Inspection on 17/10/06 for Helen Ley House

This inspection was carried out on 17th 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Helen Ley House 17/10/08

Helen Ley House 07/02/06

Helen Ley House 30/09/05

Helen Ley House 20/01/05

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

CARE HOME ADULTS 18-65 Helen Ley House Helen Ley House Bericote Road Blackdown Leamington Spa Warwickshire CV32 6QP Lead Inspector Jackie Howe Key Unannounced Inspection 17th October 2006 09:10 Helen Ley House DS0000063467.V313409.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 Helen Ley House DS0000063467.V313409.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. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Helen Ley House Address 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) Helen Ley House Bericote Road Blackdown Leamington Spa Warwickshire CV32 6QP 01926 313550 01926 888972 www.helenley.org.uk Multiple Sclerosis Society Mrs Iris Joy Durney Care Home 25 Category(ies) of Physical disability (25) registration, with number of places Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Helen Ley House is a 25 bedded care home providing 24 hour nursing care for adults with physical disabilities who have Multiple Sclerosis. The home provides long-term accommodation to two service users; the remainder of the 23 beds are for respite care. The home provides 23 single and 1 shared rooms, and all have en-suite facilities. The home has a physiotherapy department with a hydrotherapy pool for service users to use during their stay. The home is a single storey purpose built accommodation and was refurbished and extended in 2006. It is set in landscaped gardens, which are mature and well maintained in the Warwickshire countryside, a short drive from Kenilworth and Leamington Spa, with all its amenities, a variety of shops, pubs and places of worship. There are vehicles at the home to transport the residents on trips and for appointments. Information about the home is given to prospective residents and their families via the ‘Statement of Purpose’ and other information brochures. Range of fees: Three bands £756 / £868 / £1015 per week, based on dependency. Additional charges are made for hairdressing, toiletries and sundries such as newspapers and service users are asked to contribute to activities and outings. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the inspection year 2006/07 and was unannounced. It was undertaken over a period of one day, between 09:10 and 17:00 hrs. The inspection focused on the outcome for residents of life in the home, and their views of the service provided. The inspection process reviews the home’s ability to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision where improvements may be required. The manager was present through out the day. The inspector was able to tour the home, and spend time speaking with a number of residents, visitors to the home and staff. Some comments from people who use the home had been received prior to the inspection, and the manager has also provided the commission with a Pre Inspection Questionnaire. Information from these has been included in the report. The inspector ate lunch with the residents and was able to observe care practices, and how staff interacted with people currently staying in the home. During the inspection the care of three residents who use the home for respite care in particular were examined. This included reading care plans and documentation, observing care offered to them and that staff have the necessary skills to care for them. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for residents. The care of the residents who live in the home on a permanent basis, was not assessed at this inspection. Records including staff files, policies and procedures, health and safety / environmental checks and risk assessments were also read. What the service does well: The manager took up her post in March 2006, and is registered with the commission. Her appointment has had a positive effect on the home, which has undergone some significant change over the past months. The home receives regular visits from a member of the organisation to monitor the performance. The refurbishment and extension programme is now completed, and the home offers spacious, bright and cheerful surroundings, which are presented at a high standard. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 6 The services users who use the home speak highly of the facilities and of the care offered by the staff, but any comments or concerns raised at any time about the service are responded to and investigated thoroughly. Service users are actively encouraged both formally and informally to make suggestions for improvement in the services provided, and all suggestions are responded to and followed up and where possible implemented. The home offers a broad range of activities to the service users. There has been a change to the provision over past months due to a change in staffing, however after a period of instability there is a good programme of activity and entertainment available. Staff employed to meet the needs of the residents is at a satisfactory level, with some flexibility to provide more staff on busy days such as admission day on a Saturday. Staff were seen to treat the service users with respect and courtesy, and demonstrate a good understanding of their needs. Comments received about the service include: ‘ I realise I am not the only person to stay at Helen Ley house, but I am cared for very, very well. Personally I find Helen Ley house the best place I have ever had for my respite’. ‘I always find the complete care package first class and would always like to spend time at Helen Ley’. What has improved since the last inspection? What they could do better: Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 7 Records currently available to show what training has been attended by staff are limited, and some training courses have not been available for new staff to attend. There was little evidence to show that staff had attended training in Infection Control, and a number of staff have not attended training in Protection of Vulnerable Adults (POVA). Systems to demonstrate that all staff are receiving an appropriate level of supervision are being reviewed to allow for some one to one time with a supervisor and a move away from group supervision. The manager has only just reviewed this system, and has a clear understanding of what is required for the home to meet the standards. 