Inspection on 17/09/08 for Greensleeves

This inspection was carried out on 17th September 2008.

CSCI found this care home to be providing an Good service.

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

Greensleeves 31/10/06

Greensleeves 17/01/06

Greensleeves 14/07/05

Greensleeves 25/02/05

Greensleeves 06/05/04

Greensleeves 13/06/03

Greensleeves 05/08/02

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Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Greensleeves 11 Friday Street Eastbourne East Sussex BN23 8AP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Judy Gossedge     Date: 1 7 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Greensleeves 11 Friday Street Eastbourne East Sussex BN23 8AP 01323461560 01323763723 Greensleeves@eastbournemencap.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr William Barnfield Type of registration: Number of places registered: Eastbourne & District Mencap care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: A maximum of two service users with a mental disorder in addition to having a learning disability can be accommodated. Service users must be aged between forty (40) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. The maximum number of service users to be accommodated is eleven (11). Date of last inspection Brief description of the care home Greensleeves is one of three registered care homes for adults with learning disabilities provided by Eastbourne and District Mencap. The home is registered for 11 adults with learning disabilities and residents may remain in the home into old age. The home is a large detached extended bungalow that provides seven single bedrooms and two double bedrooms all but one with en-suite facilities. There is a chair lift to access the first floor. There is a separate lounge, conservatory, dining room and a large kitchen that opens onto a patio area and a large rear garden that has been Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 11 Brief description of the care home landscaped and is now much more accessible for residents. Greensleeves continues to provide a safe and happy environment whereby people can learn to live as independently as their disability will allow. Residents are enabled to access college courses, day centres and a range of leisure activities, both within the home and in the local community. Information about the service, including the Statement of Purpose, Service Users Guide and CSCI reports is made available to prospective residents, or their relatives on request as part of the admission process. The current fees at Greensleeves at the time of the Inspection are £690.00 per week. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations`2001 uses the term ‘service users’ to describe those living in care home settings. For the purpose of this report, those living at Greensleeves will be referred to as ’residents.’ This unannounced key Inspection took place over five hours on 17 September 2008. The last key Inspection was undertaken on 30 October 2006. Since the last Inspection an Annual Service Review has been completed. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key Inspection. No concerns were raised. Care Homes for Adults (18-65 years) Page 6 of 29 An Annual Quality Assurance Assessment (AQAA) has been requested for this service, and information from this has been included in this report. A tour of the premises took place to look at communal areas and a selection of resident’s bedrooms and care records were inspected. Eleven people were resident and three were spoken with individually. The care that three of the residents received was reviewed. The opportunity was also taken to observe the interaction between staff and residents in the communal areas. No resident’s or support workers surveys were sent out on this occasion. Three of the support workers on duty and the Registered Manager were all spoken with during the Inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed information about Greensleeves is available to be viewed prior to any admission to the home and there are detailed pre-admission procedures in place to ensure that residents are appropriately placed in the home. But assessment information completed should be available to view. Evidence: Information is available to prospective and existing residents in various formats. The Statement of Purpose and Service User Guide have been thoughtfully and imaginatively produced to a high standard and are both comprehensive and informative. Both documents were viewed during the Inspection and detailed they had been reviewed in 2008. The AQAA details that over the last twelve months full details of the home with photographs together with details of the organisations services has been put on the Eastbourne Mencap Website. The AQAA details that there is an admission policy and procedure in place which ensures that all prospective residents are thoroughly assessed by the management Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: team, with a view to meeting their individual care needs in all areas. The prospective resident and their family complete a comprehensive admission form, are given full information on what care can be provided and the prospective resident is invited to come for dinner with the residents, who are also free to express their views. The prospective resident is then invited to stay for six months to ensure their care needs can be met in the home. There has been one new resident in the home since the last Inspection. There was a detailed assessment supplied by the local authority to reference. The Manager stated that an assessment form had been completed by staff from the home as part of the assessment process, but the completed documentation was not available to view as it was at the organisations head office. This was discussed with the Manager who stated that it would be ensured this information is available to view. So a Requirement was not made on this occasion. The new resident was spoken with during the Inspection and confirmed they had been able to look around the home prior to their admission. