Inspection on 26/04/06 for FCH - 39 & 41 Derwent Road

This inspection was carried out on 26th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

FCH - 39 & 41 Derwent Road 30/10/07

FCH - 39 & 41 Derwent Road 11/10/05

FCH - 39 & 41 Derwent Road 27/06/05

FCH - 39 & 41 Derwent Road 01/10/04

FCH - 39 & 41 Derwent Road 05/05/04

FCH - 39 & 41 Derwent Road 30/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Fch - Derwent Road, 39 & 41 39 & 41 Derwent Road Bedworth Warwickshire CV12 8RT Lead Inspector Sheila Briddick Key Unannounced Inspection 26th April 2006 08:30 Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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 Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fch - Derwent Road, 39 & 41 Address 39 & 41 Derwent Road Bedworth Warwickshire CV12 8RT 02476 314504 02476 314504 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) FCH - Housing and Care Mrs Claire-Louise Groom Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Claire Louise Groom must achieve the Registered Managers Award Level 4 by 30th June 2006. Claire Louise Groom must have opportunity to manage a New Admission Referral to a Care Home by 30th August 2006. 11th October 2005 Date of last inspection Brief Description of the Service: 39 and 41 Derwent Road is a registered care home for six adults with a learning disability. FCH Housing and Care, (FCH), provides personal support on a 24 hour basis for the people living in the home. The service is located in Bedworth, and is within walking distance of the small town. It is situated in a quiet lay by, with its own parking area. It has been designed and adapted for people with profound physical disabilities. The two bungalows, 39 and 41, are each home to three people; staff are employed to work across the service. Service users each have their own bedroom. Shared space consists of a bathroom, toilet, a lounge and kitchen. There is a dining area in the kitchen at number 41, and in the lounge at number 39. Each bungalow has a separate laundry room. The link between the two bungalows houses the office/sleeping room for staff. There are well presented gardens to the rear of each property, which can be accessed by service users from the lounge. There is wheelchair access to the garden areas. Parking is available at the front of the property. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This unannounced inspection took place over one day and commenced at 8.15am on Wednesday April 26, 2006 and finishing at 4.30pm. The inspection involved: • • Discussions with the ‘Acting Manager’ and care workers on duty at the time. Two service users were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for residents. A tour of the environment was undertaken, and records were sampled, including staff training, health and safety, rotas and fire records. Interactions between service users and staff were observed. Surveys were sent to relatives and professionals, six were completed, three by family members, and responses analysed. • • • Finally, feedback took place with the Registered Manager and Care Manager about the inspection findings. What the service does well: The people living in this home are being supported to live ordinary and meaningful lives, which includes participation in a wide variety of activities in the community in which they live. Staff are very positive about ensuring service users achieve and enjoy their wishes and choices. Service users are supported to keep memories alive of their experiences through life story records, photographs and other memorabilia. The staff team are committed to developing and maintaining personal and family relationships for service users and are commended for this support. Care practice is supporting and respecting service user’s individuality, dignity and privacy, which is promoting well-being and independence. Comments received from professionals involved with the service included: Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 6 Concerns are always dealt with quickly and appropriately. Staff are welcoming, and well-informed. Any interventions are well discussed and carried out. I have been visiting Derwent Road for two years for staff training. I am always made welcome and they are a good staff team. 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. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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 Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is not available for the people who may wish to come and live in this home in a style that will be meaningful to them, to allow them to make an informed decision about living there. EVIDENCE: There has been no progress made in reviewing the Statement of Purpose for the home so that it is applicable to the care home setting and in a format that will meet the needs of prospective service users. There have been no new service users coming to live in this home for some time therefore this key standard was not applicable at the time of the inspection. A service user currently living in the home has expressed an interest in living more independently and the staff team are working with local social services in looking for alternative accommodation. A referral has been made to social services for a re-assessment of the service user’s needs. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and well documented care planning system in place which clearly identifies how assessed and identified needs are to be met however, staff do not always have sufficient information regarding strategies that are necessary to keep people safe. Service users are being supported well when making choices and decisions through effective use of a variety of communication methods. EVIDENCE: Two care plans were chosen at random to examine and case track throughout this inspection visit. Each care plan had been generated from the homes own assessment tool or care management assessment and covered all aspects of personal and social support. Care plans are in the form of a ‘Tenant Profile’. The Tenant Profile contains sufficient information regarding all aspects of personal care, preferred choices and known likes and dislikes. There is Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 10 particular good practice in profiles regarding sounds of everyday life that service users like to hear for example, one care plan states -- -- likes to hear the ping of the microwave when making a drink or preparing food, so ensure that he hears this. Specialist services are involved in care planning and support reviews of specific care needs, which include, epilepsy, diet, physiotherapy