CARE HOME ADULTS 18-65
Ferrers Drive (3) 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ Lead Inspector
Malcolm Kippax Unannounced Inspection 19th December 2007 11:50 Ferrers Drive (3) DS0000003196.V353699.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 Ferrers Drive (3) DS0000003196.V353699.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. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ferrers Drive (3) Address 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ 01793 875898 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) Ian Charles Miss Michelle Stephen Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd October 2006 Brief Description of the Service: 3 Ferrers Drive is run by a partnership, which operates under the name of Ian Charles. The home is located in Grange Park, which is a residential area on the outskirts of Swindon. 3 Ferrers Drive is a two storey detached property with a large garden. Each person has their own bedroom. Two of the bedrooms are on the ground floor. The communal rooms consist of a large lounge and a kitchen with a dining area. There is an office on the first floor, which is also used as a staff sleeping-in room. People living at the home receive support from the home’s manager and a team of support workers. The range of fees is £800 - £1000 per week. There are additional charges made for hairdressing, toiletries, activities, papers and magazines and transport. Information about the home and Ian Charles is available in a ‘Statement of Purpose’. Copies of inspection reports can be obtained from Ian Charles and are also available through the Commission’s website at: www.csci.org.uk Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home, which took place on 19th December 2007. A second visit was arranged with the home’s manager, Miss Stephen, in order to complete the inspection. This took place on 3rd January 2008. We obtained evidence during the visits through: • • • • Time spent with the five people who were living at the home. Meetings with Miss Stephen and with a member of staff. Observation and a tour of the home. An examination of records, including three people’s personal files. We have received other information about the home, which has been taken into account as part of the inspection: • An Annual Quality Assurance Assessment (referred to as the AQAA) that was completed by Miss Stephen in November 2007. The AQAA is the provider’s own assessment of how well they are performing. It also provides information about what has happened during the last 12 months. Three surveys about the home that were completed by the relatives of people who live at the home. Five surveys that were completed by staff members. A Quality Assurance survey that was sent to us after the visits. • • • The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visits. What the service does well:
A person’s needs are assessed before they move in, to ensure that the home is suitable for them and can provide the right support. After the move, an individual plan is written, so that there is good information about the support that the new person needs and how staff should provide this. The plans are reviewed regularly to reflect any changes in people’s circumstances. People are assisted with making decisions and can take risks within their capabilities. The risks are assessed, which helps people to be safe in the activities that they want to do. People receive support so that they can keep in touch with their family and friends. Some people were writing Christmas cards when we first visited the home. They had talked about what they would like to do over the festive period and some people had recently been to the pantomime. The relatives who completed surveys commented positively about the support that the home provides. They thought that people’s needs were being met. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 6 The home is in a well established residential area and people have contact with the wider community. They have interests outside the home, such as going to the gym, and are asked about new things that they would like to do. Within the home, people are encouraged to take responsibility for the household tasks. Some people like to be involved in the kitchen and they can help staff to prepare the meals. Everybody helps to plan the menus and can suggest meals that they would like to have. One person said that they chose to have a fresh pear and a fruit and fibre type cereal for breakfast. People receive the support that they need with personal care and to keep healthy. Staff members help people with their medication, so that this is managed safely. People receive help with making appointments. One person said that they had recently been to the dentist. Somebody else had specialist needs and they were receiving support from the Community Team for People with Learning Disabilities. House meetings are arranged, when people have the opportunity to talk together about things that affect them. A complaints procedure is displayed in the home and people are also asked about any concerns that they may have. Staff members receive guidance and training which help to protect people in the home from being harmed. 3 Ferrers Drive is homely and looks clean and tidy. People use their own rooms but also like to be together in the communal areas. There is a well furnished lounge and a dining area. Most of the laundry is done in a utility room, which is away from food areas and reduces the risk of cross infection. Checks have been carried out on new staff, which helps to ensure that they are suitable to work with people in the home. The staff team meet together regularly so that they can share any issues and agree a consistent approach. People’s health and safety are generally well protected. The people who live at 3 Ferrers Drive benefit from a well run home and from an experienced manager who is appropriately qualified for the role. What has improved since the last inspection?