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents individual care plans and supporting risk assessments provide staff with the information they need to ensure that residents individual care needs are met. Residents are treated with respect and encouraged and enabled to make decisions about their day-to-day living. Evidence: The AQAA detailed that ‘person centred’ care plans have been developed for each resident, clearly linked to the individuals assessed needs. Three residents individual plans were viewed, which were all detailed and is formulated by the key-worker, Manager and evidenced the involvement of the resident or family member, as appropriate. All the care plans contained detailed information about the individual support to be provided for each resident to enable them to achieve maximum independence and develop their skills. Supporting risk assessments were also recorded. All had been subject to a review to ensure that the agreed goals are being worked towards. It was noted that a ‘Consent form’ had been signed to acknowledge Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: agreement with the content or to any changes to the plan. Support workers spoken with demonstrated that they are aware how they should provide support to assist each resident. Greensleeves continues to operate a key worker system and support workers were observed working closely and sensitively with residents to meet their identified personal care and support needs. Regular staff meetings provide an opportunity to review the residents care needs, and for any significant changes are addressed immediately. The daily routines of the home are determined by the resident’s individual programmes, and the three resident’s spoken with confirmed flexibility in their daily routines and respect for their personal freedom and lifestyles. During the Inspection residents were observed to move around the home freely, choosing which rooms to be in and what level of company they wanted to enjoy. Residents are able to choose when to spend time on their own, and can do so in their own bedrooms. Residents, staff and records viewed evidenced that residents are consulted with regarding many aspects of their day to day living, including menu planning and choosing both individual and collective social, recreational and leisure activities. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are encouraged and supported to pursue their educational, vocational and social interests. Residents are enabled and supported to maintain contact with family and friends as they wish and links with the community enrich their social and educational opportunities. Service users benefit from recreational and leisure activities and the meals on the home are good offering both choice and variety. Evidence: The AQAA details that residents regularly take part in activities such as day services, where they can take courses in computers, craft, cooking, music and movement and gardening. A weekly programme of day service activities is displayed in the office for each resident, which is designed to meet their individual need and support them to reach their full potential for independent living. These are updated daily with the schedule for the day, including specific times for individual appointments and Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: collections. Care plans and programmes viewed, discussions with residents, and staff evidenced that residents are being supported to access a range of educational, vocational and social activities. During the Inspection the majority of residents returned to the home after attended day services. The three residents spoken with spoke of being supported to access activities in their local community and make use of available facilities. Community participation remains a focus in the home and residents are encouraged and supported to visit the cinema, theatre, local shops and other amenities. Feedback from the three residents spoken with confirmed this and on the night a support worker was observed asking the residents who would like to go to an ice show at Christmas. The AQAA details that recreational and leisure interests of residents are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities individually or as a group, reflecting their individual needs, preferences and abilities. This can include shopping trips, visits to the theatre, picnics or just a drive out for tea and cake or an ice cream. That a music night is held on a Wednesday and a reminiscence session is also held once a week. On the night of the Inspection residents gathered in the lounge to play an interactive quiz game. All the residents chose to go on an annual holiday, which this year was a week in a holiday camp in the New Forest. The AQAA details that two service users are members of a local theatre group and continue to regularly take part in amateur dramatic productions. The AQAA details that the residents are supported by staff to visit family and friends The Manager confirmed this, however not all residents have regular family contact. Feedback received from the three residents spoken with evidenced they had been supported to maintain contact and relationships with their families and friends. Resident’s reviews include the opportunity for resident’s relatives/representatives to attend if the resident wishes. The AQAA details that residents individual likes and dislikes are taken into account when planning menus and residents all enjoy a daily choice of well-balanced and nutritious meals. Support workers cook the evening meal and the AQAA stated that all support workers holds a basic food hygiene certificate. The support worker designated to cook the evening meal on the night of the Inspection confirmed this. There is a rotating menu in place, and the evening meal during the Inspection was cottage pie or pizza with vegetables followed by cheesecake. Fresh fruit is also available in the home. Diets can be catered for. On the day residents were observed eating their meal in the dining room. It was a relaxed environment, staff provide support where required, Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: taking into account the different length of time that individual residents would need to finish their meal. Feedback from the residents spoken with was that the food was good. Records were viewed of meals provided to individual residents. Residents can make snacks and some prepare their own pack lunches. An inspection by Environmental Health had recently been made and where Requirements had been made the Manager stated these had been or would be addressed as part of the planned refurbishment of the kitchen. