Inspection on 05/05/04 for Huntsmans Wood (8)

Care Homes For Adults (18 – 65)Huntsmans Wood (8)8 Huntsmans Wood Croxteth Park Liverpool Merseyside L12 0HYUnannounced Inspection5th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Huntsmans Wood (8) Address 8 Huntsmans Wood, Croxteth Park, Liverpool, Merseyside, L12 0HY Email address Tel No: 0151 259 3152 Fax No: 9999Name of registered provider(s)/company (if applicable) Community Integrated Care Limited Name of registered manager (if applicable) Mr Sidney Newton Banks Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number F020000273 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 10.1.04 If Yes refer to Part CHuntsmans Wood (8)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 35th & 6th May 2004 4-6pm & 4-5pm June BeaverID Code072789Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionLesley BoultonHuntsmans Wood (8)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementHuntsmans Wood (8)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Huntsmans Wood (8). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Huntsmans Wood (8)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 8 Huntsmans Wood is a small care home catering for two adults with learning disabilities. It is part of a larger organisation called Community Integrated Care which specialises in homes for people with learning disabilities and the elderly. The home was registered under the Community Care Act (Amendment) in 1991 and transferred registration to the National Care Commissions under the Care Standards Act 2000 in April 2002. The home is registered for three people,. There is one vacancy at present. The home is set in a residential area of Croxteth Park. The premises are centrally heated with guarded radiators, comfortably furnished and generally well maintained. There is a private enclosed garden to the rear of the house, and the service users have the benefit of a mini bus, however the local bus services are accessible within walking distance. There are shops, parks, pubs and restaurants in the area. There is twenty four hour care available at the home which includes waking night staff. The Manager of the home has recently been registered with the Commission for Social Care Inspection The staff at the home are regular members of staff, with a mix of both male and female carers, and there is very little turnover. There are no staff vacancies at present.Huntsmans Wood (8)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of home (Standards 1 – 5) 2 of the 4 standards assessed were met The home has prepared a Statement of Purpose and Service User guide that provides information that states the aims and objectives of the home and the facilities it offers, however there are some minor omissions in the Statement of Purpose that need to be added. The home has not provided an up to date statement of terms of conditions/contract for each service user. This has been made a requirement, which needs to be met within the set timescale. Individual Needs and Choices (Standards 6 – 10) 4 of the 5 standards assessed were met The Care Plans and Essential Life Plans inspected were completed to a fair standard and evidence that service users and their families were involved in the care planning was provided. However they need updating and reviewing. Past and present medical history details were documented in the files and any visits made by health care professionals were recorded. Risk assessments are completed for both personal risk and environmental risks within and outside the home. The monthly action plan evaluation records were not up to date and this needs to be addressed as soon as possible. Service users are encouraged to use the local community services such as the shops, parks and library and all staff are made aware of the need for respecting confidentiality about the home. Lifestyle (Standards 11 – 17) 6 of the 8 standards assessed were met The service users have a choice of activities which range from individual choice to group outings. Daily life at the home is flexible depending on the needs of the service user. Each of the service user takes a holiday at least once a year, either individually or as a group, abroad or in the U.K. Service users are encouraged to assist themselves as much as possible, and given the opportunity to help around the house, and one of the service users is preparing for a part time job within the company. The menus provided at the home are not being adhered to and a requirement has been made to ensure that a record of all food taken by service users is kept. The activity charts at the home does not correlate with the activities carried out each day and consideration must be given to updating these and developing an improved system of recording. Personal healthcare and support (Standards 18 – 21) 3 of the 3 standards assessed were met The records indicate that the staff support and guide service users and observation of staff interaction on the day of the inspection confirmed this. The healthcare needs are met by regular monitoring and health checks. The medication administration and procedures for storing and disposing of medicines used at the home is satisfactory. Complaints & Protection (Standards 22 to 23) Huntsmans Wood (8)Page 6 2 of the 2 standards assessed were met The home has a complaints procedure and a satisfactory adult protection policy. The staff are given training on induction on safe practice, and regular up dates when necessary. There have been no complaints recorded since the last inspection. Environment (Standards 24 – 30) 7 of the 7 standards assessed were met The home has recently been decorated to a very high standard and new carpets have been