Inspection on 09/05/06 for HFT 34 Shipston Road

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

HFT 34 Shipston Road 14/05/07

HFT 34 Shipston Road 12/01/06

HFT 34 Shipston Road 05/09/05

HFT 34 Shipston Road 17/03/05

HFT 34 Shipston Road 16/11/04

HFT 34 Shipston Road 26/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Hft - 34/36 Shipston Road 34/36 Shipston Road Stratford On Avon Warwickshire CV37 7LP Lead Inspector Kevin Ward Key Unannounced Inspection 9th May 2006 07:50a Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 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 Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 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. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hft - 34/36 Shipston Road Address 34/36 Shipston Road Stratford On Avon Warwickshire CV37 7LP 01789 261105 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) www.hft.org.uk Home Farm Trust Mrs Penelope M Barry Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Penelope Barry must achieve the Registered Managers Award before 31 October 2006 12th January 2006 Date of last inspection Brief Description of the Service: 34/36 Shipston Road is close to the centre of Stratford upon Avon, which has a wide range of shops, leisure facilities and medical services. The home provides care and support services to adults with learning disabilities. The home consists of two large semi-detached houses, each having their own separate entrances and staff team. The houses provide small group accommodation, with each house having a lounge, dining room, kitchen and laundry. All bedrooms are single rooms. There are no en-suite bedrooms, and wash hand basins are not provided in peoples bedrooms. The two houses share a sleep in member of staff, who is based at number 34; service users at number 36 are able to access the sleep in staff via a direct dial telephone. There is a large car parking area at the front of the properties and there are large, well maintained gardens at the rear of the properties. Information provided by the manager, 11/5/06 reports that the range of fees charged at the home currently varies between 578.76 and 736.35 per week dependent on individuals assessed needs. Service users are required to pay admission costs for activities and entertainments and to make a contribution to their holidays (staffing costs) in some cases where this is expensive. Service users are also expected to pay for their hairdressing, private chiropody toiletries and clothing, (although the manager reports that some clothing is also currently provided by the home). Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused on assessing the main key Standards and on reviewing progress to meet the outstanding requirements from previous inspections. Before the inspection, service users were sent questionnaires, to seek their views about the service, which were collected by the inspector during the inspection visit. The manager has also completed a questionnaire containing information about the home. The inspection involved talking with all the service users at the home as well as staff who were on duty at the time and the manager of the service. A number of records, such as care plans, staff files and fire safety records were also sampled for information to inform this inspection. What the service does well: The current people living at 34-36 Shipston Rd have been together for a number of years. The home has a suitable admission procedure in place so that they are sure they can meet people’s needs before they move in. Suitable care plans and risk assessments are in place so that staff are clear about the support they need to give to people. The people living at the home are assisted to maintain contact with relatives and receive support from them at care review meetings. Questionnaires completed by service users, prior to this inspection, indicate that people are very happy with the care and support they receive at the home. When asked about what they liked most about living at the home one person said “I like living with my friends”, one person said “ I like the staff” and another person said, “I like it because we can go to town” The home is in a good location so that people can easily walk to Stratford town centre and make use of the parks, shops, cinema, theatre, cafes and other community activities. Everyone looked very at ease and relaxed in the home as they went about their daily business. Staff were seen to be friendly and responsive to people’s requests for support and assistance. The home provides well-balanced healthy meals that are based on people’s likes and dislikes. A number of people confirmed that they take part in shopping for groceries and food preparation and said that they enjoyed the meals at the home. People are being supported to make complaints where they wish to do so and their concerns are being taken seriously and responded to properly. Most staff at the home have attended adult abuse training during the last year to equip them to recognise and report any suspicions of abuse, so that service users are properly protected. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 6 New staff starting work at the home are properly vetted to ensure that they are safe to work there and are provided with induction training and a probationary review before their appointment is confirmed. 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. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 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 Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 The judgement for this outcome group is adequate. Service users needs are properly assessed but contract information needs to be improved so that people are clear about what they are entitled to and what they are expected to pay for. EVIDENCE: All of the service users living in both houses have been together for several years and no new people have moved into the home since the last inspection. The manager explained that people only move into the home after a thorough assessment and that they are provided with opportunities to visit the home beforehand. The assessment procedure has been assessed on past inspections and found to be good. Well-detailed assessments were seen to be in place on peoples files. There is an outstanding requirement to amend the service user contract to be more specific about the cost of any extras that people may be required to fund for themselves so that this is not a source for confusion later. This is particularly important where service users may be expected to pay for extra staffing, such as special one to one holidays that do not fall within the scope of the home to fund and which would not be normally expected to fall within the Residential fees. The manager reported that no service users have been charged of any extra staff costs the last inspection. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 9 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): 6,7,9 The judgement for this outcome group is good. People needs are reviewed with their involvement and they are supported to take participate in making choices about their care and decisions in the home. EVIDENCE: Comments made by the people living at the home indicated that they generally enjoy living together at the home. Similarly comments made by people indicate that they like the staff and that they feel they are well supported at the home. Person centred planning is taking place at the home. This aims to put people at the centre of planning their care and support. Information gathered by case tracking people’s needs indicates that any behavioural issues that contribute to tensions in the home are being appropriately addressed with the support of health professionals and staff. A sample examination of people’s care plans and records confirm that their needs have recently been reviewed with the involvement of relatives and social workers. Service users confirmed that they are encouraged to take part in their reviews so that they can contribute to plans for their care and support. People’s care plans were seen to contain relevant information to help staff support people properly. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 10 This was backed by good risk assessments addressing hazards associated with everyday living, in the home and the community, so that people are supported to live their lives safely. Positive support is being given to support people to safely manage personal relationships, involving assistance from other professionals outside the home. Staff are being provided with sexuality and personal relationship training so that they are better equipped to support people where necessary. Service users care plans were seen to be locked away when not in use to safeguard people’s confidentiality. The people at the home confirmed that they are assisted to shop for clothes and personal items so that they can choose their own. Some people also take part in grocery shopping for the home and food preparation. On the day of the inspection people were seen to take part in making breakfast and washing up and wiping down kitchen surfaces afterwards. Service users also spend a day at home during the week when they receive help to tidy their bedrooms and to attend planned appointments. Service user meetings take place at the home from time to time to enable service users to take part in making decisions related to group living, such as choosing holiday destination and choosing furniture and equipment and reviewing menus. Comments made by service users indicate that they feel they are well consulted and supported to make everyday choices. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 The judgement for this outcome group is good. People are supported to have access to a reasonable range of community activities and are supported to maintain relationships with people who are important to them. Meals are well balanced and in keeping with people’ choices. EVIDENCE: Comments made by the people living at the home indicate a high level of satisfaction with their current lifestyle and the support they receive from staff. The home is situated close to Stratford town centre and people report that they regularly go out with staff to make use of the shopping centre and the parks. One person also regularly attends church with her friends. During the week people attend day services or college most of the time. The home is not staffed during the day, two days during the week, as everyone goes out. The home is staffed on the remaining 3 days to support people who are at home on these days. Comments made by people indicate they are currently happy with these arrangements. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 12 Conversations with service users and staff gave examples of people being provided with support to access the local community on a regular basis e.g. cinema, bowling, theatre in addition to shopping and parks. People are being supported to go on holiday with staff support. Plans have been agreed with service users to go on holiday to centre parks this year with a view to saving up for a foreign holiday next year. Photographs were seen of several previous foreign holidays enjoyed by people at the home. On the day of the inspection one person was celebrating her birthday and positive efforts were made by staff to decorate the home to recognise this event. A Birthday tea had been arranged on the day and a meal out with friends was planned for another evening later in the week. On the morning of the inspection, the person concerned was seen to open her Birthday cards in the company of other people at the home. Comments made by the manager and service users confirmed that the majority of people hold keys to their bedroom door and front door, indicating that people are encouraged to exercise a reasonable degree of control over their lives where it is safe to do so. One service user showed the inspector her pet rabbit that she is encouraged to care for. Another person has a fish tank that was seen to be well looked after. Discussions with people and record entries confirmed that people receive support from their relatives at reviews and that arrangements are made for people to receive and make visits to their relatives and friends. Staff are being provided with training to help them support people involved in personal relationships and additional support has been sought from other professionals to sensitively support a service user to manage a personal relationship. On the morning of the inspection people were seen to take part in preparing their breakfast and clearing up afterwards. Comments by service users confirmed that they are happy with the food provided at the home and have been consulted about the contents of the menu. The manager showed a good awareness of people’s likes and dislikes. Fruit was seen to be available in both houses and a piece of fruit is also included in people’s packed lunch. The menus have been constructed to include healthy balance and calorie counted meals. A number of service users said that they enjoy going shopping for the weekly groceries with staff support. Suitable dining furniture is available to enable everyone to sit down together to eat meals. People were seen to enjoy friendly sociable conversation at breakfast time in number 34. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 13 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): The judgement for this outcome group is adequate. Service users are supported by friendly and approachable staff and their health needs are properly addressed. The rating for this section is compromised by some shortfalls in the medication procedures at the home. EVIDENCE: Service users at the home spoke very positively about the care they receive at the home and were seen to get on very well with the staff on duty at the time of the inspection. Staff were warm and friendly and responsive kindly to people’s requests for advice and support. Staff demonstrate a proper regard for service users privacy. On one occasion the manager was seen to encourage a service user to speak to her in private when she was approached to discuss a personal matter in a communal area of the home. Service users confirmed that they have flexible bedtimes and which vary according to their wishes and stated they are allowed to stay in bed late at weekends when they are not rising for college / day service. Service users had recently stayed out until after midnight enjoying an evening out together. The home employs 1 male staff member and there is currently one male service users living at the home. The service user concerned stated that he is comfortable living with the other service users who are all female. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 14 Entries in people’s care plans and records and comments made by the manager indicate that people’s health care needs are being properly followed up and that people are being supported to access consultants and other health professional. Epilepsy protocols are in place so that staff know how to respond correctly to peoples individual needs. A good record summarising the progress regarding a consultant referral was seen, indicating that the home is taking positive action to secure the correct health support for the service user concerned. On the day of the inspection visit a service user was supported to attend a dental appointment, appropriately, as planned. Entries in people’s records indicate that they are being assisted to attend relevant community health care appointments. The manager said that well persons checks are currently overdue, as the community nurse previously responsible for this task had left the service and has only recently been replaced. A suitable medication cabinet is in place for the safe storage of medication. A sample examination of medication records indicates that medication is being properly signed for to confirm it has been given. Recent medication sheets did not contain any evidence to confirm that tablets are counted into and out of the home to ensure that medication is accounted for to evidence accurate stock control. The service users’ details were seen to have been changed on one medication sheet using tippex correction fluid. The inspector explained that this not permissible. Photographs of service users were seen to be in place at the front of people’s medication records so that staff are clear about the identity of the person for whom the medication has been prescribed. Staff records show that staff have been provided with training in the safe handling of medication. However there is not currently an assessment record in place for checking that staff have fully understood the training and medication procedure. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 15 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): The judgement for this outcome group is good. Service users complaints are dealt with appropriately and suitable procedures are in place for recognising and responding to suspicions of abuse. EVIDENCE: There have been no complaints made to the Commission for Social Care Inspection since the last inspection. The complaints log was examined and found to contain three complaints made by service users since the last inspection. The complaints have been followed up and resolved by the manager, indicating that the home takes proper account of concerns raised by people. The manager confirmed that there have been no complaints made to the home by relatives or professionals since the last inspection. A complaints policy is available for staff in the home and complaints information is available to service users in the service user guide. Comments made by service users indicate that they are happy at the home and feel able to raise their concerns with staff where necessary. There have been no adult abuse investigations during the last year. A previous investigation was carried out over a year ago, which was properly investigated. The manager confirmed that the staff member involved is now on the POVA register, which means they will not be able to work in care service again in the future. Training information provided by the manager and comments made by staff confirm that the majority of the team have recently received adult abuse training and that more training is planned to take place shortly for the 2 remaining people. Adult abuse and whistleblowing procedures were seen in the home to advise staff as to how they should report any serious concerns they may hold about the home. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 16 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 The judgement for this outcome group is adequate. Service users’ live in a comfortable and homely environment although there are a number of outstanding improvements necessary to at the home. EVIDENCE: Comments made by service users on the day and in the pre inspection questionnaires confirm that they like living at 34-36 Shipston Rd. Overall the home is comfortable and very homely. As previously noted people are involved in cleaning their bedrooms and in other domestic tasks, such as setting table, food preparation and washing up. The manager said that there are plans to refurbish the kitchen in number 34 and to fit a shower in number 36 as required at the last inspection. People’s bedrooms were seen to be comfortable and well equipped and to contain ample evidence to show that people have been supported to personalise these areas to their own liking. The décor in most bedrooms is satisfactory although two rooms would benefit from redecoration. Similarly the hallway in number 36 needs to be redecorated, as it is looking rather shabby in places. The manager explained that she anticipates the hall and the bedrooms was will be addressed by the organisation this year. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 17 The dining area in number 36 has recently been redecorated so that it is a more attractive room for people to eat in. A number of carpets in the hallways and communal areas are starting to look worn and there are some stains from drink spillages that require cleaning up, e.g. the dining room in number 36. There is a large well maintained garden at the rear of the home that people said they enjoy to sit in during the summer. The manager said that plans are in hand to refurbish and improve the kitchen 34 for the service users living there. The home was seen to be reasonably clean and free from any offensive odours. Since the last inspection good work has taken place to lay concrete, to make the area outside the garage more level and safer for people to work on. The manager said that there are plans to relay the patio slabs again later this year to ensure that there are no risks of anyone tripping on any uneven areas. The laundry rooms were seen to be tidy. There is evidence of water leaking under the floor tiles in one laundry room, which the manager had recently reported for repair. There is not currently a need for staff to launder incontinent laundry and the current washing machines are suitable for the home. Gloves and aprons are available for staff to use and an infection control policy is available in the home. The manager stated that service users are not allowed to carry any laundry through the kitchen when food is being prepared, to avoid any possibility of food contamination. Service users are encouraged to take part in cleaning the kitchen and other areas of the home. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 18 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 and 35 The judgement for this outcome group is adequate. Staff are properly vetted to ensure they are safe to work at the home and staff are trained to equip them to work at the home. EVIDENCE: Training information provided by the home indicates that over 50 of staff at the home have received training to NVQ level 2 or above and other staff are being put forward for this training. This training is necessary so that staff are properly trained to meet the needs of the people living at the home. A sample examination of recently employed staff files demonstrated that staff are being provided with a thorough induction and supportive training to equip them for their work. Comments made by staff at the home and a sample examination of recent supervision records indicates that staff receive support from the manager to carry out their jobs. Staff are being provided with training updates in Health and Safety related areas of practice. A small number of people need updating in some subjects, including food hygiene and first aid, whilst the majority are still in date. The manager was aware of this and indicated that plans are in hand to provide this training shortly. It has been over 12 months since fire training was carried out at the home. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 19 The manager said that a senior worker was shortly due to attend West Midland Fire Service; Fire Marshal’s training, with a view to providing fire safety training to the other staff at the home. The inspector explained that this training must be underpinned by training materials that can demonstrate staff have been properly trained in the relevant aspects of fire safety. The recruitment files of two recently employed staff contained the correct documentation, such as references, Criminal Record Bureau checks to confirm that staff have been properly interviewed and vetted to ensure that they are safe to work with the people living at the home. The manager said that service users opinions are sought when staff go through their probationary review and said that she would keep records of service users’ comments in future as further evidence of this. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The judgement for this outcome group is adequate. There is scope for improving fire safety checks and the quality assurance system so that service users and other relevant people are able to contribute to ongoing improvements at the home. EVIDENCE: The manager has 20 years experience working in social care services and has been working for Home Farm Trust, a provider of services to people for learning disabilities, for the last 8 years. The manager explained that she is currently in the process of training to achieve the Registered Manager’s Award to equip her for her management role at the home. It is condition of the manager’s registration that this qualification is achieved by 31/10/06. Comments made by service users indicate that they are supported to make choices on a day-to-day basis, e.g. go shopping for clothes and groceries. The small size of the home means that service users come into regular daily contact with a consistent team of staff and the manager. This helps staff and service users to get to know one another very well. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 21 A record was seen of occasional service user meetings that have taken place to discuss issues that are of importance to the people living at the home, e.g. choosing furniture and holidays. The manager confirmed that there is no current system for seeking the views of service users, relatives and professionals as part of a Quality Assurance system for the home. Only 4 monitoring visits have take place in the last 12 months. These reports are seen as an important way to demonstrate a commitment to Quality Assurance at the home. Since the last inspection action has been taken to tidy the home so that it no longer appears untidy and cluttered. Overall the home looked clean and was free from any unpleasant odours. Health and Safety records were sampled, including the fire safety log. The log shows that alarms are being tested every two weeks on average, rather than every week as required. Emergency lighting tests confirm that this equipment is being tested appropriately each month and that fire drills are being carried out at the home. Hot water temperatures are being logged and monitored and action taken to reduce the potential for people scalding themselves is now being recorded. The homes maintenance log indicates that repairs are being appropriately prioritised and reported by the manager so that the home is maintained in a safe condition. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 22 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 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 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 2 x 2 x 1 x x 2 x Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 23 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. 1 Standard YA5 Regulation 17(2) Sch. 4 Requirement The Service User contract requires more detail so that the residents have a clearer understanding of what is and is not included in the fees. (Outstanding from the last 2 inspections, previous timescale 30/4/06) Ensure that medication records are not changed or corrected using correction fluid. Keep a record to account for the number of tablets received in the home. Devise an assessment to ensure that staff properly understand the medication procedure. Timescale for action 30/06/06 2 YA22 13 (2) 07/06/06 Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 24 3 YA24 16 (2) (c) 23 (2) (b)(d) (j) A shower facility is 01/08/06 required for the bathroom in Number 36. Ongoing from last inspection, timescale 30/4/06 Make plans to improve the décor in the bedrooms discussed at the inspection and in other areas of the home. Make plans to replace the carpets where they are wearing thin. Clean stains on carpets where necessary. Proceed with plans to investigate and repair the leak under the tiles in the laundry room. 4 YA28 23 (4) (d) 5 YA37 9 6 YA39 24 & 26 Proceed with plans to 30/07/07 provide staff with fire safety training and keep evidence to demonstrate that staff have been properly trained. The Registered manager 31/10/06 is required to complete the Registered Managers Award (already started) in keeping with the conditions placed on her registration as home manager. Seek the views of service 30/06/06 users, relatives and professionals (e.g. questionnaires) to contribute to quality assurance in the home. Monitoring visits must be carried out at the home each month. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations It is strongly recommended that the manager put an assessment in place for checking that staff have fully understood the medication training and the homes medication procedures. Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Hft - 34/36 Shipston Road DS0000004242.V292488.R01.S.doc Version 5.1 Page 27 - 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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