user again confirmed that she is involved in all major decisions about the service provided. The longer-term service user was clearly well prepared for the arrival of the second person coming to live at the home. The integration of the two has happened virtually without incident. The advent of the second service user has not - it appeared - changed the focus and culture of the house as dramatically as it could have - though, of course, another two service users are yet to be admitted to the remaining vacant spaces. Risk assessments are in place appropriately for the current service users, these based on the initial comprehensive assessments and the home’s ongoing observational / experiential assessment. Impressively, both service users had been assessed with regard to participation in the November ‘Bonfire night’ fireworks display. A wider ‘generic’ risk assessment format is now in place to initially countercheck all possible avenues of risk against each individual service user - this ensuring that the risk assessment process is as ‘proactive’ as is possible. The management have clearly taken on board the requirement for risk assessments to be comprehensive - as required by the last inspection and the overall comprehensiveness of meeting this standard leads the inspector to award an ‘excellent’ grading to standard 9. General house-focused risk assessments have also been completed. Documentation is all held within the locked office on the first floor - with appropriate security being provided for varying levels of paperwork. Locked cupboards and a safe are provided for specific items in need of appropriate security. Evergreen Partnership DS0000062089.V326909.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): 11 - 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is focused on providing client-centred activities both outside the home and ‘at home’; encouragement is provided to service users to participate in local activities, as well as the more formal structured day care provision. Leisure opportunities are facilitated through staff being familiar with likes and dislikes, and enabling involvement with as much preferred activity as possible. Service users are encouraged to remain in contact with family and friends through visits to them, and these people are all made positively welcome at the home. Service users can expect their rights to be respected and upheld through a relaxed culture in the house and through choice being promoted. Service users can be assured of being provided with a nutritious and healthy diet - served in line with best catering practice, and that they may participate in catering for their own self-development, independence and enjoyment. EVIDENCE: Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 13 Both current service users have the opportunity to attend formally run day care centres (funded by the placing authority) and such activity provides solid hours out from the home can provide ongoing contact with peers and friends. One service user may attend their day centre up to five days a week, though this is not always continuously the case. Opportunities provided by day care include sports / ambling / games / swimming and free-choice activities. Other activities engaged in - through facilitation by the home’s staff - include: cinema, bowling, visiting cafes and restaurants / pubs and longer outings, if preferred. Staff and service users do the food shopping for the home and also shopping expeditions are enjoyed for personal items. The home continues to investigate and introducing the idea of newer, local clubs (Mencap, etc.) though service users do also have the need to be ‘at home’ relaxing, as well as engaging in ‘outward bound’ activity. Staff members are committed to escorting service users to these new clubs / events / etc until such times as confidence is built and an independent approach may be taken. In-house activities are designed to respond to the needs and suggestions of the service user; there are a variety of board games / TV / Video / Music and other activity resources provided by the home. More focused communication sessions and 1:1 activities are provided according to each service users’ plan. The parents of service users have both confirmed that they are made welcome at the home; it is the home’s positive intention to support clients to maintain links with both family and friends. Telephone contact is also important, and a portable house phone enables calls to be taken in privacy. One service user again stated that the daily routines of the home do not obstruct her right to freedom of choice. She has a key to her own room - and staff members respect this as her private space. Staff members positively interact with both service users, and both also enjoy spending time on their own in their own rooms - one with her computer or the television. The kitchen is well equipped and there were adequate food stocks provided. Large stocks are not necessary at the home (due to the low number resident); and the focus on going out and shopping for ‘what we fancy’ enables the direct participation of the service users in the provision of food. Food records were kept, and indicated a broad approach to nutrition. It was again good to see items served with chips being interspersed with more ‘healthy’ salad meals and other broader styles of cooking (omelettes / roasts / pasta, etc.). One service user has succeeded in losing unnecessary weight very well since being resident at the home. Evergreen Partnership DS0000062089.V326909.