Inspection on 27/06/07 for Heads Meadow

This inspection was carried out on 27th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heads Meadow 29/07/09

Heads Meadow 24/06/08

Heads Meadow 28/09/06

Heads Meadow 01/03/06

Heads Meadow 20/09/05

Heads Meadow 15/10/04

Heads Meadow 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Heads Meadow 41 Ball Road Pewsey Wiltshire SN9 5NB Lead Inspector Elaine Barber Unannounced Inspection 27th June 2007 10:30 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 DS0000028201.V336493.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. DS0000028201.V336493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heads Meadow Address 41 Ball Road Pewsey Wiltshire SN9 5NB 01672 563851 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Ms Jane Abbott Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000028201.V336493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2006 Brief Description of the Service: Valued Lives is a private organisation, which operates 5 care homes for adults with learning disabilities. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by the registered person, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough and Devizes are within 15 minutes’ drive. Slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to take people out and people contribute towards the costs of these. Most people have lived in houses owned by the organisation for several years. They may have lived in more than one of the homes run by Valued Lives. Up to five people live at Heads Meadow in Ball Road, Pewsey. All have single rooms. There is one ground floor bedroom. People have a choice of bath or shower. Plenty of communal space is available including a large kitchen dining area and three sitting rooms. There is also a large garden. The fees range from £677 to £1100. DS0000028201.V336493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included a planned visit to the home on 31st July 2007. During the visit information was gathered using: • • • • Observation Discussion with five people who lived in the home Discussion with three staff Reading records including care records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • • • • • The manager provided information prior to the inspection about the running of the home. Comment cards were received from two people who lived in the home A comment card was received from a relative. A comment card was received from a member of staff. A comment card was received from a community nurse. Comment cards were received from three doctors. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the two inspection visits. What the service does well: Each person had lived in the home a long time and established their routines. Some staff had worked with them for several years and were familiar with their needs. People’s individual needs and abilities were recognised. This ensured that people had their needs and aspirations met by the home. Each person had a record of their individual terms and conditions of residence in the home to ensure that their interests were safeguarded. People had their abilities, needs and goals reflected in their individual plans to ensure that their needs would be met and their goals would be achieved. People were able to make choices and they made decisions about their lives with assistance as needed. Risks were assessed and action to be taken to reduce risks was recorded. People were supported to take risks and access opportunities People were provided with a range of activities and opportunities, offering them full engagement with their local community. They attended a day service run by Valued Lives, which offered a range of activities. They also went out DS0000028201.V336493.R01.S.doc Version 5.2 Page 6 from the day service, for example to the shops and a café. Most people attended the local church and some people had recently been confirmed into the church. People were able to maintain and develop appropriate relationships with family and friends. Some people had visits from their families. They also had visits from friends who lived in other Valued Lives houses. They had opportunities to meet other people when they went out for example to church. People were involved in the routines of the home. Their rights were respected and their responsibilities were recognised in their daily lives. People were offered a healthy diet and enjoyed their meals. People received support in ways they preferred and required. They had individual routines which were recorded. Each person was registered with a GP and saw other health professionals as they required. People’s physical and emotional health needs were met. Medication was appropriately managed and people were safeguarded by the medication policies and procedures. People were protected by the home’s policies and practices about complaints and protection. There was a complaints procedure and information about protection of vulnerable adults. Staff received training about prevention of abuse. People lived in a comfortable, clean and safe environment, suitable to their needs. The accommodation was clean, brightly decorated and well maintained. There were different sitting areas so people could choose where they spent their time. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. More than half of the staff who worked in the home had a National Vocational Qualification. They also had a range of training. Refresher training and specialist training were also planned. There were effective recruitment practices to ensure that people were protected from being cared for by unsuitable people. The manager was appropriately qualified and experienced to run the home. She was supported by other senior managers in the organisation so that people were generally benefiting from a well run home. There was a range of health and safety measures to ensure that the environment was safe for the people who lived there and the staff. People’s health, safety and welfare were promoted and protected. DS0000028201.V336493.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. DS0000028201.V336493.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 DS0000028201.V336493.