More details have been added to people’s individual plans, so that they fully reflect their needs and the support that they require. The plans have also been organised into a single document, which means that the information is more easily available. This was recommended at the last inspection. Much of the home has been redecorated, so that the environment continues to look well kept. There is a new three-piece suite in the lounge, which is comfortable and popular with people. Opportunities for staff training and development have improved. Staff members have undertaken a range of training during the last year. This has
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 7 included courses in infection control, safeguarding vulnerable adults, health and safety, and food hygiene. The training has meant that staff are more competent to undertake their duties and that, as a result, people in the home are better supported and protected. Quality assurance is being developed, to give better information about how the home is performing. People in the home and other stakeholders have been asked for their views in surveys. Their feedback has been analysed and acted upon. This process helps to ensure that the home is run in the best interests of the people who live there. 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. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move in, to ensure that the home is suitable for them and can provide the right support. EVIDENCE: We spoke with one person who had moved into 3 Ferrers Drive since the last inspection. They talked about the move and the support that they received. Miss Stephen confirmed that the move had gone well and that sufficient information had been received about the person’s background and individual needs. This person had an individual file in the home. The file contained assessment records and other pre-admission documentation. A community care assessment had been undertaken, which provided information about the person’s previous circumstances and their feelings about a move. Other assessment forms had been completed about their likes and dislikes and their personal and domestic skills. Visits to the home, including an overnight stay, had been arranged. This gave staff the opportunity to find out more about the person and whether the home could meet their needs. There was correspondence between the home and the person’s funding authority. This concerned the home’s suitability and confirmed the
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 10 involvement of a care manager. Information had been exchanged with the home about how the person could be helped to feel settled. Review meetings had been held after the move, when people talked about the move and how well the person had settled in. Minutes of the review meetings had been kept. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. People have individual plans, which give good information about the support that they need and how staff should provide this. People are assisted with making decisions and can take risks within their capabilities. This helps them to have independent lifestyles. People are encouraged to make choices, although there are house rules that could work against this. EVIDENCE: People had individual plans that described their personal care and support needs. These had been reviewed and updated during the last six months. The plans were in a similar, written format and consisted of a number of forms. They were well organised within files and easily accessible to staff. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 12 In their surveys, staff confirmed that they are given up to date information about the needs of the people they support. One staff member commented, ‘staff are always verbally informed of any changes, as well as it being written on care plans’. Miss Stephens reported in the AQAA that people had been encouraged during the last year to participate more actively in decision making, especially with care planning, reviewing and with updating risk assessments. This was reflected in the plans, which looked more detailed and ‘person centred’. It was also reported in the AQAA that there were plans to develop a way of measuring the effects of care plans through a better link with the review process. The plans covered a range of needs, in areas such as household tasks; developing social activities; meal arrangements; personal care; health and managing behaviour. In addition to identifying areas of need, there were sections in the plans that showed the agreed objectives for support and the actions that were to be taken. Information about people’s likes and dislikes and personal preferences were also included in other records, including a ‘Resident Profile’. People’s files included records of risk assessments that had been carried out for some of their individual activities. The assessments reflected an individual approach and recognition that people had different abilities and needs. For example, one person had a risk assessment about making a hot drink and another person had one about going out for walks. The plans included a section on ‘Choices’ and ‘Dreams’. Information had been recorded about the things that people wanted to do in the future. These included, for example, going out on day trips to new places. There was discussion with Miss Stephen about the recording of the goals that people hope to achieve in the future. It was agreed with Miss Stephen that it could be useful to identify timescales for particular goals and show the tasks that would need to be completed in order to achieve them. Decisions about people’s individual goals and needs were being made at review meetings to which relevant people from outside the home were invited. People also met together regularly to discuss issues and to make decisions about the day to day arrangements. Minutes were kept of the meetings. A list of ‘house rules’ was displayed in the office. These included having set times for meals and the need for baths and showers to be taken before 9.00 pm. Visitors were also asked to leave the home before 9.00 pm. From conversations with people during the visits it appeared that these rules were not being rigidly enforced. However, such rules are contrary to principles of normal living and something that should be reviewed and discussed with the people living at the home.