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from the provision of flexible and respectful personal and healthcare support. Systems in place to manage medication, but it should be ensured these are followed to protect residents. Evidence: Residents at Greensleeves are supported to manage their own personal care, some with the offering of verbal prompts where required. Risk assessments are in place to ensure the safety of residents. Care plans viewed evidenced that following consultation with residents, specific guidelines have been developed for all staff, ensuring that support is provided in a structured and consistent manner and in a way that the resident prefers. Relationships between staff and residents and the care given were observed to be very good, and residents were treated with respect at all times. The three residents spoken with confirmed that the staff treated them with respect The AQAA details that residents are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: required. That resident’s continue to be supported to access a range of health care professionals in the community. The home continues to work closely and effectively with the Community Learning Disabilities Team, which provides support and guidance in addressing residents psychological needs. The three care plans viewed and staff feedback evidenced this, and there were records of appointments with, or visits by, health care professionals. The AQAA details that policies and procedures relating to the control, storage, administration and recording of medication are in place. Medication storage and a sample of the recording were viewed and the administration practices were observed when evening medication was administered. A monitored dosage system (MDS) for the administration of prescribed medicines and the Manager stated that a local pharmacist continues to carry out monitoring visits, but the records were not available to view during the Inspection. There were a number of omissions in the recording of administration of medication. This was discussed with the Manager, who stated this would be addressed and this would be raised with the staff team to ensure accurate recording is maintained. That this had also been identified at the recent pharmacists visit following which staff training needs are in the process of being reviewed, with further training being provided where identified. The Manager also agreed to undertake a risk assessment with immediate effect where medication is kept is a refrigerator to ensure that the health and safety of the residents. So Requirements were not made on this occasion. Training records viewed and support workers spoken with all stated they had received medication training. The Manager stated that, following risk assessments, one service user continues to self-administer their own medication and that with all risk assessments; this situation is kept under regular review. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to enable residents or their representatives to raise any concerns about the care being provided and that residents are protected from abuse. Evidence: The AQAA details that the complaints policy and guidelines are clearly displayed in the entrance hall of the home and that this information is also available in easy read format for residents. That no complaints in relation to the service have been received during the last year. The CSCI have not been informed of any concerns in relation to Greensleeves. The resident’s spoken with stated that they were aware of the complaints procedure and knew who to speak to if they were not happy. During the Inspection residents were confident to approach the Inspector and were articulate in their feedback regarding their positive experiences at the home. The AQAA details that the Manager holds regular meetings with the residents at which they can express their views on the care provided. That the key worker system enables good communication between staff and residents, who are encouraged to voice any concerns freely to the management team and key workers. The AQAA details there are written policies covering adult protection and whistle blowing. The Manager stated that a copy of the East and West Sussex, Brighton and Hove Multi-Agency Adult Protection Guidelines is available for reference in the home. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: Support workers undertake specific adult protection training, in accordance with the multi agency guidelines for the protection of vulnerable adults. This was evidenced through discussions with the three support workers spoken with during the Inspection, who all demonstrated an awareness of the policies and procedures, and their individual training records. Care Homes for Adults (18-65 years) Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment is good and provides residents with an attractive, comfortable, clean and homely place to live. Resident’s benefit from the provision of all necessary specialist equipment. Evidence: Greensleeves has been purpose built to a high specification to meet resident’s individual and collective needs. Décor in the home is to a good standard, and furnishings are of a good quality and domestic in style. A tour of the building was made. A conservatory has been provided at the rear of the home since the last Inspection. The AQAA details that there is ongoing improvement of the facilities in the home, that the re-decoration of several rooms in the home has been undertaken and improved in the last few months, a loop system has been fitted into the lounge and one resident’s bedroom, two new wheelchairs and two new electric beds have been purchased. Over the next twelve months a new kitchen is due to be fitted and a further bathroom is due be converted into shower rooms. The three residents spoken stated they were happy with the homes environment. Resident’s accommodation consists of seven single and two double bedrooms situated Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: on both floors in the home. There are sufficient numbers of toilets located around the building, with all but one of the bedrooms providing en-suite facilities of a bath or shower, toilet and wash-hand-basin. The one bedroom without an en-suite is situated next to communal facilities. A sample of the bedrooms were viewed all of which had been personalized, displayed resident’s individual styles and interests. Temperature regulators are fitted to all hot water outlets, accessible to the residents. Records were viewed of regular checks of the hot water supply at these outlets to ensure these are maintained close to the recommended safe temperature of 43°C. The residents spoken with confirmed there is adequate heating and hot water provided in the home. Communal space consists of a lounge, dining room and a conservatory. There is a landscaped garden at the rear of the property, which the AQAA details will continue to be developed with the addition of new plants. One of the residents spoken with confirmed they had enjoyed making use of the garden in the better weather. All necessary specialist equipment is made available to meet residents assessed mobility needs, including assisted baths, wheelchairs and hoists. There is a chair lift from the ground to first floor and there are grab rails in bathrooms, toilets and corridors. The AQAA details that there is a policy in place for managing infection control and that Department of Health Guidance has been used to assess current infection control management. Care workers undertake the cleaning in the home and that a regular cleaning schedule is in place. There is also rota of cleaning jobs for residents to undertake, as their abilities will allow. The home was clean and free from offensive odours at the time of the Inspection. The three residents spoken with