fitted throughout the home. Each service user has their own bedroom which is well furnished. There is a large private garden which is not overlooked. The standard of housekeeping in the home is high and all staff attend to the laundry daily. The home provides a shower and bathing aids to meet the service users needs and there is a separate staff toilet. Staffing (Standards 31 – 36) 4 of the 6 standards assessed were met There is a good compliment of staff, and staffing levels remain consistent with little turnover. There is a mix of male and female experience care staff. During informal staff interviews the Inspector was satisfied that the staff were able to demonstrate that they had a good knowledge and understanding of the service users needs. The staff are given training in various aspects of care and health and safety. Conduct and Management of the Home (Standards 37 – 43) 4 of the 7 standards assessed were met The Manager of the home has worked at the home previously, and is currently being registered with the National Care Standards Commission. The Manager was not on duty on the day of the inspection. The policies and procedures produced by the home on a local level were relevant to the home, and are updated as and when necessary. The safety certificates required by regulation were up to date and available for inspection. The fire log was recorded to a satisfactory standard indicating that regular checks are carried out and staff are given training and hold regular fire drills.Huntsmans Wood (8)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action 1 Reg. 4 YA1 The registered person must ensure that there 31st is a Statement of Purpose and Service user January Guide that meets the requirements set out in 2004. Schedule 1 of the National Minimum Standards 2000.Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard N/A CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Huntsmans Wood (8)Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action 1 Reg. 4 & 5 YA1 The registered person is required to provide the information listed in Schedule 1 of the By May Care Home Regulations 2000 and Standard 1 31st 2004 of the National Minimum Standards. The registered person is required to provide each service user with an up to date contract/terms of conditions The registered person must ensure that all the records relevant to each service user are updated and reviewed on a regular basis and specialist advice followed as per their instructions. The registered person is required to ensure the service users are offered regular planned activities that have been agreed and discussed with both the service user and or their families and an up to date record kept and evaluated regularly. By 31st May 20042Reg 4 & 5YA53Reg 15YA6By 31st May 20044Reg 12.3YA14By 31st May 20045Reg 16(i)YA17The registered person is required to ensure that a record of all food taken by service users is kept and that directions from special By 31st advisors are followed as required and May 2004 discontinued as necessary in the care plan.Huntsmans Wood (8)Page 9 6Reg. 13(2)YA20The registered person is required to ensure that the administration and recording of all medication is carried out in line with the By 31st national minimum standards and Care Homes May 2004 Regulations 2000. The registered person is required to ensure that the staff personnel files are completed in accordance with Schedule 2 of the Care Homes Regulations 2000.7Reg 18YA34By 31st May 2004RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard *1YA22It is recommended that the complaints policy be amended to ensure that the name of Commission for Social Care Inspection is included (same contact details as NCSC), and it is further recommended that a file be introduced to keep any records relating to complaints in one place. It is recommended that the home provides evidence that all care staff are given copies and have access to the General Social Care Council’s code of conduct as per this Standard.2YA34* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire YES YES NOHuntsmans Wood (8)Page 10 • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES NO YES NO YES NO YES YES NO NO NO YES NO YES 1 X X NA NA NO YES 7 X 6/5/04 4PM & 5PM 3The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met Huntsmans Wood (8) (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 11 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Huntsmans Wood (8)Page 12 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. 390.20 390.20 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing, outings. 2 Key findings/Evidence Standard met? The home has produced a Statement of Purpose and Service User guide which gives information regarding the aims and objectives and philosophy of care of 8 Huntsmans Wood. It gives general information about the home, however there are minor omissions in the Statement of Purpose and Service User guide such as a copy of an updated complaints policy. The registered person is required to provide the information listed in Schedule 1 of the Care Home Regulations 2000 and Standard 1 of the National Minimum Standards. Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The two services users currently living at the home have lived there since opening thirteen years ago. A vacancy has occurred recently, however there are no plans to admit at present. The Manager informed the inspector that a full assessment of any potential new service user would be carried out prior to admission to ensure that all needs could be met.Huntsmans Wood (8)Page 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home provided evidence to support this standard. Consultation with relevant agencies such as community nurses, dieticians, GP’s, dentists and chiropodists takes place on a regular basis and is recorded in each service users file. The current service users have access to a hoist and wheelchairs and specialist equipment throughout the home.