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive support that enables them to follow their interests and be part of the local community. People can choose the meals that they like and help to prepare them. EVIDENCE: People were engaged in different activities when we arrived at the home on 19th December 2007. Three people were out shopping with a staff member. Two other people were at different day activities in the community. People returned home during the afternoon and quickly settled into their own routines. We spoke to two people who were spending time together in the lounge. One person was working on a tapestry and somebody else was knitting a blanket. They said that they had some regular activities outside the home, such as going to a gym, attending some local clubs and visiting relatives. Another
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 14 person was writing Christmas cards in the dining room. They said that they were looking forward to seeing their sister who was visiting them the following day. A staff member said that people in the home often volunteered to help in the kitchen and took responsibility for some other jobs such as cleaning their rooms. During the visit on 19th December 2007, one person was helping a staff member to prepare the tea. The menu was on display in the kitchen. People said that they talked about the meals at the house meetings and made suggestions for the menu. People could choose what to have for breakfast. One person had a fresh pear and a bowl of a ‘fruit and fibre’ type cereal every day. They said that they had learnt about health eating and were pleased to have lost some weight. People said that they liked the meals. They ate together in the dining room in homely surroundings. ‘Ian Charles’ had sent surveys to people during the last year and analysed the results. It was reported that people in the home had highlighted food as being one of the key things that was good about the home. People has said that there was a good variety of foods and that the food was cooked and presented nicely. The home looked very festive at the time of the visits and people talked about what they wanted to do over Christmas. Some people had already gone to the pantomime in Swindon. When we returned to the home on 3rd January 2008, we saw a special Christmas menu that had been written. Most people did not leave the home by themselves and received support from a staff member. Following assessment, one person was able to go out by themselves. Each person had unstructured time during the week. This could be spent on household tasks, such as cleaning bedrooms. In their surveys, the relatives confirmed that they thought the home always supported people to live the life that they choose. One relative commented ‘I have always been told that they are adults and have a choice’. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 29 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the support that they need with personal care and to keep healthy. Staff members help people with their medication, so that this is managed safely. EVIDENCE: Information about people’s different personal and healthcare needs was recorded in their individual support plans. The plans included guidance for staff about when they should support people with their physical care and appearance. In the case of one person, this included support with treating a skin condition. There was guidance for staff to check this everyday and to record their observations in the person’s individual file. These records were being maintained. There was evidence of other monitoring on a regular basis, such as of weight and of bodily functions. These would help to identify changes, which could indicate a health concern that needed to be followed up. The plans referred to some ‘hands-on’ support that people needed, such as help with cutting nails. There was guidance about the support that people needed with bathing and with personal care. Sometimes the support from staff was in the form of prompting and encouragement.
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 16 In their surveys, two relatives confirmed that the home always provided people with the care or support that they expected. One person responded ‘usually’. Records were kept of the appointments that service users had with their GPs and other healthcare professionals. Forms were completed after each appointment. These provided a good report of the outcome and any action that needed to be taken as a result. One person said that they had recently been to the dentist. It was seen from the records that another person did not like going to the dentist and they had received support with attending a specialist service. In their survey, one staff member reported that supporting people with their medical appointments was one of the things that the home did well. People’s individual files contained records of the contact they had had with a Community Team for People with Learning Disabilities (C.T.P.L.D.). Miss Stephen spoke about a particular matter that was being followed up with the C.T.P.L.D. Correspondence about this was kept on the person’s file. Some new guidelines about managing people’s behaviour in the home were being produced. Some of people’s care needs and daily activities had been the subject of risk assessments. Assessments had been undertaken in respect of medication. People received support from staff with the safekeeping and management of their medication. The medication was kept securely and records were being maintained of its administration. Examples of the current records were looked at and these were up to date. There was a medication file, which included medication profiles and records of medication received into the home. A stock check was being carried out regularly. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. People’s views are listened to. Staff receive training and guidance which is helping to protect people. EVIDENCE: A complaints log had been set up. Miss Stephen said that no complaints had been received about the home since the last inspection. The Commission has not received any complaints about the home during this time. A complaints procedure had been produced. Miss Stephen reported in the AQAA that people in the home are regularly informed of the complaints policy and procedure should they wish to make a complaint. It was seen from the minutes of house meetings that people were being asked if they had any complaints. People were also raising issues that they wished to discuss with others. In their surveys, two relatives confirmed that they knew how to make a complaint about the home. The staff members confirmed that they knew what to do if a concern was raised with them. One staff member commented ‘we are made aware of the correct procedures for dealing with, and reporting concerns’. A copy of the complaints procedure was displayed in the front hall. People’s personal files contained a ‘Resident Profile’ that included information about activities or events that they might dislike or find harmful. There were risk assessments, with safety measures identified, which helped to minimise the risk of people being harmed.
