Inspection on 09/10/06 for Glanmore

This inspection was carried out on 9th October 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glanmore 27/07/07

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

CARE HOME ADULTS 18-65 Glanmore 156 Holyhead Road Wellington Telford Shropshire TF1 2DL Lead Inspector Rebecca Harrison Key Unannounced Inspection 9th October 2006 09:10 Glanmore DS0000065368.V311342.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 Glanmore DS0000065368.V311342.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. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glanmore Address 156 Holyhead Road Wellington Telford Shropshire TF1 2DL 01952 251975 01902 873730 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) suehullin@tracscare.co.uk TRACS Ms Patricia Mary Ferguson Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate adults aged 18-65 years with a learning disability with or without associated mental health needs. Service users accommodated on the second floor must be fully ambulant. This service may accommodate within existing numbers one named service user with mental disorder only. Not applicable – New service Date of last inspection Brief Description of the Service: Glanmore is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of six adults with a learning disability with or without associated mental health needs and one named person with a mental disorder. The home is a large detached property situated on the outskirts of Wellington, Telford. The home is within an easy distance of local amenities such as shops, a college, pubs and medical facilities and a short journey from Telford Town Centre. Glanmore was registered with CSCI on 26th May 2006. The registered provider is TRACS Ltd with the responsible individual being Ms Susan Hullin and the registered manager, Ms Patricia Ferguson. The aims of the home are included in the Statement of Purpose which states that ‘Glanmore is committed to supporting clients towards leading as fulfilled life as possible, in an environment which: ° Places value on individual beliefs, choice and aspirations. ° Promotes maximised independence and community integration ° Provides a safe, nurturing and homely environment. The current fees charged per person range from £1800.00 to £2400.00 per week. CSCI reports for this service can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 09.10 a.m. and lasted 8.5 hours. It was carried out by talking with the two service users, staff on duty, the manager, case tracking two service users, observing work practices, reviewing a number of records and a full tour of the home. 22 key National Minimum Standards for younger adults were assessed in addition to Standards 1,3,4,5,33,36 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, staff on duty and the manager were welcoming and co-operated fully throughout the inspection. The purpose of the inspection was to assess ‘Key’ National Minimum Standards and to review the progress made by the home since the home was initially registered on 26th May 2006. No formal complaints have been referred to the Commission for Social Care Inspection (CSCI) however CSCI were notified of a concern in relation to the conduct of one service user who has since been discharged from the home. The home has received sixteen complaints to include two external complaints. No referrals have been made under adult protection procedures. What the service does well: Staff have a good understanding of the individual needs of the people they support and have developed positive working relationships with service users and other agencies. The organisation appears committed to providing a qualified workforce. The team functions well and both staff and service users were complementary in relation to how the home is managed. Service users are involved in all aspects of decision making and attend regular resident’s meetings. They have access to an independent advocacy service and are provided with designated key workers and co-workers for consistency and continuity of support. Daily routines are flexible and service users are responsible for cleaning their rooms, undertaking laundry tasks and basic cookery, which helps promote their independence. A Client Charter indicating all service users rights is included in the homes Statement of Purpose and Service User Guide. The home is equipped to a high standard and soft furnishings are of good quality and provide people with a comfortable and homely place to live. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 6 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. Glanmore DS0000065368.V311342.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 Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with sufficient information about what the service has to offer and terms and conditions of residency. EVIDENCE: A Statement of Purpose and Service User Guide is available and the manager reported that she has updated both documents in relation to the recent change of category of registration to accommodate within existing numbers one named service user with mental health needs. The application was approved by CSCI on 19th September 2006. It was stated that the revised documents will be available shortly and made available to service users and their representatives. Three people have been admitted to the home since it opened on 10.07.06. One person admitted via emergency admission has since been discharged following a breakdown of the placement after a number of incidents that involved the police and a formal complaint regarding the person’s conduct. Discussions held with the manager evidence that the home was clearly unable to meet the persons needs and was inappropriately placed. The manager fully acknowledged this and reported that the assessment obtained was not an Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 9 accurate reflection of the behaviours displayed and the compatibility and vulnerability of others led to the termination of placement. The admissions procedure was discussed with the manager as the provision to accommodate people on the basis of an emergency admission is not stated in the Statement of Purpose or in the admission procedure for the home. However the Service user Guide states that ‘Emergency Admissions are subjected to the same assessment process and clients are encouraged to visit, have a meal and stay over night….’ The two people currently residing at the home are placed on a short-term placement and are due to be moving to other homes managed by TRACS shortly. An Overview Assessment undertaken by the placing authority in addition to a comprehensive needs assessment compiled by the organisation was available on the file of the one person case tracked and a care plan and guidelines were available on the other persons file, who has been placed with the organisation for a number of years. It was reported that all future admissions would be based on a schedule of introductory visits to the home with unplanned admissions avoided where possible. Two other people are currently undertaking introductory visits to the home and one person is due to move in shortly. A date has yet to be finalised for the other person. The manager reported that the introductory visits for both people appear to be proving successful. Service level agreements were available on the files of the two people currently accommodated. One was signed by the service user and registered manager and the other signed by the manager. It was reported that the service user declined to sign the document. Glanmore DS0000065368.V311342.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 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 adequate. This judgement has been made using available evidence including a visit to this service. Care-planning systems are in place to adequately provide staff with the information they need to satisfactorily meet service users assessed needs. Individuals are involved in decisions about their lives, and play an active role in planning the support they receive. People living at the home are supported to take responsible risks. EVIDENCE: Detailed support plans were available for the two people currently accommodated. A support plan for the person who previously lived in another of the organisations home requires updating as parts of the plan refer to an educational placement and health information accessed via the former placement. Staff spoken with confirmed that they are provided with sufficient information to confidentially support the needs of the two people accommodated. A reactive management plan was not available on the file of the one person reviewed whose behaviours can challenge, to ensure that staff Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 11 are consistent in their approach and that any behaviours are managed positively. The manager confirmed that this would be developed over the initial thirteen week continuous assessment period however the person was placed on short-term care and due to moves services on 11.10.06. The manager was advised that this should be undertaken prior to admission for any future admission. Observations made and discussions held with service users indicated that they are able to make informed decisions. Each person has an allocated key worker and co-worker to support them and service users confirmed that they have regular opportunities to spend time with these people in addition to attending monthly residents meetings. Minutes of meetings held were available and each person provided with an agenda to raise any items to discuss prior to the meetings. One service user also reported that he has an advocate and a solicitor to represent his interests and the relevant contact details were available on file. Minutes of a meeting also evidence that both of these people where in attendance. As previously stated both service users are due to move on to other TRACS homes shortly. The minutes of a placement meeting were available on one file which evidence that the person has requested to move for personal reasons, which he shared with the inspector and this was also recorded. Discussions held with the manager confirm that the organisation is looking to support his request and an alternative placement has been sought but a date not yet confirmed. Risk assessments to support individuals taking responsible risks both in the home and community were available on both files reviewed. The manager confirmed that she has undertaken appropriate training in risk management in order to compile such assessments. Glanmore DS0000065368.V311342.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 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 good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style, and supported to develop their life and social skills. Rights and responsibilities are promoted and people provided with a varied diet in accordance with their personal preferences. EVIDENCE: Lifestyle objectives were available on the one file reviewed which identified short-term goals for employment and learning opportunities and stated that these would be followed up when the person transfers to a new placement shortly. The other service user reported that he has previously attended college courses, however does not wish to pursue his education at his current placement. Discussions held with both service users and daily records seen evidence that people have been supported to access their local community and make use of facilities and services. One person reported that he accesses the community Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 13 independently. Another person stated that he was recently supported to go to the cinema, play golf and attend a football match and that staff have helped him find out about local football leagues and his key worker is taking him to a gym. Both people have personal mobile telephones and a payphone is also available for service users to maintain contact with families, as they do not live local and therefore are unable to visit. A family and friends information sheet was available on both care files and provides contact details. Both service users reported that that they will live nearer to their families once they move to their new placements. Preferred forms of address were available on the files of the two people accommodated. Service users confirmed that they open their personal mail and that the homes daily routines are flexible. They reported that they are responsible for cleaning their rooms, their laundry, and basic cookery, maintaining the rear garden and assisting with general household jobs, which promote their independence. This was evidenced in daily records seen and through observations made throughout the inspection. All bedroom doors are lockable and service users can choose when to be alone or in the company of others. The home operates a no smoking policy and the service user who smokes is aware of this policy and therefore smokes outdoors. A Client Charter indicating all service users rights is included in the homes Statement of Purpose and Service User Guide. Menus are currently under review and have recently been discussed in a residents meeting and people asked about personal preferences. Fresh fruit and vegetables were readily available. One service user reported that the home is compiling a winter menu. A health eating recipe book has recently been developed and numerous other cookery books were readily available. One person stated that he recently baked two cakes with staff support and it was evident that he appeared to enjoy the activity. During the inspection both people were seen to make their own refreshments. It was reported that one prospective service user has a special dietary requirement and the manager stated that she is confident that the home is able to meet her needs and separate equipment has been provided to avoid cross contamination of food. The menu seen during the inspection appeared well balanced and offered choice. Both service users stated that ‘The food is alright’. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Medication procedures are robust and safeguard service users. EVIDENCE: Support plans evidence that the two people currently accommodated attend to their own personal care needs and daily records state when people have taken a shower etc. Both people were well presented and it was evident through discussions held with one individual that he takes much pride in his personal appearance. Times for rising and retiring are flexible as evidenced in daily records seen and people are able to choose and shop for their own clothes supported by staff. Consistency and continuity of support for service users is provided through designated key and co-workers. Discussions held with service users indicate that they have developed positive relationships with both their designated key workers and team members. Records available on both service users daily files evidence that they have been supported to attend appointments with the general practitioner at the local practice. The manager stated that the local health practice have been very supportive in relation to service users healthcare needs. One service user Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 15 reported the difficulty and frustration not being able to make an appointment with the local consultant psychiatrist although he has since been reassessed by a consultant in Birmingham arranged via his solicitor. A health plan for maintaining his positive physical and mental health was available on file. Care documentation evidence that both people had basic checks completed on admission to include weight, height and clothes measurements etc. Medication procedures appeared satisfactory at the time of the inspection. It was reported that all but four staff have undertaken accredited distance learning training on the administration and safe handling of medicines and are awaiting certificates. None of the service users are currently prescribed controlled drugs although the manager reported that she is arranging a suitable storage facility should the need arise. Consent for the administration of medication and self-medication assessment forms were available on both service user files and there was evidence that both people have agreed to staff assistance concerning the administration of their medication. The manager reported that only prescribed drugs are administered and PRN guidelines are in place. Temperature charts for the fridge and medication room are maintained and the home has a comprehensive medication policy in place in addition to Guidelines provided by the Royal Pharmaceutical Society for Care Homes. The manager was advised to date when refrigerated medication is opened to ensure that the medication is used within the specified best before date or storage restraints in line with the organisations own policy. A pharmacist from the supplying chemist visited the home on 24.07.06 and the manager confirmed that the few recommendations made have since been met. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: No formal complaints have been referred to the Commission for Social Care Inspection (CSCI) however the CSCI were notified of a concern in relation to the conduct of one service user who has since been discharged from the home. The home has received sixteen complaints to include two external complaints and a concern raised by CSCI in relation to an external complainant. The home maintains a complaints register and it is evident that all complaints, however minor are logged and all efforts to resolve such complaints are gain a satisfactory outcome is paramount. One complaint remains unresolved and the manager is working within the organisation to address this in the best interests of a service user as soon as possible. Discussions held with both service users evidence that they have a good understanding of the complaints procedure and they indicated whom they would approach if they were not happy with the service provided. Staff guidelines are in place for a person known as a persistent complainant, which provides the person with thinking time should he wish to retract a complaint. A copy of the complaints procedure is readily available and displayed in the home in addition to the Statement of Purpose and Service User Guide. No referrals have been made under adult protection procedures although a service user did make a recent allegation against a staff member which when Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 17 interviewed by police he immediately withdrew. The manager reported that the service user telephoned the police and therefore a referral to the local team was not made and the situation since resolved. The manager and some staff members have received training in the protection of vulnerable adults (PoVA). The manager stated that she is to obtain dates for forthcoming training to ensure all staff are familiar with the procedure. Leaflets on Adult Abuse provided by Shropshire County Council and the Borough of Telford and Wrekin were available. The manager confirmed that she has obtained the local policy and procedure however this was not available at the home on this day of the inspection. It was reported that all but three members of staff have received training on Studio III physical intervention and the manager is waiting for dates for the remaining staff that have yet to attend the three-day course. The manager confirmed that no service user is subject to physical restraint. It was reported that both service users have their own bank account. One person has a cash card and the home holds this on his behalf until he requests it to go to the bank and then returns it back to the staff. Records to support this are in place and discussions held with the person confirmed that he has requested this arrangement and is happy with the procedures in place. He retains his own money and receives a bank statement and a risk assessment for the management of his finances is in place. It was reported that the home are currently having to provide monies out of petty cash funds for the other person due to problems with obtaining benefits from social security. A record of monies paid is maintained and the manager reported that she has discussed the situation with the person’s social worker. The organisation provides each service user with a set monthly allowance to spend on structured activities in the community. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A full tour of the home was undertaken. The home provides accommodation over three floors consisting of a lounge, spacious conservatory, dining room, kitchen, laundry and seven bedrooms, all with en-suite facility. An enclosed garden is provided at the rear of the property. The two service users present at the inspection were happy to show the inspector their rooms, which were very personalised and reflect individuality. Both people confirmed that they had a choice of room and appeared happy with the accommodation provided. One person said if he was remaining at the home on a long-term basis he would have like to change the décor of his room. The home is equipped to a high standard and soft furnishings are of good quality and provide people with a comfortable and homely place to live. A Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 19 planned maintenance schedule was not available for inspection however the manager reported that a budget is allocated for maintenance and renewal. Domestic staff are not employed therefore it is the responsibility of service users and support staff to ensure that the accommodation is maintained to a clean and hygienic standard. The home was found very clean and well presented during this unannounced inspection. Staff confirmed that they receive training on infection control procedures. Cleaning schedules are in place and personal protective equipment readily available. Products hazardous to health are appropriately stored and data sheets and assessments available for all products used and the file found well presented. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed, trained and enthusiastic staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Discussions held with two staff on duty evidence they are knowledgeable and have a good understanding of the individuals whom they support. Staff were observed to be accessible, good communicators and interacted appropriately with the two service users present and spoke positively about their roles and responsibilities. The home currently employs nine support workers of whom two have obtained NVQ qualifications and the manager reported that five staff are currently registered and working towards their award. On arrival at the home there were three staff on duty to support the two people accommodated in addition to the manager. Staff spoken with stated that teamwork is effective and staff are employed in sufficient numbers to meet the individual needs of the people accommodated. Both service users considered that there is enough staff on duty to support them throughout the day. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 21 Personnel files for the most recently recruited staff member and a further two files were randomly selected and reviewed. Two files contained the relevant information required by the Care Homes Regulations and the other file contained all the relevant documentation with the exception of a CRB disclosure. The manager confirmed that a CRB had been received by head office. A POVAFIRST had been obtained and available on file. Personnel files were found well presented with clear evidence of interview in addition to equal opportunities documentation. Discussions held with service users indicated that they have had some minor involvement in the recruitment of staff by meeting prospective staff when they attend for interview and passing on their comments to the manager. The manager reported that she hoping to recruit a further four or five staff shortly based on the number of new admissions and the needs of prospective service users. All staff are contracted to work 35 hours per week. During the inspection a new employee was seen undertaking induction training. Discussions held with her indicated that she has previous care experience and is well supported by her colleagues and made welcome by the team. She reported that she is waiting for dates for medication and Studio III training in addition to mandatory training. She has been issued with a copy of the General Social Care Council Code of Conduct as seen during the inspection and reported that she has been provided with numerous other pieces of information to support her learning of the client group accommodated. She also confirmed that she has read all care documentation and is currently shadowing staff. The manager confirmed that the induction booklet meets the Learning Disability Award Framework (LDAF) specification. Staff spoken with reported that they are provided with good training opportunities and have attended numerous training courses since their appointment. A generic staff training and development plan for December 2006 to August 2007 for all TRACS establishments was available in addition to individual staff training and development schedules. These evidence that staff have been provided with both mandatory and service specific training courses. The manager committed to providing an overall training matrix for her team. It was reported that all staff would undertake mental health breakdown training in preparation for a new service user. Staff receive support and supervision they need to carry out their duties. Evidence of formal supervision and appraisals at one, three and nine months were available. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 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 approachable and supportive, having a positive impact on service users and staff. Quality assurance systems are available and the premises are maintained in a safe manner safeguarding service users and staff. EVIDENCE: Ms Patricia Ferguson is the registered manager of the home and is contracted to work 35 hours per week. Ms Ferguson has been employed by the organisation for three years and she is nearing completion of the Registered Managers Award/NVQ 4 in Care. Since her appointment to manager she has undertaken numerous training courses appropriate to her role to include Health and Safety, Communication, Cultural Awareness and Diversity, Personality Disorder, Brain Injury, Adult Protection, Stress Management, Medication, Learning Disability and Mental Health and training in safe working practices. The service users and staff spoken with were complimentary in relation to the Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 23 registered manager. One service user considered the home is in need of a deputy manager. One service user stated ‘I would have liked to of seen more of Pat when I first moved in but she was off training’. This comment was fully acknowledged by the manager at the end of the inspection who reported that she would like to spend more time with service users and staff. Two staff stated ‘Pat is a very good manager and makes me feel part of the team’. Another reported that ‘Pat is a great manager, always available, open and very approachable’. A Quality Assurance Audit was undertaken by the organisations Divisional Functional Administrator on 23.08.06 and a report was available. The home achieved an overall score of 91.2 . A small number of recommendations were made and the manager confirmed that these have since been met. A completed quality questionnaire was seen on one of the service users files dated 9.8.06 and the comments stated were generally positive. Under ‘What’s good about the home?’ the person stated ‘Having staff that don’t wind you up’. Under ‘What’s not so good’ he stated ‘having clients kicking off’ other comments included that the person would like a snooker table and to change the décor of his bedroom. It was reported that the other service user declined to complete a questionnaire. Visits required under Regulation 26 are undertaken and reports forwarded to CSCI. A service user reported that responsible individual, Ms Sue Hullin regularly visits and always makes time to speak to him and others and that such visits are unannounced. He also stated that ‘TRACS are a very good company’. In preparation for the inspection the CSCI received a completed survey from a service user and the comments indicate that the person should have spent more time considering moving to this placement however he did receive enough information about the home prior to moving in. Other comments indicate that the person is involved in decision-making and that the staff always treat him well. The manager reported that she has not yet had the opportunity to seek the views of families, advocates or health and social care professionals on how the home is achieving goals for the people accommodated. How the home promotes equality and diversity was explored with the manager who stated that staff are provided with training in equal opportunities through their induction in addition to training in culture and diversity. The team also have a good gender and race mix of staff. She also stated that service users are provided with opportunities to access a range of community facilities and services and stated that ‘The service is geared at a level that people won’t fail’. All records seen throughout the inspection were presented to a good standard and stored securely. Health and safety procedures appeared satisfactory at the time of this inspection. Risk assessments, accident records, temperature monitoring Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 24 charts, fire and emergency lighting records, cleaning schedules, staff training and service certificates were reviewed. Although engineering controls have been fitted to water outlets, records indicate that bath water temperatures have exceeded the recommended temperature on a number of occasions therefore the manager agreed to report this to maintenance department and develop a risk assessment in the interim. The heating and water system has been problematic which was evidenced during two pre-registration site visits undertaken and the manager stated that an engineer is booked to visit the home the day following the inspection to look at the system. An internal health and safety audit was undertaken on 13.07.06 and the report available. One staff member spoken with confirmed that she has attended mandatory training in safe working practices and courses are being arranged for the newly appointed staff member. The manager reported that she has received accredited training in health and safety in addition to risk management and is on the organisations health and safety committee. Minutes of these meetings were available in addition to a health and safety policy. A staff member is currently undertaking minor repairs to the premises due to the difficulties in getting repairs undertaken within a appropriate timescales which was also evidenced through discussions held with a service user who stated ‘maintenance could do with improvement and us provided with a permanent maintenance man’. It was reported that the Fire Officer has not visited since the home was registered. An Environmental Health Officer visited on 25.04.06 and a small number of recommendations were made which the manager stated have since been met. CSCI have been notified under Regulation 37 of a number of events affecting service users and action has been taken by the home. A number of these events have required police presence. Glanmore DS0000065368.V311342.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 2 2 3 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 3 x Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 26 N/A 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(1)(c) Requirement The Statement of Purpose must include the criteria for admission to the home, including the homes policy and procures for emergency admissions. The home must not offer a place to any prospective service user whose needs it cannot meet. Service users whose needs require a reactive management plan to be developed should have one in place prior to admission to the home and linked to the service user plan. Timescale for action 20/11/06 2 3 YA3 YA6 12 15(1) 01/11/06 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the support plan for the individual identified at the inspection be updated to reflect his current service provision and that his request for a move to an alternative placement be agreed as soon as possible. Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Extracts may not be used or reproduced without the express permission of CSCI Glanmore DS0000065368.V311342.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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