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Discussion took place with the Manager of the home about this standard. Trial visits would be arranged prior to any admission that would be gradual in nature and involve spending time with the other service users to ensure compatibility. Emergency admissions would not possible at this home.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 1 Key findings/Evidence Standard met? The service users have a tenancy agreement on file with Maritime Housing. There was no evidence provided of a contract or statement of terms and conditions with the parent company. The Manager of the home informed me that the service users’ families have them to read and sign. The registered person is required to provide each service user with an up to date contract/terms of conditions within the timescales stated. This has been made a requirement on previous reports.Huntsmans Wood (8)Page 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 1 Key findings/Evidence Standard met? The essential life plans contained information that would enable all staff to have a good understanding of the service users’ needs, likes and dislikes personal traits and non-verbal communication indicators. Each file had a personal and social history as well as information on family background. However there was no evidence of any recent review. The care plans were inspected and were found to be in need of updating and reviewing. The monitoring charts such as weight monitoring and action plans were also in need of updating. Advice from the speech therapist was documented in one of the service users care plans however there was no evidence that this had now been discontinued. Personal and environmental risks assessments are carried out, reviewed on a regular basis and changed if necessary. The registered person must ensure that all the records relevant to each service user are updated and reviewed on a regular basis and specialist advice followed as per instructions. Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Service users are encouraged to make decisions for themselves. Evidence was provided in each file to support this. Choices include activities of daily living as well as pursuing individual hobbies. Evidence was also provided in the Essential Life Plans and through discussion with the staff on duty of consultation with service users families in decisionmaking.Huntsmans Wood (8)Page 15 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? There has been no change in policy since the last inspection, service users are usually present when house meetings are held, and are involved in shopping for the home. Service users families are informed of any changes within the home. Evidence that service users accompany staff on household shopping trips was provided, plus evidence that service users are involved in daily household tasks.Standard 9 (9.1 – 9.4) Staff enables service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Evidence was provided to support this standard. Risk assessments are carried out for both personal and environmental risks. All risk assessments are reviewed regularly and changed as necessary giving an explanation why the change is needed. Like many of the other documents recording care, evidence that consultation with either the service user or their advocate is always sought.Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Confidentiality is maintained at the home by all staff that are giving training during their induction period on the importance of maintaining confidentiality and good record keeping. All documentation relating to the service users is kept securely in the home and the premises is alarmed. Access to files is open to service users and their advocates if wished.Huntsmans Wood (8)Page 16 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Evidence was provided to support this standard The service users are encouraged by all staff to develop independent life skills such as washing and dressing and choosing clothes. Evidence was also provided to indicate that service users make use of the local community by using shops and parks, local museums and local pubs and restaurants. There is an established rapport with the neighbours and other CIC small homes in the area, and the service users are often invited to staff member’s homes for visits.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 2 Key findings/Evidence Standard met? One of the service user has commenced voluntary work at the local library on a part time basis supported by a member of Bridgeworks ( part of of C I C Limited). However the inspector was informed that the keyworker is not always available on a weekly basis. It is recommended that alternative arrangements be made to facilitate this activity to ensure a more consistent approach. The service users go on regular holidays both at home and abroad, and one of the service user’s goes home every week from Thursday to Sunday and is looked after by her family.Huntsmans Wood (8)Page 17 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Evidence was provided to support this standard. Service users are encouraged to use local facilities such as shops, library, doctors, dentists and opticians. They have formed good relationships with neighbours and local shop assistants. Service users are offered the opportunity of using local pubs and restaurants. The service users have a minibus for transport, as they are both wheelchair users using public transport such as buses would create problems. However, the home is able to access taxis if necessary. Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 2 Key findings/Evidence Standard met? The service users are offered a range of activities to pursue either together or individually with support from staff such as visiting the local parks and places of interest or going to the cinema. On the day of the inspection both service users had visited members of staff’s homes. However, the activity programme in each service users file did not appear to be followed as it did not compare to the daily record of events and the monthly activity evaluation plan was not consistently completed. The Manager informed the inspector that this was due to driver availability, however there are alternatives the home staff could access, therefore: The registered person is required to ensure the service users are offered regular planned activities that have been agreed and discussed with both the service user and or their families and an up to date record kept and evaluated regularly. Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Visitors are welcome at the home at any reasonable time and can either use the service users’ bedroom or the communal rooms such as the lounge or dining area. Any visits that need to be carried out in private can be conducted in the manager’s office at the rear of the property. Visits are encouraged from other service users in other C.I.C homes in the area, and from family and friends.Huntsmans Wood (8)Page 18 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Evidence was provided through discussion with the staff and by direct observation, that service users privacy is maintained by for example, knocking before entering rooms, provision of keys for each service users bedroom and preserving dignity when assisting with washing and dressing. A policy and awareness of gender sensitive issues was also provided and discussed with staff. The Essential Life Plans for each service user detail what each individual likes to do and is able to do, and include details of how privacy is to be respected and of daily routines. Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? There is a five-week menu pinned to the notice board in the kitchen, however on the day of the inspection visit the meal served did not correspond to this menu. One of the service users is currently being assessed by a speech therapist who has recommended that a record is kept of the meals taken, however the Manager informed the Inspector that this has now been discontinued but this had not been entered on the care plan. The registered person is required to ensure that a record of all food taken by service users is kept and that directions from special advisors are followed as required and discontinued as necessary in the care plan.Huntsmans Wood (8)Page 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The home does not provide nursing care, should this type of care be necessary then this would be provided by the district nurses through each service users G.P. Observation on the day of the inspection provided evidence that staff treated the service users with dignity and respect.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 1X3 Key findings/Evidence Standard met? Evidence was provided in the records to indicate that all healthcare needs of service users are continually being assessed and evaluated, and when necessary action is taken to address any health matters that arise. All staff are aware of how to contact the relevant agencies such as GP.’s dentists etc., and staff will accompany any service that needs to visit hospital for consultation.Huntsmans Wood (8)Page 20 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 1 Key findings/Evidence Standard met? None of the current service users self medicate. Policies are in place to support staff to assist any service users who wish to self medicate. The medication administration records were inspected and the following issues need to be addressed:1. The amount of medication received for each service user was not entered on the monthly MAR sheet making checking the stock balance difficult. 2. The stock balance was counted regularly each week, however the balances were invalid without having a record of the amount remaining before new stock was added. 3. Medication administration directions were not always entered on the MAR sheets, and all of the entries were hand written. The registered person is required to ensure that the administration and recording of all medication is carried out in line with the national minimum standards and Care Homes Regulations 2000.Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? There has been a death recently at the home and the inspector was informed that the staff and service users have coped with the matter well. There are policies and procedures in place to support both service users and their families to come to terms with the loss of a member of the household.Huntsmans Wood (8)Page 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 2 Key findings/Evidence Standard met? The home has a comprehensive policy and procedure relating to complaints. It has recently been revised to include reference to the service user guide and the NCSC local office name and address. Copies of the complaints procedure have also been sent to service users relatives. It is recommended that the policy be amended to ensure that the name of Commission for Social Care Inspection is included (same contact details as NCSC), and it is further recommended that a file be introduced to keep any records relating to complaints in one placeHuntsmans Wood (8)Page 22 