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 18 There had been no safeguarding adults referrals during the last year. The home had written policies and procedures which covered safeguarding adults, the prevention of abuse and whistle blowing. There was a flowchart displayed in the office showing the action that needed to be taken if a concern was raised that involved possible abuse. Staff members had received training in the protection of vulnerable adults during the last year. A staff member who was met with said that she had read the ‘No Secrets’ booklet, which gave guidance about the local procedures for safeguarding adults. There was a risk assessment for people’s finances, which included the misuse and abuse of money. Miss Stephen described the arrangements in place for supporting people with managing their personal money. Staff members did not have direct access to people’s money, but could take money for specific purposes. This money was then accounted for using a system of numbered receipts. Staff members and the person concerned were both signing the personal money account records when a transaction was made. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good overall. This judgement has been made using available evidence including a visit to this service. People live in an environment that is homely, clean and well maintained. However, the lack of a fire risk assessment means that some further measures may be needed to ensure that people are safe. EVIDENCE: 3 Ferrers Drive is in a quiet location in a residential area on the outskirts of Swindon. The people who live at the home used local amenities and went into Swindon regularly. There was a bus route nearby. There was a parking area at the front of the home and a garden at the rear. Each person had their own room, which they could decorate and keep as they wished. It was reported in the AQAA that the home had been painted inside and outside during the last year. There were plans to improve the bathroom facilities. There was a large lounge with a television and a new three-piece suite. This room was well decorated and furnished. People were using the room during
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 20 the visits and said it was very comfortable. The lounge was looking very festive, with a well decorated Christmas tree and lots of presents underneath. The home had a domestic type kitchen, with a dining area. When people came home from their activities they had drinks and chatted together at the dining table. There was a washing machine in the room. Miss Stephens said that any items that could present a hazard in terms of cross-infection were laundered in a separate utility area that was off the front hall. There had been a requirement at the last inspection for staff to receive training in infection control. A course has since been arranged, which staff attended in April 2007. The accommodation looked well maintained, tidy and clean. There were fire alarm and emergency lighting systems. A log book was being maintained, which showed that the home’s fire precaution equipment and systems were tested regularly. Fire drills were being carried out and staff had received instruction about what to do in the event of fire. However, the suitability of the fire precaution arrangements in the home had not been the subject of a fire risk assessment. It was confirmed with Miss Stephen that the assessment process needed to be followed, as a means of ensuring that the appropriate safety measures are in place. Miss Stephen was recommended to look at the guidance on fire safety risk assessments in residential care premises that is available from the website: www.firesafetyguides.communities.gov.uk. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate and improving. This judgement has been made using available evidence including a visit to this service. More courses are being arranged, so that people will be supported by staff who are better trained. Checks are carried out on new staff, which helps to ensure that they are suitable to work with people in the home. EVIDENCE: It was reported at the last inspection that staff were not sufficiently well trained in the work that they performed. Requirements had been made for staff to receive further training in particular subjects. Miss Stephen reported on the progress that had been made in training since the last inspection. Records were looked at, which confirmed the details of the training courses attended. Training had been arranged in various subjects, including health and safety; infection control; food hygiene; protecting from abuse; safe storage and handling of medication; and first aid. Some courses had been arranged on two dates, so that the staff team could all attend. Other courses were attended by individual staff who had not yet received training in a particular subject. Copies of course certificates were kept on the staff members’ files.
Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 22 One of the requirements from the last inspection concerned the need to provide staff with training in the principles of caring for adults with learning disabilities. There had been a mixed response to this. One staff member has attended a ‘Principles of Care’ course and Miss Stephens said that it had not been possible to get another place on the course. More staff had attended a course on managing behaviour and communication skills. Two staff had completed their National Vocational Qualification (NVQ) at level 2. This left one person on the staff team who had not yet achieved their NVQ at level 2 or was not currently working towards this. It was agreed with Miss Stephen that further opportunities should be sought for staff to receive training in learning disability related subjects. Courses about nail care and about epilepsy had been arranged for January 2008. A new member of staff was going to attend a food hygiene course, as they had not been present for a course that staff had attended earlier in the year. This new member of staff had started in September 2007. They had a personal file in the home, which included information relating to their recruitment and subsequent employment. There was evidence of appropriate checks having been carried out before they started working in the home. These included Criminal Records Bureau (CRB) and Protection of Vulnerable Adults list (POVA) checks. Two written references had been received, including one from the staff member’s previous employer. Proof of identity had been obtained and evidence of this was kept on file. The staff member had completed an application form. Part of the form was for monitoring purposes and included a statement to confirm that the information in this section would be kept confidential and only used by the H.R. department to help in the monitoring of equal opportunities. The section included questions about ethnic origin. Questions were also asked about medical history and previous convictions, which would usually be included within the main part of the application form. This meant that, if the statement about confidentially were being adhered to, then some relevant information would not be available to the people interviewing the applicant. The staff members who completed surveys confirmed that checks such as CRB and references had been carried out before they started work. A staff member who was met with described the induction that they had received when starting in the home. They felt that they had been well supported. An ‘in-house’ induction checklist had been followed. In the AQAA, Miss Stephen reported that one of the things that the home could improve on would be link their induction and training to the Induction and Foundation element of the Skills for Care framework. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 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. 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. People live in a home that is generally well managed and safe. People are asked for their views about the home, which helps to ensure that it run in their best interests. EVIDENCE: Miss Stephen had been in post as the home’s manager for over eleven years. Miss Stephen has completed NVQ in care at level 4 and achieved the registered managers award. It was reported at the last inspection that the manager needed to ensure that inspection requirements are responded to within the timescales identified. The requirements that were identified or outstanding at the time of the last inspection have now received attention. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 24 ‘Ian Charles’ had produced a policy for quality assurance. Some records, including those relating to an internal quality review, were not available when the quality assurance arrangements were looked at on 3rd January 2008. We have since received a report from the home, which showed the outcome of a quality assurance survey conducted in 2007. Feedback had been received from the people who live at the home and from other stakeholders, including family members and outside professionals. People’s views had been analysed and the results collated. The report showed the action that had been taken as a result of the feedback received. Overall, the comments received about the home were very positive. For the purposes of future inspections, all the records relating to quality assurance, including internal reviews, should be available in the home. Heath and safety issues were being discussed at staff meetings and at the house meetings with people who lived at the home. Some regular checks were being made, as a means of ensuring that the equipment and the accommodation were kept in good order. Risk assessments had been done on a room by room basis to help identify any hazards and to remove or reduce these. The assessments were reviewed on 1st December 2007. Information about the servicing of the electrical, gas and heating systems in the home were confirmed in the AQAA. Control of Substances Hazardous to Health (COSHH) assessments had been completed for products held in the home. Records were being kept to show that the temperature of the hot water was being checked regularly to ensure that it was at a safe level. Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 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 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 13(4) Requirement A fire risk assessment must be carried out in order to ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Timescale for action 31/01/08 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 YA6 Good Practice Recommendations That, where appropriate, timescales are identified for people’s individual goals and a record is kept of the tasks that need to be completed in order to achieve them. This will assist in monitoring the goals and will help to ensure that they can be achieved without delay. That the need for the current house rules is reviewed and their content discussed with the people who are affected by them. This will help to ensure that any rules are reasonable and are in people’s best interests.
DS0000003196.V353699.R01.S.doc Version 5.2 Page 27 2. YA7 Ferrers Drive (3) 3. YA34 That appropriate advice is obtained about the design and content of the staff application form. In particular, confirmation needs to be obtained about what information should be asked for in the main body of the form and what should be asked for in connection with the monitoring of equal opportunities. This is to ensure that there is an effective equal opportunities policy and that the people who conduct staff interviews have the information that they need. That new staff receive an induction that meets the national standard for the social care workforce and the needs of people with learning disabilities. That further opportunities for training should be provided to staff in learning disability related topics, particularly in subjects that are relevant to people’s individual needs and diagnoses at the present time. 4. YA35 5. YA35 Ferrers Drive (3) DS0000003196.V353699.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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