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, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their needs and aspirations assessed and met by the home. Each person had an individual contract and statement of terms and conditions with the home. EVIDENCE: There had been no admissions to the home since the previous inspection, in September 2006. People’s needs had been assessed over time. All the people who live at Heads Meadow have lived within Valued Lives for a number of years. They have therefore established their routines. There has also been continuity and stability in the staff team. Many have several years’ experience. This has given them a depth of knowledge regarding people and their needs. People are given assistance and support with personal care as required. They are able to access a range of health care services. Relevant professionals and therapists are involved in addressing individual needs. DS0000028201.V336493.R01.S.doc Version 5.2 Page 10 Education, occupation and leisure opportunities are all provided by the organisation. Each person had a statement of terms and conditions agreed with Valued Lives. These had been produced in formats designed to be appropriate to them. The documents were signed by relevant representatives as review meetings took place. Four of the people also had a contract with their local authority, which paid their fees, and with Valued Lives. Staff were negotiating with the local authority of the fifth person to obtain a contract. DS0000028201.V336493.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): 6.7.9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had their abilities, needs and goals reflected in their individual plans. People made decisions about their lives with assistance as needed. People were given opportunities and supported to take risks. EVIDENCE: The care records of three people were read. Each person had an old style care plan, which provided detailed information about how their care needs would be met. These plans had been reviewed in July 2006. However, these plans were very comprehensive and sometimes it was difficult to find information. New style care plans had been introduced which were clearer and easier to follow. Two of the people had new care plans. A new plan had been started for the third but this needed to be completed. The two people who had new care DS0000028201.V336493.R01.S.doc Version 5.2 Page 12 plans also had additional guidelines for each aspect of care. These guidelines needed to be developed for the third person. There were weekly review sheets. Two people had recently had reviews with their care managers. A relative said in their comment card that they always felt that the care home met the needs of their relative. They also said that the staff always gave the support and care to their relative that they expected and always met people’s different needs. Personal preferences were respected. The records showed that people were encouraged to make choices. They showed that people had chosen activities for their day service. Staff gave examples of people choosing their menus using recipe cards. People were observed choosing where to spend their time when they returned from their day time activities. Some people were in the sitting areas while others were in their rooms. People’s rooms were individually decorated and furnished according to their choice. The care plans and risk assessments placed a high emphasis on choice and independence. Two people had a range of detailed risk assessments. These included the action to be taken to reduce risks. They also focused on promoting independence, choice and opportunities for people. The service manager said that the third person had old style risk assessments but these could not be found. New risk assessments needed to be developed for the third person. DS0000028201.V336493.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, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were provided with a range of activities and opportunities, offering them full engagement with their local community. People were able to maintain and develop appropriate relationships with family and friends. People’s rights were respected and their responsibilities were recognised in their daily lives. People were offered a healthy diet and enjoyed their meals. DS0000028201.V336493.R01.S.doc Version 5.2 Page 14 EVIDENCE: The records showed that people had a range of activities. Each person had an individual timetable of activities at the activity centre run by Valued Lives. Some people went to the Gateway club on a Thursday evening. People who were spoken to on their return from the day service said that they enjoyed their day time activities. Staff reported that each person had had a holiday this year in the caravan owned by the organisation. They also said that people had had a range of outings during the summer. People’s individual needs and preferences were taken into account when choosing outings and activities. The daily records showed that people had a wide variety of activities at their day service. These included craft, bingo and music. People also used community facilities such as the café, shops and the cinema. One person said that they enjoyed going shopping for clothes. They also said that they went to church and had recently been confirmed. They also saw visitors from the church at their day service. Two people who completed comment cards said that they could usually make decisions about what to do each day and they could do what they wanted to do in the evenings and at weekends. The records showed that at home people listened to music and watched TV. They were also involved in the routines of the home according to their abilities. The service manager stated that people were encouraged to be involved in laying the table, drying the dishes, shopping, vacuuming, preparing vegetables and sorting laundry. One person said that they were involved in meal preparation. One relative said in their comment card that the service usually supported people to live the life they chose. Staff respected their privacy and knocked on doors