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? All staff are aware of the home’s Adult Protection Policy and the Whistle Blowing Procedure. There have been no incidences reported since the last inspection. Staff are given training on induction on issues surrounding Adult protection, and attend any further training/study days covering this subject.Huntsmans Wood (8)Page 23 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The premises are leased from Maritime Housing who are responsible for maintaining the fabric of the building, and the parent company is responsible for internal decoration and provision of furniture. The home has recently been re-decorated throughout to a very high standard and is comfortably furnished. The standard of housekeeping was very high. The shower room is equipped with facilities to aid safe bathing, and the garden area has a large flagged patio containing suitable garden furniture.Huntsmans Wood (8)Page 24 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence YES NO NO 3 X X X Standard met? 3 3 X3 X X XThe bedrooms provided for service users are adequately sized and enable the service users to be moved around the room in wheelchairs. There is a large lounge/dining room and a fair sized bathroom. There are separate toilet facilities for staff. None of the service users share a room.Huntsmans Wood (8)Page 25 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The bedrooms were well decorated and personalised to individual taste, each had a lockable piece of furniture and posters and pictures on the wall as well as TV/video or music centres. Privacy locks are provided and each room is equipped with suitable bedroom furniture. The rooms are centrally heated and provide adequate space that meets the current service users needs.Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The bathroom and toilet shared by service users was clean well maintained and equipped with suitable lifting aids to enable them to shower in safety. The décor was domestic in nature and the room was centrally heated. The requirement made at the last inspection in respect of the sink in the staff room toilet has been met in full.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The lounge/dining area of the home was comfortably furnished with bright modern furniture with matching curtains and soft furnishings. There was a large television and music centre, and the provision of photographs, ornaments and plants made the room appear domestic and homely. The kitchen was a good size and fully fitted. The kitchen appliances are modern and maintained by the parent company. The records inspected indicated that regular monitoring of the fridge and freezer temperatures are carried out. The décor in the kitchen, whilst clean and in sound condition, is dated and not in keeping with the décor in the remainder of the house. There are no changes planned to the kitchen at present.Huntsmans Wood (8)Page 26 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The hoists, wheelchairs and other lifting aids used at the home are regularly serviced and repaired if necessary. All of the communal rooms used by service users are on the ground floor, access to and from the front and back of the house was satisfactory and service users have freedom of movement around the home. The washing machine and dryer are housed in the garage away from the main part of the home and care is taken to isolate any soiled laundry from household laundry.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was clean, odour free and the standard of housekeeping on inspection was very high. The staff help maintain the high standards within the home, and it was apparent on the day of the inspection visit that the staff took pride in keeping the place clean. All of the staff have laundry and cleaning duties and are aware of COSHH regulations.Huntsmans Wood (8)Page 27 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? An inspection of the staffing rota provided evidence that the home is adequately staff by a stable work force. Some of the staff at the home have many years experience of working with service users with a learning disability and there is very occasional use of agency staff. If necessary the home’s staff will cover any absences or they will use the company’s “bank” staff. On the day of the inspection, there were two regular members of staff on duty.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home does not supply nursing care to any of the service users, nor are they registered to do so. The home is confident that the above number of staff with NVQII training will rise to meet the required target by the year 2005 as two members of staff are currently undertaking NVQII training.Huntsmans Wood (8)Page 28 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 2 X No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 263 X Nursing X XX 263 XX 263XXNo. of full time equivalent Staff with nursing qualification (where applicable)X3 Key findings/Evidence Standard met? The staff rota indicates that sufficient and regular staff members are available on duty twenty four hours a day, this includes one waking night staff member. The staff on duty on the day of inspection appeared to have a very good rapport with the service users and offered assistance in a friendly and patient manner. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The staff files inspected provided evidence that a satisfactory recruitment procedure is carried out as the recruitment package included checking two references before commencement of employment, a checkable work history, completion of an application form and an enhanced CRB check. However, there were some omissions from some of the files such as a recent photograph and proof of identification. The registered person is required to ensure that the staff personnel files are completed in accordance with Schedule 2 of the Care Homes Regulations 2000. It is recommended that the home provide evidence that all care staff are given copies and have access to the General Social Care Council’s code of conduct as per this Standard.Huntsmans Wood (8)Page 29 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 3 Key findings/Evidence Standard met? The staff and the Manager of the home have regular training updates that include basic food hygiene, moving and handling, first aid and fire safety training. All new staff undergo a company induction as well as an in-house induction programme.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Evidence was provided in personnel files that supervision is given on a regular two monthly basis and records kept. The staff are also offered pre-appraisal questionnaires which can be used as a self evaluation tool. The Manager of the home is offered supervision by their Service Manager, also on a regular basis.Huntsmans Wood (8)Page 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO3 Key findings/Evidence Standard met? The Manager has recently completed the Commission for Social Care Inspection fit person process including a fit person interview. She is currently doing an NVQ level IV management course which she hopes to complete by the end of this year. The Manager has worked at the home for over eighteen months and has had previous experience of working with people with a learning disability.Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager feels she has an open and honest management style and is firm but fair. Staff can approach the manager to discuss matters concerning the running of the home both formally and informally and in the one to one sessions (supervision). Staff can also request training through the manager who will contact the training department on their behalf.Huntsmans Wood (8)Page 31 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The home carries out regular quality assurance audits and the Service Manager visits the home monthly and also carries out a thorough audit of service users’ health and welfare, accidents, risk assessments both personal and environmental, and staffing levels. A financial audit is conducted once a year by the parent company. There is an annual survey sent out to relatives of service users asking for their views of the home from Head Office.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The records required by registration to ensure health and safety of the service users and staff who work at the home were inspected and found to meet this standard in full. The standard of all record keeping at the home is high and records are kept securely although accessible to service users or their families if they wish to see them.Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? A sample of the policies and procedures used by the home was inspected. The company provide a comprehensive policy manual which has recently been revised. The home has a file of local policies and procedures applicable to the service. However it was difficult to find a specific policy as the index did not correlate with the contents of the file. It is recommended that this be reviewed to enable staff to find policies and procedures more easily. The policies inspected met this standard.Huntsmans Wood (8)Page 32 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Through constant monitoring and regular auditing the health and safety of both service users and staff who work at the home is protected as far as reasonably practical. Outside agencies such as the gas service, fire brigade and electricity board carry out regular safety checks and have issued safety certificates. The staff are given regular fire evacuation training. Staff are also given basic food hygiene training and first aid.Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The company has provided evidence of financial viability to the National Care Standards Commission Headquarters in Newcastle. An up to date liability insurance certificate was on display as well as a Health and Safety at Work notice. The system for recording personal and household allowances has changed since the last inspection. Receipts for all transactions are now kept on the premises instead of being forwarded to head office. This improves the way the finances at the home are audited and inspected. The personal allowances of one service user was checked and found to balance. The other service user’s finances are handled by the family. Both service users have separate bank accounts and regular bank statements are sent from head office.Huntsmans Wood (8)Page 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateJune Beaver Jenni AllenSignature Signature SignatureHuntsmans Wood (8)Page 34 Public reports It should be noted that all CSCI inspection reports are public documents.Huntsmans Wood (8)Page 35 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 5 May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Huntsmans Wood (8) Page 36 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 22 June 2004 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YESOther: enter details here Huntsmans Wood (8)Page 37 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr C E Eggleston of CIC (8 Huntsmans Wood) confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mr C E Eggleston of CIC (8 Huntsmans Wood) am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Huntsmans Wood (8)Page 38 - 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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