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 20 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the home aims to provide personal care in an individually focused and sensitive way, and will seek to promote their health and wellbeing through ensuring appropriate contact with health care professionals - and also through the home managing any medication regimes, where appropriate. Service users can be assured that they will be supported when ill and as they age - with appropriate steps being taken to ensure sensitive and individualised care, including end of life care, once sufficient detail in this regard is on file. EVIDENCE: Healthcare support is generally provided from the Shotfield Health Centre in Wallington and the Stafford Pharmacy provides the medication service and also the Pharmacy inspection / advisory visits. Access to other paramedical services such as opticians and dentists will be accessed as much as possible from ‘mainstream’ services unless a specialist focus is advised. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 15 Psychology / Psychiatry and Speech & Language specialist input is provided via the Integrated Community LD Team / Orchard Hill. Medication is provided in MDS (monitored dosage system) ‘blister packs’ – ensuring a safer method of administration than the traditional bottles / packet system. Medication storage and the records kept for the service users medication were examined and found well generally well maintained. A previous recommendation that a ‘medication profile’ should be established for each service user - enabling the home to record the medication / prescription history of each service user - has been adopted with a renewable sheet system now being in place. The inspector audited / tracked one service user’s medication profile history and found one anomaly - in that the stopping of a anti-inflammatory - though discontinued in practice (and hence not posing a direct opportunity for error) had not been properly ‘signed off’ in the accompanying documentation. It is important that the home maintains a very accurate - and continuous narrative to show how, when and why prescribed medication is stopped or changed. The inspector’s previous strong recommendation that as much detail concerning the individual’s / relatives wishes concerning steps to be taken should they be taken seriously ill or suddenly pass away - is kept confidentially on site - still requires more work and the recommendation is reiterated. This measure saves much heartache / trauma at the time of any such incident, and empowers the home to act in the individual’s - and relatives’ - best interests. Evergreen Partnership DS0000062089.V326909.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be sure that complaints and comments will be taken seriously and that their opinions are respected and taken into account. The home has provision in place to ensure the protection of service users from the possibility of physical, material or financial abuse or neglect, and has robust procedures to respond to any allegation or suggestion of such acts including support for staff to feel confident to ‘Whistleblow’ if, and where, appropriate. EVIDENCE: There have again been two informal complaints received, substantiated and resolved by the house since the last inspection visit. The standard was fully inspected during previous visits and found ‘met’. With regard to adult protection, a recurrent minor issue of concern - regarding unfounded allegations, had been properly reported to the host local authority, rightly ensuring that exploration of any issues of abuse is openly and transparently investigated. The home has it own policy regarding adult abuse and the current Local Authority Safeguarding Adults guidelines. Advocacy input is being sought for the newcomer to the home to support her independence. Financial recording was generally in good order, it being noted that service user was involved in signing for their personal allowance monies. Evergreen Partnership DS0000062089.V326909.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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to reside in a well-maintained clean, hygienic and comfortable environment, the premises being homely and very suited to the home’s Statement of Purpose. The home and service is designed to encourage independence, privacy and the maximisation of each individual lifestyle. EVIDENCE: The second bedroom on the ground floor has now been occupied; this leaving two upstairs yet to be populated. A shower cubicle has been installed in the ‘new’ service user’s bedroom to provide for their needs; this meaning that two rooms now have ensuite showers - all four have washbasins. Two toilets are provided on the first floor level and one is situated downstairs. Maple House is a very pleasant well-furnished environment in which to live; each service user has access to extensive well prepared communal areas, as well as a single bedroom each. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 18 All bedrooms are over 12 sq metres in dimensions; two of them now have an ensuite shower. On the first floor, also, are a separate toilet, a bathroom with toilet and Jacuzzi spa bath, and the office / staff room. The ground floor has the fourth single bedroom, with a shower-room and toilet close by. The lounge, sun lounge, and kitchen are also off the front hallway; the dining area is off the kitchen area, closer to the back door and over-looking the back garden. Garaging - close to the back door - is used for storage. The home has a fully integrated fire alarm system, and other health & safety precautions - such as thermostatic mixer valves on hot water outlets, are fitted as standard. The majority of the house remains even now ‘pristine’ in cleanliness and general decorative order. Bedrooms await the advent of service users to decorate and furnish their own space – and communal areas – though pleasant, again, will become very different once pictures and posters appropriate to the service users’ characters are introduced. The inspector wrote on the last inspection that he “looks forward to seeing the place properly ‘lived in’ – with a few bumps and scratches evident from the service users really enjoying living there!” Ironically, with the furniture of the new service user - much of which came with her, the sentiment has exceeded itself - and the inspector strongly recommends that the service user be encouraged to co-operate with the registered provider in finding some newer furniture which is in better condition and more fully operative. Sadly the chest of drawers was broken, and the generally poor condition of the furniture items left a lot to be desired. It is accepted that it was probably important for ‘familiar things’ to accompany the service user when first moving - however, now the settling in phase is through, a move towards gently upgrading some of the poorer quality items is clearly essential. Notwithstanding the above concern - which needs careful joint handling, the general quality of furnishings and décor remains very high. Evergreen Partnership DS0000062089.V326909.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, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect staff members to be competent and suitably trained / qualified, and provided at the home in sufficient numbers (in line with minimum standards) to fully meet the needs of service users. Service users can be assured that recruitment practices are generally fair, ensure their protection and safety, and that appropriately trained staff will be provided to meet their identified needs. The service provided by staff is adequate but would be enhanced if they were consistently supervised and supported through their employment processes. EVIDENCE: The staff team continues to develop – seven staff members were now employed at the home permanently (with one on a bank basis). More are being brought ‘on line’ in response to the need now to fully establish a fuller ‘24/7’ staffing regime fitting to the level of need / service user number. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 20 By the end of current recruitment, nine staff members will be directly within the home’s employment, with further staff input projected as the population of the home develops. At the time of the inspection visit, the two service users were receiving a 1:1 service during the daytime and one staff to two service users during the evening / overnight - when seniors are on call. Staffing is often ‘doubled up’ at weekends to allow for focused activities. CRB (Criminal Records Bureau) checks are obtained for all staff - all now have full CRB / PoVA checks completed by the managing company. All necessary references and checks are completed before staff members start employment. The manager is reminded to record the interviews undertaken and to evidence such explorations into areas such as any gaps in employment, etc. A greater exploration into the content of training courses claimed as prior experience is also recommended - as some training provided through care agencies can be somewhat ‘tokenistic’. Staffing qualifications currently held included SEN nursing backgrounds (with an attendant management focused course being undertaken) - as well as a staff member having a NVQ at level 2 in Care. Both the Acting Deputy Manager and one of the support workers are undertaking their Level 3 NVQ, and another is just completing their Level 2 coursework. The remainder of staff are being considered for the LDAF Level 2 NVQ certification. Clearly the manager has a critical eye on training potential for staff and the ensuring that levels of staff meet the national minimum standards, or above. Three seniors have undertaken Person-Centred Planning Facilitators Courses and two have engaged with Health Action Planning training. All staff members have been trained in ‘Autism & Challenging Behaviour’ and all have undergone Adult Protection training. Some staff members have attended ‘Mental Health & Learning Disability’ training. Two staff have undertaken the Intermediate Level Course in Care & Control of Medicines. Five staff members now have First Aid certificates and these alongside other ‘statutory’ courses must be borne in mind whenever the training profile and plan for the home is being confirmed. Four staff have food hygiene training, with more staff booked to attend - and the same figure applies to manual handling training input. Supervision records evidenced some laxness in maintaining regular twomonthly sessions with all staff - and a more recently recruited staff member’s induction record was also found to be incomplete. Some other small anomalies in record keeping and documentation, suggesting that the ‘eye had been taken off the ball a bit’ were pointed out to the manager - who recommitted to ensuring that such anomalies would be resolved. Evergreen Partnership DS0000062089.V326909.