Inspection on 12/02/08 for Heywood Sumner House

This inspection was carried out on 12th February 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heywood Sumner House 13/01/09

Heywood Sumner House 31/10/06

Heywood Sumner House 16/01/06

Heywood Sumner House 19/07/05

Heywood Sumner House 26/07/04

Heywood Sumner House 03/03/04

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

CARE HOME ADULTS 18-65 Heywood Sumner House Cuckoo Hill South Gorley Fordingbridge Hampshire SP6 2PP Lead Inspector Sue Kinch Key Unannounced Inspection 12th February 2008 11:00 Heywood Sumner House DS0000055844.V357076.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 Heywood Sumner House DS0000055844.V357076.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. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heywood Sumner House Address Cuckoo Hill South Gorley Fordingbridge Hampshire SP6 2PP 01425 652350 01425 655736 heywoodsumner@truecare.co.uk 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) Truecare Group Ltd Post Vacant Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12) of places Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users may only be accommodated in category MD if they are also accommodated by reason of LD. There is a dispensation to accommodate two named service users in the MD category. 31st October 2006 Date of last inspection Brief Description of the Service: Heywood Sumner House is part of the Truecare Group managed by C.H.O.I.C.E. Ltd. The home is located in the rural village of South Gorley between the market towns of Fordingbridge and Ringwood. It provides accommodation for up to 12 residents who have a learning disability. The property is detached with car parking for several vehicles to the front of the building and well-maintained and accessible gardens to the side. Accommodation comprises of single bedrooms located on both the ground and first floor. There are two lounges and a dining area on the ground floor, together with various other facilities including an activities/games room. The current range of fees is £1,483.00 - £2,541.00 per week. Items not covered by fee include hairdressing, chiropody, toiletries, and holidays. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection consisted of a review of the file held at The Commission for Social Care Inspection (the Commission) office and of an Annual Quality Assurance Assessment (AQAA) document completed and sent in by the manager before the inspection visit. The visit took 7.5 hours. Most residents were met and spoken with at varying lengths. Five staff and the manager were also spoken with during the visit and the operations manager at the end. Parts of the physical environment were assessed and some records and documentation were examined. Surveys were sent to a sample of staff and residents. Four completed survey forms were returned from residents who were assisted by staff. Four were also returned from staff. What the service does well: What has improved since the last inspection? What they could do better: Requirements have been made about concerning staffing and management standards. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 6 Work is still needed to evidence that the staff recruitment process includes a full set of pre-employment checks. A training plan and full record of training must be in place based on staff training needs to ensure that staff are suitably trained in all areas of care including understanding autism, communication adult protection and whistle blowing to meet the needs of residents. Evidence of induction and supervision must be fully recorded to demonstrate that staff are fully supported to learn and about and reflect on their roles in meeting residents needs. A full quality audit system must be in place to ensure that health and safety checks such as in house fire system checks are regular, to minimise the risks to residents. Training for staff in topics relating to health and safety such as infection control and fire safety must be consistently provided and recorded to ensure that resident’s needs are met. 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. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need to choose a home, which will meet their needs, and reviews are held following admissions to monitor this. EVIDENCE: Heywood Sumner House has an admissions policy, which includes preadmission assessments, trials and reviews. In the surveys from the residents three out of four people said that they had been asked if they wanted to move to the home. The fourth person said they had not but had received enough information before moving into the home. In the AQAA the manager said that there is a detailed assessment before admissions involving the referrals team the home manager and the organisations assistant psychologist. She said that there is a transition plan for new residents and regular reviews take place depending in the needs of the resident. Since the last inspection one new resident had been admitted. Records showed that the pre-admission assessment had taken place, a transition plan had been used there had been regular meetings to monitor progress. The manager said that the admission had been an emergency although a pre admission visit had been made the day before the admission. However, information had been gathered to provide staff Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 9 with initial guidance on how to support the resident including information about communication, behaviour, health, risks, and use of the community. The speed of the admission was discussed with the manager who said that it would usually be a longer process. During the visit the prospective resident did have an opportunity to meet existing residents. The manager said that it was priority for people to fit into the home and she would hope to increase these opportunities for meeting existing residents next time an admission is planned. The statement of purpose, located in the front corridor opposite the office, was reported by the manager to have been updated. In the AQAA she said that she planned to up date the service user guide and to enable residents to take the lead in the design and the communication tools used. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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 living in the home are benefiting from reviews of their care needs and the developments of plans based on their individual wishes and preferences whilst taking risks into account. EVIDENCE: During case tracking personal records for four of the residents were sampled. The manager said that all care plans were up to date and had been re-written since the last inspection. In the files sampled a range of information was provided and mostly with evidence of recent updates. The information is detailed and samples viewed included general information in a profile, communication, family contact, priority action plans, risk assessments for behaviours and activities, behavioural assessments and guidance including fully documented de-escalation techniques and restrictive interventions, daily monitoring sheets, health monitoring, incident monitoring and activity plans. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 11 The information is organised consistently and in the two files sampled concerning reviews there was evidence that these had been taking place. In one of the files there was a lot of information but no actual care plan although information sought during the inspection was found in other parts of the file. The manager said that there should be a care-plan and thought that a member of staff was working on it she agreed that it needed to be completed. A requirement was made in the last inspection report to ensure that any physical interventions to safeguard residents and staff are detailed in the individual residents’ care plans. Since that last inspection Truecare has told us they are moving from using prone restraint and are changing to use other interventions and at this inspection the manager said that prone restraint is no longer used. A member of staff gave examples of less restrictive interventions now used when residents are agitated such as going for long walks and another mentioned using a beanbag. Staff said that physical interventions are now used less at the home. During the inspection comments were received particularly from staff about recent changes within the home that have been benefiting the residents. They said that the residents have been consulted about what they want to do and have been encouraged to be more active. One staff member commented that one person had changed so much that they could now be supported out in the community on a one to one basis. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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 living in the home are being given increased opportunities to pursue interests and activities in and out of the home and with personal development. Residents’ rights and responsibilities are increasingly recognised in the daily routines of the home and meal planning promotes choice. EVIDENCE: Since the last inspection a day care worker has been recruited to focus on providing more activities based on resident’s needs and wishes. During conversations separately with staff and residents comments were made about the increase in the number of activities that some people are enjoying and others that they have tried out. One person spoken with already had a busy weekly schedule but was also joining in with new activities. Another was reported by staff to have taken part in a number of things out of the home that they had not been involved with for some time. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 13 The day service worker was on duty during the site visit and was involved in organising and supporting activities. Three people had gone horse riding in the morning, each supported 1-1 by staff. Another had been supported to go to the cinema and others were supported in the kitchen making lunch. Plans were in place to support some people to go swimming in the afternoon though those involved chose not to go. People also talked about other trips including going for walks and bowling using the homes, and public, transport. One member of staff spoken with had just returned from an overnight stay on the Isle of Wight with a resident and another member of staff. This was reported to have been a very successful trip. A timetable is available for each week in the front hall but is only a written timetable, which is not accessible for some people. A staff member said that one with a picture format was to be developed. There was evidence that other styles of communication are being used in the home .We saw staff using sign language and communication boards during the visit. The manager said that communication passports were in place but needed to be updated. In staff feedback there were three comments about residents not always having a choice about activities and one said sometimes there were sanctions for not taking part. This was not evident during the inspection visit and not agreed to be part of the policy by the management. But the manager said that if an activity is missed out of choice the opportunity to do it that week might be affected by other plans already made. One member of staff commented on staff having varying abilities to motivate residents and that some were more effective than others and some needed to adapt to new ways of working. Residents are encouraged to be involved in household tasks to varying degrees depending on their needs and interests. These tasks include cleaning, cooking and taking responsibility for their rooms. One resident spoke about cooking the lunch and said that they enjoyed doing it and did it often. Help is given with personal family and sexual relationships some aspects are included in care plans. Professional support is provided to help with this and plans are in place to promote equality and diversity in work carried out on relationships and sexuality. Residents are also supported with family contact and one person talked about regular trips to stay with their family. The manager said that residents are being encouraged to eat together and that improvements had been made to provide dining room facilities in two areas so that residents could choose whom to eat with. A member of staff said that there are menus planned with the residents and that it is mostly kept to. Two people spoken with had enjoyed their lunch on the day of the visit and one said that the food was always good. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Residents’ healthcare and personal support needs are increasingly met both by members of staff and through referral to healthcare specialists. Residents are protected by the home’s medication handling policies and procedures. EVIDENCE: Personal care needs are documented in the care records for residents and identifies varied support depending on needs. One staff member said that changes to the environment would include the installation of a shower for one resident who currently does not like the shared facilities provided. The resident confirmed that this was planned. Since the last inspection it was raised through adult protection meetings that the home needed to improve its use of external professionals in providing health care for the service users. The home has used the company’s psychology assistant but in records viewed during the inspection and information shared by staff and the manager there was evidence that input from other professionals has increased. Although one staff member commented that it could still improve, others spoke of the use of speech and Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 15 language therapists, and of psychiatric input and records held in the home support this. The records viewed during the inspection included evidence of recent appointments or checks with community nurses, doctors, a psychiatrist, dentist and optician. The manager also reported to use specialist services such as neurology, audiology, and diabetic clinics. Medication is held securely in the home and the staff said that the team leaders on each shift are responsible for administration. One has delegated responsibility to oversee the medication system. Samples of records of administration, receipt and disposal of medication were viewed and some cross-checked with drugs held in the monitored dosage system and were in order. Drugs for one person were dispensed into a pot but had not been given. A member of staff said that this was not a normal procedure but the staff member dealing with medication usually gives medication to residents individually and straight away. In this instance the staff member had mistakenly thought that a resident was at home when administering medication and these had been held for when that person returned. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. A complaints system is in place for residents to use and systems are in place to keep them informed about it and to make it more accessible. Systems in the home have been under review and are changing to increase adult protection and safeguard people living in the home but more evidence of adult protection training is needed. EVIDENCE: Minutes were available of a residents meeting on 31/1/08 to show that the complaints procedure was discussed with five residents who attended and it was agreed that a tape, book and picture format of the complaints procedure would be produced. Residents completing survey were aware of how to make complaints. Two residents spoken with at the home said that they did not have any complaints to make. Since the last inspection the manager said two complaints were reported. These are logged and correspondence is held in a confidential manner but showed that the home had responded to them. Staff in the surveys said that they felt it was their role to support residents to raise issues. Since the last inspection, in 2007, some serious allegations of abuse were made about the service brought to light by senior managers of Truecare who reported the matter under adult protection procedures and ensured that they Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 17 were represented at following meetings. The outcome was that the home needed to use their staff disciplinary procedures and it triggered the need for changes in care practices such as some physical interventions used. It also highlighted the need for staff training in adult protection and whistle-blowing procedures. A number of other issues arose from the above adult protection meetings such as the frequency of care plan reviews, monitoring of health checks, staff training, and input from health professionals. During this inspection checks were made to see if these had been followed up. There was evidence from discussion with the management, staff and from records that progress has been made these are addressed in sections throughout this report although more evidencing of staff training in adult protection is still needed. The operational manager said that staff had been trained in June 2007. This was not recorded in the files viewed. A member of staff spoken with said that it had taken place. Records of training adult protection training and whistleblowing need to be held in the home. Since the above adult protection issues the home’s management has continued to use the local adult protection procedures following some incidents and reported them to CSCI. The home had ten residents at the time of the inspection and some with very complex needs at times needing specific interventions to support challenging behaviours. The manager confirmed that staff are required to fill out incident sheets as necessary and the psychologist monitors them .The manager also monitors these said that this includes checking that agreed procedures are used. She also said that the management have role in observing practices. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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. Improvements to the environment are ongoing to increase the suitability of it to meet residents’ needs. EVIDENCE: The manager had reported in the AQAA that some work had been taking place to improve the environment and since the last inspection some re-decoration of two residents rooms and the hallway had taken place. There is also a new fire detection system and new cattle grid to the entrance of the grounds. Since the last inspection the Commission has been informed of temporary changes in use of one room to improve the environment for one resident. Further work was reported to be planned and at the site visit management staff and residents spoke of the building work taking place in the annexe. Plans are in place to: extend two bedrooms; provide an ensuite in a resident’s bedroom, complete more redecoration and provision of a sensory room. Further temporary bedroom arrangements had been made for some residents Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 19 but a staff member explained how the needs of the residents had been taken into account in the decision-making process. Residents spoken with were aware of aspects of planned changes to the environment and two spoke of looking forward to its completion. A sample of bedrooms were viewed and some were adequately decorated with evidence of personal possessions but one had marked walls, another had no curtains and a third had no carpet or curtains and a large stain from a leak on the ceiling which had been there for some time. Staff had knowledge of plans to address these short falls. A laundry facility is available for use at the home. The laundry floor was noted to be in need of re-sealing at the last inspection and although it was not viewed at this visit the manager confirmed it had been completed. The manager stated in the AQAA that there is a policy in the home on infection control but that only nine of the current staff have received training in this. She manager said that a Truecare programme of training is in place to increase the numbers of staff trained in infection control but no specific dates were yet set for staff. A member of staff at the inspection visit said that disposable equipment is available for use when staff are using infection control procedures. Two of the residents in the surveys said that there is a cleaner to keep the home clean. The home was clean on the day of the inspection visit. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures, staff training and supervision all need to be rigorous to ensure that staff are adequately equipped to support residents consistently and given opportunities to reflect on the quality of care they are providing them. EVIDENCE: In the last twelve months levels of permanent staff have dropped and at the point of the inspection visit it was reported that four new staff had begun working at the home in the previous two months. On the day of the inspection staff levels were sufficient to allow some residents to have 1-1 support and two staff had just accompanied a resident on an overnight stay away from the home. However, it was reported by the deputy that there are still five staff vacancies and two bank or agency staff were on duty during the inspection. However this did provide a ratio of eight staff for ten residents on the day of the inspection visit. Comments had been received about staff levels having been variable but the manager said that these staff levels are now consistently provided. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 21 Verbal and written feedback was provided from staff indicating how the service is now moving forward and that support and guidance had improved. One staff member said that residents are more active and one was described as a lot calmer, another that the service is more person centred and staff ratios are better, and another that many changes are good and more support is available. Another said that staff were friendly but some staff still need to change and others were reviewing their approaches. Three staff said that they receive regular supervision another had not had any. Two comments were received about not feeling supported enough. Two people commented on getting supervision when it is asked for and one person does not feel listened to or given enough explanation. Records of supervision indicate that all staff are not receiving it regularly and the management target of six times a year is not met. The outcome of adult protection meetings in 2007 had implications for staff training and in particular in areas such as adult protection whistle blowing, understanding autism, communication and recording and restraint. The operations manager said that these matters were followed up. Some evidence from conversations with staff and the manager and from a sample of records was found to support this. Where sampled all staff had received training in the behaviour management and restraint. The manager said that more work was needed in areas such as autism. However the training records for these areas of training, general areas of training and induction are not maintained sufficiently to show that all staff working in the home have received all the training needed. In addition although some further training was mentioned by the manager and the company does provide regular training courses there was no clear plan of training in place for all staff based on their assessed needs. The company holds staff recruitment records centrally but should have some information in the home to demonstrate that all the required pre employment checks had been completed before staff are employed. Evidence was requested for four staff and the forms required to be available were not. The manager obtained information about POVA First and CRB checks and staff had as required only begun work after the POVA First had been completed but records of how one person had been supervised in the month before the CRB was completed was not in place. Information about references and other checks were not in the home. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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 management changes are leading to the development of a service based on the needs of the people living in the home but further work will enhance this to ensure that systems, including those related to aspects of health and safety, are effective and fully monitored. EVIDENCE: The home had a temporary manager after the last registered manager left the home and the current manager has been in post since July 2007.The Commission has yet to receive an application form for registration. This was discussed with the manager who thought that this could be submitted within two weeks. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 23 Mixed views were received from staff about the support that they receive from management. There were general statements about positives for the residents who are doing more and staff getting more idea on how to support people’s behaviours. They reported to have regular staff meetings but in the staff section above some less positive comments about support are also recorded. The manager in the AQAA said that there is a quality assurance system developing in the home and that there is a development plan needing reviewing and updating. At the inspection this was seen and the manager gave an example of the improvements to the environment being a direct response to feedback from residents and relatives. The manager is aware that some of the other quality assurance system in the home needed development and has set up a quality assurance file to aid this. As noted in other sections of this report quality monitoring is needed for areas such as staff recruitment, induction and training, supervision, and aspects of health and safety to ensure that required standards are attained. Aspects of health and safety were looked at during this inspection. There was not enough evidence of staff receiving fire training. Weekly in house fire system checks have restarted but had not been completed since 25/1/08. Previous to that the checks, due to problems with the system had not been completed testing for some months. The fire system has now been replaced. Fire drills had been completed within the appropriate timescales. Checks of the hot water had been resumed after the issue had been raised in regulation 26 reports. Only nine staff were reported in the AQAA to have received infection control training and no information was given about food safety training. The manager said that a number of staff needed training or refresher training. Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 24 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 x 3 3 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 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 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 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 2 x x 2 x Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19 Requirement Evidence of recruitment checks must be held in the home to demonstrate that residents are supported by staff who have been appropriately checked. A training plan and full record of training must be in place based on staff training needs to ensure that staff are suitably trained in all areas of care including understanding autism, communication adult protection and whistle blowing to meet the needs of residents. Evidence of induction and supervision must be fully recorded to demonstrate that staff are fully supported to learn and about and reflect on their roles in meeting residents needs. A full quality audit system must be in place to ensure that health and safety checks such as in house fire system checks are regular, to minimise the risks to residents. Training for staff in topics relating to health and safety such as infection control and fire safety must be consistently DS0000055844.V357076.R01.S.doc Timescale for action 12/03/08 2 YA35 18(1) 12/05/08 3 YA36 18(2) 12/05/08 4 YA39 13 12/05/08 5 YA42 13 12/05/08 Heywood Sumner House Version 5.2 Page 26 provided and recorded to ensure that resident’s needs are met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Heywood Sumner House DS0000055844.V357076.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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