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. Helen Ley House DS0000063467.V313409.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 Helen Ley House DS0000063467.V313409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Service users are presented with information with which to make an informed decision, and their needs are assessed. EVIDENCE: The home has a ‘Statement of Purpose’ and information guide for all service users to read. The Statement of Purpose is reviewed annually, and a new copy is sent to each service user. The next review is due in December 2006. As the current version is due for review, the manager ensures that any inaccuracies or changes are brought to the attention of the service user with an accompanying letter. A number of service users do not come from a nearby locality, which makes assessing a potential service user prior to admission difficult. Instead the home seeks an assessment from health care professionals and social workers and sends out a questionnaire to the service user and their GP. Staff spoken with said that this information was normally sufficient for the home to assess if it can meet the needs, but that a more thorough assessment is completed following admission, and updated on subsequent visits. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 10 Assessment documents seen confirm that a thorough assessment is undertaken by the nursing and physiotherapy staff on admission. Prior to every new stay, each service user is telephoned to receive an update on their condition and so that the home is aware of any changing needs, and medication. The home also send a form to be completed by the service users GP, so that they are up to date with any changes from a medical perspective, and to be made aware of any concerns the GP may have. In practice this form is not often completed by the GP, but the service user or their relative supplies the required information. The assessment process is also used to define dependency, which is linked to the fees charged for the stay. There are three funding bands, which the funding co-ordinator agrees with all referring agents or private clients. Helen Ley House DS0000063467.V313409.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 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 group is good. This judgement has been made using available evidence including a visit to the home. Service users changing needs are recorded and reassessed, and risks involved in relation to leading an independent life style are reviewed and supported. EVIDENCE: The care plans of three service users were examined during the inspection. All of the care plans seen, belonged to people who use the service for regular respite care. The care plans of the two residents who live permanently at the home were not read at this inspection. Care plans seen were found to be detailed and well recorded. Each care plan contains a detailed assessment, which is completed initially at the first admission and then updated for subsequent visits. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 12 Personal needs and wishes were identified in relation to the gender of the carer preferred, and recreational and spiritual needs. Records show that staff have not regularly received training in care planning and would benefit from training in producing care plans with more emphasis on ‘person centred care’ approaches so that they can feel confidant that each individual is not only receiving the assistance they require but that it is always offered in the way the individual service user prefers. There was evidence to show that care needs and assessments related to risks are reviewed at each stay and that care plans are updated accordingly. Service users spoken with were aware of their care plans and that these are updated to reflect their changing needs. Respite time spent in the home is for some service users a time to try out new experiences and attend events, which would be difficult for them at other times of the year. The individual programme of activity tries to make sure that all the service users who wish to do so are encouraged and supported to take risks, make choices and be independent as much as possible. Individual communication aids and tools are used as appropriate. Helen Ley House DS0000063467.V313409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15, 16 and 17 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Service users are given the opportunity to join in a wide range of activities and therefore able to choose an activity appropriate to their age and interests. Food available is of a high quality and there is plenty of choice available. EVIDENCE: As the majority of service users are only using the service for occasional respite care, standard 13 was not assessed at this inspection. The inspection coincided with ‘younger persons week’. This is part of a series of ‘themed’ weeks, which also includes ‘ladies’ and ‘men’s’ weeks. The manager said that these take place approximately three times a year, and some people choose to come in just for those particular weeks, and meet up with friends from other visits. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 14 Service Users are informed before admission, about what activities will be taking place during their week, and asked to indicate what they would like to take part in. They are then given an opportunity to discuss this with the care staff at the beginning of their stay and an individual programme is drawn up, and a copy given to each guest and staff so that every one is fully aware of what is taking place. Some activities are very popular and are over subscribed, and in these circumstances, guests are offered alternatives. The activities displayed as available for ‘younger persons week’ included: Internet tutorials, quizzes, shopping trips, magic show, a trip to the cinema in Coventry, hair and beauty sessions, in-house film shows, reflexology, talks by guest speakers and a trip to the local Chinese restaurant. Additionally the home provides cards, dominoes, jigsaws, library books and has a large selection of DVD’s and CD’s available for use. The home provides a selection of computers, which are connected to the internet, and during the inspection the service users were seen to be making good use of these. Since