before entering their rooms. People chose whether to be alone in their rooms or in company. People could have pets and in the house there were a cat, a budgerigar and a parrot. Staff reported and the records showed that people kept in contact with their families. Relatives and friends visited them at home. One relative said in their comment card that the home always helped their relative to keep in touch with them. People also had friends from the other Valued Lives houses. One person said that they no longer had contact from their family but they did have friends in the other houses who visited them. People could meet other people who did not have similar needs when they accessed community facilities. The local vicar provided a special service for people from Valued Lives. The service manager reported that other people from the community were starting to join in with this. There was a varied menu, which reflected a balanced diet. A large amount of fruit and vegetables was offered. Advice had been sought from a dietician DS0000028201.V336493.R01.S.doc Version 5.2 Page 15 about the menu. Attention was paid to nutritional needs and there was a section about nutrition in the care plans. People were offered choices within a nutritional framework. They chose dishes for the menu from picture menu cards. People helped with cooking and setting the table or clearing away after meals according to their ability. One person who was spoken to said that they enjoyed the food. DS0000028201.V336493.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People received support in ways they preferred and required. Their physical and emotional health needs were met and they were protected by the home’s policies and practices about medication. EVIDENCE: Staff assisted people with various levels of personal care and provided supervision when needed. This varied depending on their individual abilities. People had established routines, such as their preferred time for getting up. These routines were recorded in their personal notes. Staff support was available if people needed assistance to attend set appointments. Assistance was also given to choose clothes on a daily basis. Staff organised shopping trips with people. Each person had an allocated keyworker. One responsibility of this role was to ensure that people had sufficient clothes and toiletries. DS0000028201.V336493.R01.S.doc Version 5.2 Page 17 Valued Lives had a policy about staff of the opposite gender providing personal care. This provided suitable safeguards both for people who lived in the home and for staff. There was a strong focus on health promotion, and also responding to any needs that arose. Each person was registered with a GP. Everyone received regular health monitoring. This included dental and vision check ups. Any specialised services, such as speech therapy or occupational therapy, were also accessed as required. When significant health problems occurred all possible steps were taken to secure treatment for these. Information about the main needs of individual people was available for staff. The relative who completed a comment card was satisfied with the care that was provided. A community nurse in their comment card stated that individual’s health care needs were usually met and the service usually seeks advice and acts upon it to manage and improve individual health care needs. They also said that staff were sometimes reluctant to accept changes to medication because of their concern for the individual and did not always feel it was in the person’s best interests. However three GP’s said in their comment cards that they are able to see their patients in private, staff demonstrate a clear understanding of people’s care needs, specialist advice is incorporated into the care plans and medication is appropriately managed. Health action plans were being developed for people to ensure that their health needs were met. All appointments took place in private, although a staff member would give assistance as needed. Records were kept of all contacts with any health professional. Medication was stored in a locked cupboard. However, it was in a position where the medication could be affected by heat and steam. There is a risk that some medicines can be affected by changes in temperature so the internal temperature of the cupboard should be monitored. Each person had an individual named box to store all their medication. Staff had received training in medication handling, and in some more specialised techniques. Changes to medication were documented and signed. Each person had a list of homely remedies, which they could take, approved by the GP. Records and letters from a consultant showed that medication was regularly reviewed. There was a medication stock control system and records were kept of medication received into the home, administered, and returned. There was a requirement at the last inspection that clear guidelines must be agreed with the prescriber for the use of ‘as required’ medication. These should be available for all staff to access. This had been met. The reasons for giving as required medication were now included at the front of the medication records. Two people whose records were read had protocols for as required medication agreed with the community nurse, GP and consultant. A third had DS0000028201.V336493.R01.S.doc Version 5.2 Page 18 an epilepsy management plan, which included guidelines for as required medication. DS0000028201.V336493.R01.S.doc Version 5.2 Page 19 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, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were generally protected by the home’s policies and practices about complaints and protection. Some people may still be at risk of harm because their plans to manage their behaviour were not agreed with professionals involved. EVIDENCE: The organisation has information available about how to make a complaint. A pictorial version of the complaints procedure was available within the Service User Guide. Contact details for the CSCI were included. The Annual Quality Assurance Assessment completed by the owner showed that there had been no