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, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and run on a basis of positive leadership, with a competent manager - supported by the positive encouragement of the registered providers. The views and opinions about the service expressed by service users will be noted and positively taken into account by the registered providers and acted upon. The health, safety and welfare of service users is generally well protected, with all safety provision suitably ‘tightened’ and ‘regularised’ - recognising the vulnerability of current & incoming service users now resident at the home. Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager, Daniel (Danny) Roberts, has a more than ten-year history of working in this field of social care; his focus must now be on achieving his Level 4 Registered Managers Award which will consolidate his caring experience with management skills to the required level approved by this Commission and Skills for Care. The Deputy Manager holds management responsibilities in the manager’s absence. Lines of responsibility seem clear - and all the small staff team express a sense of joint responsibility for the service. Quality assurance mechanisms have - on the 1:1 basis encountered thus far at the home - relied on verbal communication and feedback from the service user, her family and interested professionals. Due to the profoundly different natures of the two service users communication skills, the 1:1 focus continues. It is beholden on the manager to ensure that as the service grows, suitable and adequate mechanisms are put in place to regularly assess the service from stakeholder’s feedback. The service users at the house were seemingly happy with the service, one reporting again that she could engage well with staff and felt that her opinions / preferences were heard and acknowledged. Both service users’ relatives reported to the Commission they were happy with the service being provided most of the time, that they were welcomed at the home - and involved with decision-making in respect of their loved one, and that they were kept informed of matters relevant to them. Both also indicated that they have not had access to inspection reports at the home and this is something the home is recommended to rectify by making reports more openly available. The Commission’s Pre-inspection Questionnaire sent to the house and duly returned in good time, required details about maintenance and servicing contracts - all of which have been satisfactorily evidenced to the inspector. Fire Drills and associated fire alarm testing provisions are now carried out and recorded. An occasional weekly ‘miss’ was noted in the fire check records - this should be monitored and not allowed to occur, as should not a mis-message concerning smoke detector points being out of order resulting in the manager not being notified; this issue was immediately resolved on the day of the visit. There were eventually no significant outstanding issues relating to health and safety on the day of the inspection. The manager agreed to clarify the status of the electrical installation testing which should extend to five years - but was only ‘signed off’ for one. Evergreen Partnership DS0000062089.V326909.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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 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 3 4 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Evergreen Partnership DS0000062089.V326909.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. 1. Standard YA36 Regulation 18(2) Requirement That the registered manager ensures that supervision sessions are regularly provided to all staff members within the home to provide both support and developmental input for each individual. Timescale for action 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations That medication profile records should be accurately and thoroughly kept to ensure that an audit trail for all adjustments to medication can easily be ‘tracked’. That as much detail concerning an individual’s / relatives’ wishes concerning steps to be taken should the service user be taken seriously ill, or suddenly pass away - taken and stored confidentially - should be gained in respect of each individual and kept on file. 2 YA21 Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 25 3 YA26 The house should balance the issue of a service user’s ‘ownership’ of furniture which is no longer fit-for-purpose and of poor quality, with the service user’s right to good quality, functional and attractive provision. The manager is reminded to record interviews undertaken and to evidence such explorations into areas such as any gaps in employment, etc. A greater exploration into the content of training courses claimed as prior experience is also recommended - as some training provided through care agencies can be somewhat ‘tokenistic’. Checks such as fire alarm tests must be regularly undertaken on a weekly basis without fail - and any rectification of resulting failures should be actioned immediately by staff - in the absence of the manager, with the permission of the registered providers. Clarification regarding the mains electrical testing check which usually extends over a five-year period should be checked with the contractor. 4 YA34 5 YA34 6 YA42 7 YA42 Evergreen Partnership DS0000062089.V326909.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Evergreen Partnership DS0000062089.V326909.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!