confirmed the home was kept fresh and clean. There is a separate laundry room for residents to use. Routine fire checks of the building, which had been completed were viewed and were adequate. Care Homes for Adults (18-65 years) Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures should be fully evidenced and training is provided to staff to enable them to perform their roles effectively. Evidence: The home was calm and relaxed on the day of the Inspection, and the staffing in place on the day provided support for the residents to access a range of activities. The Manager stated staffing levels vary in accordance with resident’s individual programmes and day centre commitments. A ‘waking night’ member of staff was due to be on duty that night. Staff spoken with felt that staffing levels were currently sufficient to undertake their role effectively and spend individual time with residents. They also spoke of a team that are very supportive of each other and of good communication. The AQAA details that the recruitment of new staff includes the completion of an application form, an interview, the taking up of references and a Criminal Record Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: Bureau check (CRB) is completed. That residents continue to be actively involved in the recruitment and selection process with all prospective members of staff. Only one new member of staff has been recruited since the last Inspection and documentation viewed evidenced the recruitment process followed for staff. But there was no record of a POVA First check having been received prior to the member of staff commencing work in the home. This was discussed with the Manager who stated that this had been completed but some of the recruitment documentation is held at the organisations head office, but that it would be ensured that evidence would be available in the home for future Inspections. So a Requirement was not made on this occasion. New staff also complete a probationary period. Staff spoken with confirmed they have received a job description and a copy of the General Social Care Council Code of Conduct. A sample of records was also viewed to evidenced the existing staff working in the home have also undertaken a CRB check. The AQAA details that of the sixteen members of staff, eleven hold NVQ Level 2 in care and a further three are working towards this qualification. The AQAA details that Induction procedures are in place, which meets the requirements of Skills for Care Induction standards and new support workers recruited to the home will be taken through. Records viewed for the one new member of staff confirmed they had received an induction. Support workers spoken with spoke of completing or were due to complete a range of training and all spoke of good training opportunities for personal development. All staff feedback confirmed that supervision is provided to meet requirements. Records were not available to view during the Inspection. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The overall management of the home is good with effective systems to protect residents being put in place. Evidence: The Registered Manager has worked in care for over seventeen years and has managed the home since 2000. He has completed the Registered Managers Award and NVQ Level 4 in Care. From direct observation and through discussions with residents and support workers, it is evident that the Manager continues to demonstrate a clear sense of leadership and direction. He is clearly motivated, positive and approachable and continues to create an open and inclusive atmosphere within the home. The Manager stated that a quality assurance system operates in the home to enable feedback to be sought through surveys to be sent to residents, relatives/representatives and other professionals who attend the home and regular meetings held in the home. The Manager, staff and two of the resident spoken with confirmed that residents meetings regularly occur, but the records of these meeting Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: were not available to view on the day. Records viewed did not evidence a regular annual audit had been undertaken. The Manager stated that surveys have now been sent out to seek further views of the care provided. Feedback from the quality assurance process needs to be collated, published and available to reference by interested parties. The AQAA detailed that policies and procedures are in place and have been reviewed this year. There was a record of the last monthly-unannounced monitoring visits by a representative of the organisation made to meet the requirements of Regulation 26, which was read. The Manager stated that regular visits were made and copies of these visits should be available to view in the home. Central training lists compiled and were viewed, but were not up-to-date. This was discussed with the Manager who stated that these were in the process of being updated. This issue was raised at the last Inspection and a system should be in place to ensure these records are maintained. Support workers spoken with and individual training records viewed evidenced they had received training in moving and handling, infection control, basic food hygiene, fire and first aid training. The Manager stated that staff were in the process of receiving their annual appraisal when training needs would be discussed and identified. The three support workers spoken with confirmed they had had an appraisal completed. A fire risk assessment is in place, and a system to ensure a regular detailed check of the environment and fire precautions is carried out and is recorded. Records were viewed of fire training provided in the home and the three support workers stated they had attended this training. During the tour of the building it was observed that a number of doors in the home were wedged open. This was discussed with the Manager who rectified this during the Inspection and stated this would be discussed with the staff team to ensure the health and safety of the residents was maintained. So a Requirement was not made on this occasion. The AQAA detailed that the maintenance of equipment and services has been carried out and the Manager was also able to update this information of further checks that have been undertaken since the AQAA was completed. Accident records were viewed and were detailed. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 34 19 That the recruitment procedure for new staff is fully evidenced. To protect residents. 31/10/2008 2 39 24 That the quality assurance process is available to view and the outcome is collated. To protect residents 31/10/2008 3 41 17 That all the required records 31/10/2008 are maintained and available to view To protect residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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