and significant behaviours. A community nurse who visits the home stated on written feedback that concerns may be raised with parents and are always dealt with quickly and appropriately. Known risks are well recorded on the Tenant Profile however support strategies had not been clearly recorded for staff to follow to minimise the risk, for example, kitchen activities and aromatherapy activities. Psychology services support the service in reviewing changing needs however care plans do not evidence that strategies being used have been agreed with specialist services. Key worker meetings are held very regularly and records show that service users are involved as much as possible in the review process. Whilst the home has worked hard to ensure information is thorough and complete on care plans the case tracking process at this inspection showed some shortfalls in linking all information together into the care plan. For example, a key worker meeting for one service user recorded their mood as being low, a letter from the psychologist for the same period states that they were pleased with the service user’s progress and an incident record at that time records the service user causing harm to another service user. There was no specific care programme in place or strategy of support for the service users emotional care needs to link these incidents. The service is involving service users in decision-making using a variety of communication a involving signing, makaton symbols, pictures, photographs and audio tapes. Finances are managed well and risk assessments are in place. If service users are not able to make decisions regarding their finances family members are acting as an advocate. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The system for service user consultation in this home is good with a variety of evidence available to indicate that service users views are both sought and acted upon. Links with the community are good and support and enrich service users social and educational opportunities. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The people living in this home either access a day service or participate in the home’s established day opportunity structured programme. This is led by a staff team with specific day activity responsibility. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 12 At the time of the visit people were either at day services, having lunch out before going to Mallory Park, (a motor racing circuit), or attending college for flower arranging classes. Diary records seen show that a wide range of activities in the community is being accessed. For example, in one week a service user had been to Stratford-upon-Avon for the day, visited a Water Park, had been shopping in the local town and enjoyed a pub lunch. Activities are happening throughout the week, evenings and at weekends. Staff spoken with said that peoples lifestyle is good and, we provide plenty of activities and they are equally structured. Staff are fully aware of the individual interests of service users, i.e., football, horror movies and music sessions. There is evidence in the home, and in service users diaries, to reflect these interests are accessed and enjoyed regularly. Throughout the visit staff communicated well with service users, offered choices and gave time for decision making. There is good evidence in care planning and around the home to show that service users are supported to maintain relationships with family and friends. This includes, overnight stays with family, holidays with family, attending family celebrations with staff support and maintaining family links with relatives living overseas by telephone, audio or video format. Service users have been supported to develop family histories and this has included returning with service users to places they grew up. The staff team are to be commended for this commitment. Life story records are maintained to a high standard and have done so for a number of years. It has recently been the 10th anniversary of the people coming to live together and as part of the celebration they put together a display of their achievements in meeting their personal goals. This in itself demonstrates how well the service is supporting and promoting ordinary and meaningful lives for the people living there. Personal achievements have included, a ride in a police car, a visit to Euro Disney, speedway racing, a plane journey, off roading in a Land Rover, going to the Liverpool Football Stadium and visiting the Eden Project. Food provision in this home is good. Menu plans are completed weekly with service users and consider healthy eating with various communication aids being used to enable choices to be made which includes picture cards and cookbooks. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 13 Mealtimes are not set and happen according to the days activities. Menus show that meals are varied and tasty. There was sufficient fresh and convenience food in the home. Food was being stored safely and fridge and frigid temperatures are maintained well. Specific dietary needs as part of management of diabetes is supported and monitored by a diabetic nurse and includes training staff in awareness of diabetes management. Staff access training in Healthy Eating through a Distance Learning programme. The Commission for Social Care Inspections Highlight of the Day information has been accessed and staff are looking at ways the advice can be implemented. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The healthcare needs of the people living in this home are assessed and recognised with evidence of specialist services being readily available to them. Medicine management is generally safe and being administered by trained staff. EVIDENCE: Care plans clearly describe service users preferences about how they are moved, supported and wish their personal care needs to be met. Staff spoken with demonstrated a good understanding of the individual care needs of the people living in the home. Care practice observed throughout the inspection visit was sensitive and promoted dignity, independence and privacy. Staff communicated at all times about the action being taken when supporting people. Examples of good care practice included, • Chatting socially with a service user while her hair was being brushed into a style of her choice. DS0000004327.V288891.R01.S.doc Version 5.1 Page 15 Fch - Derwent Road, 39 & 41 • Positioning a service user suitably in front of the television screen to watch a programme of the service users choice, which they appeared to be enjoying tremendously. There is a diverse staff