changes to the information about complaints. It also showed that all relatives had been given a copy of the complaints procedure in response to a recommendation at the last inspection. One relative who completed a comment card could not remember how to make a complaint. They also said that the service responded appropriately if they raised concerns about their relative’s care. There had been no complaints since the last inspection. Both people who completed comment cards said that they knew who to speak to if they were unhappy and they would speak to staff if they had a complaint. DS0000028201.V336493.R01.S.doc Version 5.2 Page 20 There was also a wide range of information about adult protection issues. This included details about multi-agency procedures within Wiltshire. A ‘Protection’ section in each individual’s care plan gave information about the various safeguards in place. These included recruitment checks, staff training, and key individual abilities and relationships that contribute to upholding someone’s welfare. Since the last inspection there had been two vulnerable adult referrals. These related to incidents when a person who lived in the home had hit staff. Advice was being sought from the vulnerable adults unit about this. There was a requirement at the last inspection about strategies for management of behavioural needs. These must contain appropriate guidance, show who has been involved in devising them, and be kept under regular review. Progress had made towards meeting this requirement. There was a detailed behaviour management policy and guidelines had been developed for some people. Staff were waiting for the community nurse to agree these. Physical interventions were being used with some service users on occasions. Individual guidelines described the holds, which may be used. Staff had received appropriate training in these techniques. Staff managed money on behalf of people. Appropriate financial records were kept with receipts. DS0000028201.V336493.R01.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lived in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Heads Meadow was a detached house, set in its own grounds in a residential area of Pewsey. Local amenities were within walking distance. The home was next door to a pub. The property was domestic in style. Décor was homely, using strong colours. It was furnished to a good standard, and appeared well maintained. Any minor issues that arose were attended to as quickly as possible. Redecoration of particular rooms took place as needed. DS0000028201.V336493.R01.S.doc Version 5.2 Page 22 There was a separate utility room for the laundry. Since the last inspection a cleaning company had cleaned the accommodation twice a week. The home was cleaned to a high standard. Both people who completed comment cards said the home was always fresh and clean. The property was not owned by Valued Lives, and they had been required to vacate it by the end of September 2006. The timescale had been extended indefinitely so the provider was considering improvements for the accommodation. There was a plan to redecorate the accommodation in lighter colours. DS0000028201.V336493.R01.S.doc Version 5.2 Page 23 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): 31, 32,34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. People were protected by the home’s recruitment practices. Arrangements for supervision and appraisal had been made so that people would benefit from well supported and supervised staff. EVIDENCE: Heads Meadow had five regular staff who covered most of the shifts at the home. Two staff had left since the last inspection and two agency staff were working in the home. This was the first time the home had used agency staff. There was a minimum of two staff on duty during daytime hours and one person sleeping in at night. There was an out of hours on-call system. There were three or four staff during the main part of the day. On the day of the inspection the rota showed that there were two staff on duty. These two staff DS0000028201.V336493.R01.S.doc Version 5.2 Page 24 accompanied the people who lived in the home to the day service and supported them there. There were other staff at the day service to assist with activities. Both people who completed comment cards said that the staff always treated them well. There were policies about recruitment and selection practices. All the staff employed had had all the required recruitment checks. This had been verified at previous inspections. A recommendation was made at the last inspection that when new staff are recruited a reference should be obtained from the previous employer. If they have left school or college a reference should be obtained from the school or college. No new staff had been recruited. New staff had an initial short induction followed by a three month probationary period. During this time they worked under supervision. Sleep-ins were done alongside a colleague at first, until the staff member was judged competent to work alone. Four members of staff had a National Vocational Qualification at Level 2 or above. One was working towards NVQ level 3. The home therefore had above 50 of staff with an NVQ level 2 or equivalent. Staff had core training including health and safety, food hygiene, first aid, medication, including special methods of administration, and abuse awareness. There were also courses about epilepsy, challenging behaviour, person centred planning, physical intervention, autism, and dementia in people with Down’s Syndrome. This range of training ensured that staff could meet the diverse needs of the people who lived at Heads Meadow. Refresher training had taken place in November 2006 for health and safety and first aid. Food hygiene refresher training was planned for this September. Staff were waiting for the community nurse to arrange refresher training for administration of medicines by special methods. Staff meetings took place. The notes of meetings in January and July 2007 were seen. The service manager reported that the assistant manager had had an appraisal recently but this was not yet written up. She reported that she and the other service manager had planned in six supervisions a year for each member of staff and these had just been started. The other service manager had the records and had taken some people from another house away on a holiday so it was not possible to verify this. At the previous inspection the assistant manager reported that they worked alongside the staff and gave informal supervision. DS0000028201.V336493.