the last inspection a member of staff who had worked at the home for some considerable time, and was responsible for the activities and entertainment programme has left. Her loss to the home was felt quite badly by a number of regular guests to the home, and initially some rather negative comments were received, and this was repeated on comments cards received by the commission prior to the inspection. ‘ Entertainment and outings are now lacking, due to the non replacement of the organiser’. Another member of staff has been appointed to the post, but there are a reduced number of hours now available. Ensuring that as many people as possible are given an opportunity depends on the availability of volunteers, and additional staffing. The activity organiser spoken with said that it was not normally too much of a problem to find support staffing. On the day of the inspection, service users said that they were able to join in most of what they wanted to and were positive about what was available. Other positive comments have been received in letters to the home, one received and signed by a number of guests said: ‘ We would like to say how much we appreciate Rodney’s hard work on the entertainments that he organises. We all found the race night excellent, and the quizzes he organises are an added bonus to our stay’. During the inspection, it was noted that service users are offered privacy and are as independent as possible. Bedrooms are lockable by their occupant. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 15 The inspector ate lunch with the guests in the main dining room. Space was limited, as there were a number of people using it, some with quite large personal chairs. There are plans to swap one of the lounges with the dining room to provide more space. The menu on the day of the inspection was salmon in citrus and parsley sauce, or cottage pie, with mashed potatoes, carrots and peas. There was a vegetarian choice of mushroom and leek linguine with garlic bread. For desert there was apricot upside down pudding and custard, or fruit or ice cream, followed by a cheese selection, and biscuits. Guests were also offered tea and coffee, and a selection of cold drinks and juices were available. Service users spoken with said they were happy with the choices available, and that the standard of food was good. Cooked breakfast is available on a Sunday, and a hot supper is available every day. Service users were assisted with eating their meals by staff who were attentive and offered food at an appropriate pace. Staff demonstrated good knowledge of the dietary needs of the service users, and also where there was concern over the amount eaten, what supplements may be required. The menu is on a four weekly cycle and is changed seasonally. Menus seen showed a good balanced diet with plenty of choice. The cook demonstrated a good knowledge of special diets, including the different levels of soft and puréed foods. Stocks in the kitchen were plentiful, and stored appropriately with adherence to food hygiene standards. Helen Ley House DS0000063467.V313409.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 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 group is good. This judgement has been made using available evidence including a visit to the home. Care plans read show that people using the service are offered care which responds to their assessed needs, and their physical and emotional health are identified and professionally handled. EVIDENCE: Care plans read indicate that the level of personal and health care offered to service users during their respite stay, is well assessed, documented, and given by staff who are professional in their approach to care. Service users spoken with confirmed that the care they received was good and met their needs. ‘Am I satisfied? Very much so’. Physiotherapy and use of the hydrotherapy pool is part of an individual care package, and service users are able to intersperse their physiotherapy time in with a social activity. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 17 Each service user receives a full physiotherapy assessment at each stay, and information from other health care professionals caring for people whilst at home is used as part of this assessment. Current physiotherapy availability is a little restricted and the manager and the organisation are currently looking to review this to allow for physiotherapy five days per week. Service users using the service found it to be a valuable part of their stay, and whilst some find the sessions ‘exhausting’, said that they found it to be beneficial. The nursing staff are thorough in their health screening and reassessment processes, and there was evidence that there is good communication between the home and other health care professionals such as GP’s and district nurses to relay concerns or improvements noted during the stay. A complaint has been received recently from a relative about the standard of care received, and in particular about communication between the home and her with regard to changes in care needs during a stay. This complaint is currently being investigated, but in the mean time, the manager is looking at ways communication between relatives and the home can be improved. As the majority of service users are not from the local area, GP cover is supplied by a local GP service. Staff spoken with said that the service offered was good. Dental, optician and chiropody services are also available if required. Each individual service user for their stay generally brings in their own medication. A letter is sent out prior to admission reminding services users to bring along sufficient stock, and to ask for information regarding changes in medication. Sometimes changes in medication are made by the service users’ GP prior to the stay, so that the nursing staff can closely monitor the change. The majority of service users have their medications administered by staff, but some prefer to do this themselves as they do at home, and this is supported by staff. All Medication Administration Records (MAR) seen had been well completed, and all files had a photograph of each service user to minimise the risk of wrongful administration. Controlled drugs are kept and stored correctly, and recorded in a register. As the majority of medications are brought in by the service users, the nursing staff do not generally have to order and check prescriptions, apart from for the two permanent residents in the home, or for emergency medicines such as antibiotics prescribed during a stay. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 18 Each individuals’ medication is however checked in by the staff, and any discrepancies or concerns are discussed with the service users’ GP or in some cases, as admissions are at the weekend, with the local GP or the service user’s carer at home as appropriate. Helen Ley House DS0000063467.V313409.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 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 group is good. This judgement has been made using available evidence including a visit to the home. Service user’s views are actively sought, listened to and responded to, and the home has policies and procedures in place to protect service users from harm. EVIDENCE: The registered manager has a very proactive approach to seeking the views of those using the service and to responding to complaints or comments received. With such a large number of people using the service throughout the year, there are a number of comments received. Sixteen complaints have been received and recorded. All complaints made have been responded to by the manager, investigated as appropriate, and the results of the investigations are fedback to the complainant. Excellent records are kept, with outcomes recorded. The commission has received one complaint earlier this year related to care provision and a lack of communication between a relative and the home. This is currently being investigated by the organisation, and the manager is not yet fully aware of the outcome. The home has a detailed complaints procedure, which is easily accessible. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 20 Policies and procedures for the protection of vulnerable adults against abuse are in place, as well as a policy for ‘whistle blowing’. Staff recruitment records show that appropriate pre employment checks for all new staff are undertaken. Recognising the potential signs of abuse, are introduced to staff at induction, and also within the National Vocational Qualifications (NVQ) that a number of staff have undertaken. Specific training in Protection of Vulnerable Adults (POVA) has not been available recently, and a number of new starters to the home have not been able to undertake this training. The manager is aware of the lack of certain training courses, and said that POVA training would be included in the 2007 training plan and made available for all staff to attend. The home does not currently have a copy of the Warwickshire multi agency policy for responding to potential abuse, nor a copy of the Department of Health ‘No Secrets ‘ document. The manager has not had to make a referral to the POVA register, or for investigation but is aware of the procedures to follow. Policies and procedures regarding service users’ money, including the safe keeping of money and valuables are robust. Helen Ley House DS0000063467.V313409.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 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 group is good. This judgement has been made using available evidence including a visit to the home. Service users are offered facilities, which are of a high standard and provide a comfortable and safe environment. The home is clean, well maintained and hygienic. EVIDENCE: As previously mentioned, the home has recently undergone a major refurbishment and extension of its facilities, and this has had a significant impact on the home with the availability of spacious and new facilities. All individual bedrooms have been extended to allow for en- suite facilities and new bathrooms, sluices and storage have been made available. A ‘serenity room’ has been provided as a space for quite reflection. This room has large stained glass windows, and enjoys views over the gardens and surrounding countryside. Music and reading materials have been provided, including spiritual literature for different faiths. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 22 The home now has four individual wings each one is identifiable by a name and a pictorial sign so that service users can find their way around. Personal rooms also are numbered and have the pictorial sign for the wing, which are placed at an appropriate height to accommodate wheel chair users. Personal rooms are well presented and decorated, and are bright and cheerful. Rooms are large enough to allow the use of specialist equipment and lifting aids. Storage cupboards such as wardrobes are accessible to promote independence. There are a selection of communal rooms and spaces and these were noticed to be used well during the day. There is a smokers’ room, which also has access to the outside, with an automatic door, which can be used independently by wheel chair users. The large lounge houses a very large flat screen TV for film viewing, and also has books and items of interest. This lounge is not used as frequently as the other areas of the home, but is useful for large group occasions. Since the refurbishment the home now has new sluice and laundry facilities. Storage facilities are good and there was little evidence of hoists and chairs in corridors. A resource room has also been created which service users, their visitors, staff and student nurses on placement, use. There are a large number of information pamphlets and brochures, which are available in different languages and different formats about multiple sclerosis and the latest information regarding new initiatives and research. Helen Ley House DS0000063467.V313409.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 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 group is adequate. This judgement has been made using available evidence including a visit to the home. Records seen do not demonstrate that all staff have received training appropriate to their role and current arrangements for staff supervision, do not meet the required standards, which may mean that staff are not fully aware of or undertake correct procedures. The homes recruitment practices are robust. EVIDENCE: The home employs over 100 care and ancillary staff, with 23 registered nurses. Rotas seen confirm that staff are employed and rota’d to work in sufficient numbers to meet the needs of the service users. Staffing is flexible and more staff are on duty on a Saturday, as this is ‘admission day’ for those using the respite service. There is sufficient ancillary support from cleaners, and from caterers to support the care and nursing staff, and the home also employs administration, gardening and maintenance staff. There is a clear management structure within the team with staff understanding their roles and responsibilities. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 24 The home regularly employs staff from overseas. The manager said that although generally their English is satisfactory, there are some staff whose command of English is not as good as others, but she ensures that staff work in pairs, and puts a foreign language speaker with a member of staff whose English is fluent so that there is not a communication concern. A number of service users are of different nationality, and having multi lingual staff is often an advantage to the home. Physiotherapists are currently working on a contractual basis over four days per week. The organisation has plans to change this arrangement to provide a more flexible service to the service users. Learning and development records kept on individual staff files have been introduced by the new manager and are therefore not a true record of all training previously achieved. Other records seen indicate that some mandatory courses such as Infection control and Protection of Vulnerable Adults (POVA) have not been made available for over a year so that a number of new staff have not attended this training, or had an opportunity to have their training refreshed. The manager is aware of where there are shortfalls, and the training plan for the remainder of 2006 identifies Food Hygiene and Infection Control as mandatory courses for staff to attend. The training plan for 2007 has not yet been formulated, but the manager has stated that this will include POVA training. The home exceeds the standard of 50 of staff holding a National Vocational certificate (NVQ) or equivalent, in care with more staff currently working to achieve this. Staff files read show that recruitment checks undertaken are thorough, and records held are stored appropriately. The manager is also in the process of introducing a format for staff supervision, which will meet the required standards. Currently all members of staff have received an annual appraisal, but regular supervision sessions to address practice and individual development needs of staff have not taken place. The manager has written a policy for supervision, and is hoping that supervisory and management development training will be part of the training plan for 2007. Helen Ley House DS0000063467.V313409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome group is excellent. This judgement has been made using available evidence including a visit to the home. Service users benefit from a home, which is well managed, and where their views are taken seriously. The health and safety of the service users is given due regard and consideration and records are well kept. EVIDENCE: The manager has been in post since March this year. She is an experienced manager and has spent a number of years in the care industry, although working with this client group in a respite setting is a new experience for her. Since appointment she has been very involved in the refurbishment programme and the official reopening of the home, which took place in September. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 26 Staff spoken with, were positive about the manager and her management style. They felt that she was ‘doing a great job’ and was ‘easy to talk to’. Since appointment the manager has introduced a number of new procedures to ensure that the home is well run, and has plans for future developments. Quality assurance is taken very seriously, and the manager holds regular meetings with senior staff ensuring that they are informed about all the feedback and comments she receives about the service and ensuring that ideas they may have, are considered. The home has a suggestions box which staff and service users alike are encouraged to use. There is evidence in the home that suggestions made are introduced, for example the inclusion of pineapple juice as a drink of choice, fresh fruit bowls being made available, and names and room numbers for bedroom doors being in larger print and placed at an appropriate height. Residents meetings are held on a regular basis and the minutes are displayed near to the resource room. Quality audits are undertaken quarterly and annually. The manager produces an action plan from the audit, which is discussed with senior staff and an annual quality report, which is made available for everyone to read. The home gives all aspects of health and safety for its staff and service users due consideration and thorough checks are made. Fire safety lectures are undertaken at regular intervals, and weekly tests are undertaken. Required checks of lifts, lifting aids, electrical wiring, portable appliances, water temperatures, gas installation and fire equipment have been undertaken. Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 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 N/A 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 4 X X 3 X Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 Requirement The registered manager must ensure that all staff are given appropriate training to the work they perform, particularly in regard to Adult Protection and Infection Control. The registered manager must ensure that all staff working in the home are appropriately supervised, and that this supervision covers all areas directed in the National Minimum Standards. Timescale for action 31/01/07 2. YA36 18 31/01/07 Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 29 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 YA6 YA23 Good Practice Recommendations It is recommended that the manager explore training opportunities to develop staff in ‘person centred’ care planning approaches. It is recommended that the manager obtain a copy of the Warwickshire multi agency policy in responding to abuse, and a copy of the Department of Health ‘No Secrets’ document. It is recommended that a training matrix be devised, to ensure ease of identifying what training is required for each individual staff member. 3. YA35 Helen Ley House DS0000063467.V313409.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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