team supporting service users with their personal care needs according to individual wishes and chosen activities. There are systems in place to ensure that the health-care needs of service users are monitored on a regular basis. Individual records on care plans were up-to-date and in good order. Staff working in the home are liasing with health-care specialists for a variety of support needs including diabetes, epilepsy, continence management and physiotherapy. Service users have the opportunity to attend routine screening clinics if they wish and flu vaccination is offered annually. The service is aware of the concerns a relative has regarding service users being offered minimum annual health checks. How this is addressed by the service was discussed with managers. Currently the service user’s GP does not offer an annual health check, other than Wellman or Well Woman clinics. The service is aware that a Health Action Planning programme is being implemented by the Community Learning Disability Team for all people in the area with a learning disability and intend to support service users fully as they become involved in the programme. Care planning and health monitoring records for service users demonstrate that staff have a good awareness of the changing health-care needs of service users and take prompt action for referral to appropriate specialist or services as these arise. The service manager and acting manager demonstrated their responsibilities in maintaining and promoting the health care of the people living in the home and confidence in the systems they have in place for monitoring health-care needs. Medication management in this home is generally good. All people administering medicine only do so after completing accredited training and the management monitors their competency regularly. The Medication Administration Records (M.A.R Charts) for two service users were examined. Some minor discrepancies were identified on records and in the storage of medicines as follows: • • Paracetamol tablets given as required on one day had no record of why the medication had been administered on the reverse of the chart. Boxes of Rectal Diazepam had no opening date on them. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 16 • It is practise in the care home for two staff to sign for all medicine administered. This can be misleading as double signatures were against all dosage times on the MAR sheet, for example, the record for one tablet to be administered twice per day and signed by two staff suggests that four tablets may have been prescribed in the day. It was noted that when family members take medicine out of the home to be administered by them at home. they are signing the administration record. This does not guarantee that the medicine has been administered, or at the prescribed time. A good practice recommendation was discussed that when medicine is taken out of the service for administration, the MAR sheet should record D and the reason why documented on the reverse side of the MAR chart. Consent to medication being administered has been sought when possible from service users and documented on their care plan. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system and can evidence that service users views are listened to and acted upon. There are policies and procedures in place for the protection of service users from harm. EVIDENCE: Throughout the inspection visit staff demonstrated good care practice in enabling service users to make choices and make their views known about the days activities. This was done sensitively and at a pace and level to individual needs. During discussion, staff spoken with demonstrated a good knowledge of how individual service users make their views known and care plans include details of the preferred communication style of the person. Staff spoken with had attended training in Equality and Diversity. They felt that people living in the home ‘were safe’ and that ‘activities are equally structured’. Staff are accessing training in the Protection of Vulnerable Adults (POVA) and were able to demonstrate through discussion an awareness of their role and responsibility within this. Policies and procedures for the management of service users finances are robust and include individual risk assessment and training for staff in record Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 18 keeping. Where a service user is not able to sign agreement to their financial management then family members, or their advocate, are doing so. Information regarding Advocacy Services available locally is displayed in the home. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is warm and welcoming and provides service users with a safe place to live. EVIDENCE: Both living environments were clean, bright, comfortable and homely. All external areas are well maintained with tidy gardens. Service users enjoy the garden in the warm weather and get involved in garden activities, going to local garden centres to purchase plants. The ‘old’ boundary wall, which was unsafe and in a dangerous condition at the last inspection has been replaced making the area safe. This was not the responsibility of Friendship Care Housing but they have taken this action in the interests of the safety of the people living and working in the home until ownership of the boundary can be confirmed. Redecoration has taken place at 41 Derwent with new flooring being laid in the hallway and corridor. The flooring is more suitable to the needs of the people Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 20 living there, taking up dirt from shoes and wheelchairs. The gas fire in the lounge no longer used has been disconnected from the main supply. Staff said that it is planned for the surround and fire to be removed in the planned maintenance programme for 2006. Service user’s bedrooms in both accommodations were clean and attractively furnished to meet individual needs. Bathrooms are fitted appropriately with sufficient aids and adaptations necessary to meet assessed needs. This includes bath chairs, adjustable bath/showering facilities and removable bath panels to enable safe hoisting. The hoist over the bath at 39 Derwent can be used for either a bath chair or sling and therefore adaptable to meet individual bathing needs. Toilets and bathrooms are in good decorative order, warm and welcoming. Individual toiletries are kept in trays in bathrooms – this presents no risk for service users at 41 Derwent but may do at 39 Derwent. Laundry facilities are domestic in style and washing procedures displayed show that effective infection control is being practised. Cleaning schedules are in place for monthly, weekly and daily general cleaning and cleaning of service user’s bedrooms is scheduled into their weekly activities so they can be involved. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well-trained, and enthusiastic staff team who work towards common goals. EVIDENCE: The recruitment records for two staff were examined. These staff were new to the service since the last inspection. Both records were in good order and contained all records and information required by the Care Homes Regulations. This included, evidence of Criminal Record Bureau clearance and that two written references had been obtained prior to an appointment being made. There is an excellent and thorough Induction Procedure completed with new staff, which is implemented from the 1st day the employment commences. This is signed and dated by the manager and staff member at each meeting. On employment staff are given a copy of the General Social Care Council’s Code of Practice. Staff spoken with felt that they were a cohesive team, they felt involved saying, ‘we all know what is going on’ and ‘ we have regular supervision and team meetings’. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 22 Staff said that training opportunity was good and supporting specific needs of the people living in the home. Recent training has included Bereavement and Counselling and Equality and Diversity. There is an active NVQ in Care assessment programme in place and staff also complete Learning Disability Award Framework, (LDAF) training. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported well by her senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The registered manager is currently on maternity leave and satisfactory arrangements are in place for the running of the home during her absence. The responsible person working in the home at the time of the visit demonstrated through discussion they had the skills and knowledge necessary for promoting and maintaining the health and well-being of the people living and working in the home. They demonstrated a good understanding of the inspection process and participated well in this. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 24 Throughout the inspection visit it was observed that service users were listened to and involved in all aspects of life in the home. Feedback from relatives received as part of this inspection indicated that they are consulted about the care of their family member and that they were satisfied with the overall care provided. A visiting Distance Learning Tutor who has been visiting Derwent Road for two years commented that they are always made welcome and they are a good staff team. The service also sends out annual questionnaires to staff, relatives and consultants and this was currently taking place. The acting manager said that following the results of the questionnaire an action plan would be completed to address any service improvement that may be identified. Records examined showed that staff are being trained in safe working practices as part of their induction and at regular intervals to refresh their knowledge and skill. This includes fire safety, moving and handling, first aid, food hygiene and infection control. Health and safety checks in the home take place regularly and outcomes are documented. All records regarding health and safety were up to date and in good order. This included fire safety records which evidence that fire alarms are tested weekly and emergency lighting is tested monthly. Fire drills take place with the most recent being during the night time and this took place in April 2006. Any accidents or incidents that happen in the home are recorded however these are not always forwarded to the Commission for Social Care Inspection as required under Regulation 26 of the Care Homes Regulations 2001. Accident records examined evidenced five incidents that affected the health and well-being of service users had not been reported. The environment has been assessed for risk and these are due for review. Risk assessments include the use of fire guards as part of fire safety management. Staff spoken with had a good awareness of risks in the home for the people living there and the strategies in place to keep them safe, however the strategies were not always recorded on risk assessments, for example, accessing the garden area and kitchen facilities. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 25 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 N/A 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 2 X Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The statement of purpose and service user guide must be made available in a format suitable for service users needs. (Previous timescales of 1/4/05, 30/9/05 and 01/01/06 not met) The registered manager must ensure that there is care plan in place for each assessed need of a service user and that these are reviewed as needs change and documented on the care plan. The registered manager must ensure that risks in any activity in which service users participate is, so far is reasonably practicable, free from avoidable risks and that strategies to minimise risk are agreed with specialist services and documented on the service user’s care plan. The practice of keeping toiletries in bathrooms must be assessed for risk of harm and appropriate action taken, in the event of any risk being identified, to keep people safe. DS0000004327.V288891.R01.S.doc Timescale for action 01/08/06 2. YA6 15(1) 30/06/06 3. YA9 13(4)(b) 30/06/06 4. YA9 13(4)(c) 30/06/06 Fch - Derwent Road, 39 & 41 Version 5.1 Page 27 5. YA20 13(2) 6. YA42 42.7 The registered manager must 15/06/06 make arrangements for ensuring that medicines are handled according to the guidelines from the Royal Pharmaceutical Society of Great Britain All accidents and incidents that 27/05/06 occur in the home, or any event that affects the health or wellbeing of the service user must be reported to the Commission for Social Care Inspection. Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 28 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 It is recommended that when medicine is taken out of the service for administration, the MAR sheet should record D and the reason why documented on the reverse side of the MAR chart. It is recommended that the practice of keeping toiletries in bathrooms on open shelves be discontinued. 2. YA24 Fch - Derwent Road, 39 & 41 DS0000004327.V288891.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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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