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager was suitably qualified, competent and experienced and on the whole people benefited from a well run home. The home was not providing evidence that they took responsibility for their own quality assurance and that people’s views underpinned all self-monitoring, review and development by the home. People’s health and safety were protected by the systems in place. EVIDENCE: The registered person for the organisation was Mrs Jane Abbott. She was also the registered manager for Heads Meadow. She had lengthy experience of working with people with learning disabilities and had owned and operated her own services for many years. She had a learning disability nursing DS0000028201.V336493.R01.S.doc Version 5.2 Page 26 qualification and was working towards NVQ Level four in management. She was supported by other senior staff within the organisation. Together, they oversaw all five services run by Valued Lives. The other registered managers within the organisation provided support to the various homes if needed. The other registered manager who was present throughout the inspection had a City and Guilds qualification in health and social care. She was also working towards NVQ Level 4 in management. For the last two inspections the registered manager had been working on their quality assurance for the service. The quality assurance framework was based on the systems in the house including policies and procedures, care plans, records and staffing. A consultant had provided advice and guidance about quality assurance. The views of people who used the service, relatives and visiting professionals had been collected. These had been collated into a quality assurance report for the whole service covering five homes. There was also a draft review report of the previous three years. Areas for improvement were identified. At the last inspection the owner reported that they needed to complete the summary of what had taken place over the last three years and type up the goals for the next three years. It was also identified that a copy of this report needed to be finalised, sent to the Commission and made available to all people who used the service. A requirement was made and this had not been addressed. The annual quality assurance process was due to be started again by collecting the views of people who lived in the home. The service manager reported that there were no plans to do this. Two people who completed comment cards said that the carers always listened and acted on what they said. One staff member in the organisation has lead responsibility for health and safety issues. There were folders in each home, which contained a range of relevant policies, and risk assessments. There was a monthly health and safety checklist. Checks were also made by relevant contractors e.g. servicing of the boiler and portable appliance testing. Potentially hazardous substances were stored securely. There was also product information relating to these. Radiators were covered and there were thermostatic valves on taps to reduce the risk of scalding. Checks and instruction relating to fire safety were seen to be recorded and up to date. Locking of exterior doors has been agreed with the fire safety officer. At the main inspection it was recommended that fire risk assessments should address issues for each separate area of the property. This had been addressed. A new risk assessment had been produced which considered each area of the premises and identified specific risks and the steps in place to minimise these. DS0000028201.V336493.R01.S.doc Version 5.2 Page 27 There were risk assessments in place for people who lived in the home about possible hazard areas, such as use of the stairs, or accessing the kitchen. DS0000028201.V336493.R01.S.doc Version 5.2 Page 28 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 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 X 34 3 35 3 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 2 X X 3 x DS0000028201.V336493.R01.S.doc Version 5.2 Page 29 x YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 3. Standard YA23 Regulation 12-1136&715-1a Requirement Strategies for management of behavioural needs must contain appropriate guidance agreed with professionals involved, show who has been involved in devising them, and be kept under regular review. (Timescale from 23/03/04 not met) COMMENT: Some progress had been made since the previous inspection. This part of Regulations also applies to the above Requirement. The registered person must supply to the Commission a copy of the report about the quality assurance survey and make a copy of the report available to service users. Timescale of 30/11/06 has not been met. The registered person must continue to implement an effective cycle of quality assurance and ensure that the views of all stakeholders are represented. Timescale for action 30/09/07 2. 3. YA23 YA39 17-1a Sch3-3q 24 30/09/07 30/10/07 4. YA39 24 31/12/07 DS0000028201.V336493.R01.S.doc Version 5.2 Page 30 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. 2. Refer to Standard YA20 YA34 Good Practice Recommendations The temperature of the medication cupboard should be monitored to ensure it does not exceed the limits identified in the patient information leaflets. When new staff are recruited a reference should be obtained from the previous employer. If they have left school or college a reference should be obtained from the school or college. Comment: No new staff had been recruited so it was not possible to check this recommendation from the previous inspection. DS0000028201.V336493.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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