Inspection on 27/10/06 for Ivydene

This inspection was carried out on 27th October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Ivydene 70 Belmont Road Portswood Southampton Hampshire SO17 2GE Lead Inspector Chris Johnson Unannounced Inspection 27th October 2006 10:00 Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivydene Address 70 Belmont Road Portswood Southampton Hampshire SO17 2GE 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) ILIACE Limited Mrs Claudia -Maria Mist Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One current service user aged over 65 with a physical disability may be accommodated. Date of last inspection Brief Description of the Service: Ivydene is a large residential home providing care and support for up to 10 service users with learning disabilities and service users with both learning and physical disabilities. The home is set in a quiet residential area of Portswood close to the main shopping precinct, pubs and restaurants and also situated close to parks and leisure facilities. The home is in keeping with other homes in the area and accommodation is provided over two floors. The home provides a mixture of single and double rooms, bathing and toilet facilities, a separate dining room, kitchen, lounge and a conservatory. The cost of living at the home ranges from £750 - £1225.00 a month. Depending on residents’ financial circumstances they pay a contribution to these costs. Additional charges are made for chiropody. The home was taken over in February 2006 by ILIACE Limited. ILIACE provide operational management of the home, including staff training and recruitment and policy implementation. The registered manager Mrs Claudia Mist manages the home on a day-to-day basis. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards, compliance with regulations and that the people living at the home were safe and properly cared for. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out on 27th October 2006. During this visit a tour of the premises was completed that included looking at service user’s bedrooms and all communal areas of the home. Staff and care records were inspected; staff and residents were spoken with and staff were observed during their day-to-day interactions with residents. All regulatory activity since the home has been registered was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. All residents were sent questionnaires prior to the visit and two of these were completed and returned. Telephone interviews were held with three relatives and one care manager who has quite a lot of involvement with the home. Comment cards were also sent to four GP’s. The manager completed a pre inspection questionnaire prior to the visit. Although the home has been inspected in the past this was the first inspection since the new provider ‘ILIACE Limited’ had taken over ownership of the home. What the service does well: People’s needs are fully assessed prior to admission so that the individual and the home can be sure that the placement is appropriate and will meet the person’s needs. New residents are provided with a good level of support enabling them to settle into the home. One care manager responsible for placing someone at the home commented, “I found the home to be very supportive and proactive trying to make the placement successful”. Residents’ needs are kept under regular review and recorded in detailed and personalised plans of care that promote independence. Residents are supported to take risks as part of their everyday lives and these are very well managed. The opportunities for residents to engage in activities and keep in contact with friends and family are good. They are free to choose how they live their lives and to engage in activities of their own choosing. Residents’ right to make choices and lead an independent life are promoted and respected. Residents are fully supported with their healthcare needs. Support with personal care is good and carried out in such a way as to ensure that residents’ independence is maintained and promoted. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 6 Residents are made aware of their rights and systems are in place for residents to address any concerns or complaints that they may have. The home protects residents from the risk of harm or abuse. Residents live in a safe and well-maintained environment. The home is well furnished, homely and comfortable. High standards of hygiene are maintained. People contacted during this inspection commented on the cleanliness of the home, the homely environment and the recent improvements that had been made. One person remarked, “ It is like a home, just as you or I would have. It is very homely”. Another commented, “ The home is always spotlessly clean”. The home maintains adequate staffing levels. Staff receive appropriate support, supervision and training to ensure that residents receive a good standard of care. Robust recruitment procedures provide protection to residents. The home is well managed and the manager has a good knowledge of residents’ needs. The value base and ethos of the management and staff team appear to be in the best interests of residents. What has improved since the last inspection? On taking ownership of this home the provider submitted an action plan to the Commission for Social Care Inspection detailing how they intended to improve the physical environment and address the concerns raised with the previous provider. Since taking over the home many improvements have been made to the physical environment to provided residents with a more homely and safer place to live. They include, improved access to the downstairs bathroom making it more accessible to wheelchair users. All hot towel rails in bathrooms now have guards fitted. The hall and stair carpet have been replaced, as the previous carpet was unsafe. The hallway and most bedrooms have been redecorated and new lighting has been provided throughout. New kitchen units and flooring have been fitted. The conservatory has been recarpeted and furnishings replaced. Work has commenced on improving the garden. The standard of written information has also improved and this ensures that there is a less likelihood that residents’ care needs will be overlooked. The management arrangements have also improved with the registration of a new manager in March 2006. This means that there is more accountability and better support for the care staff. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 7 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. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 4 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. People’s needs are fully assessed prior to admission so that the individual and the home can be sure that the placement is appropriate and will meet the person’s needs. New residents are provided with a good level of support enabling them to settle into the home. EVIDENCE: The assessment records of a resident who had recently moved into the home were examined. These demonstrated that a thorough assessment process is carried out prior to admitting someone new into the home. Included in this procedure is a very detailed assessment placement report. A placement officer from within the Iliace organisation carries this out. All assessments are carried out in conjunction with the manager of the home and in partnership with relevant professionals. Prospective residents are encouraged to visit the home and spend time there before making a decision as to whether it is the right choice for them. One care manager commented, “I found the home to be very supportive and proactive trying to make the placement successful”. They also confirmed that a suitable and thorough assessment process had taken place prior to admitting their client. New residents are assisted to settle into the home by the manager and staff. One new resident had undergone an ‘integration week’. This had been Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 10 undertaken by the manager and involved going out into the community with the person, familiarising them with the area and facilities within the area, assisting with introductions to other residents and staff. This included providing them with pictures of staff. During this settling in period new residents are provided with all relevant information, such as their rights and ground rules. The homes complaints procedure is explained to them and where necessary behaviour contracts are established. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents’ needs are kept under regular review and recorded in detailed and personalised plans of care that promote independence. Residents are supported to take risks as part of their everyday lives and these are very well managed. There is a need however to ensure that all plans are in a format that ensures that residents can access and understand the information that it contains. EVIDENCE: The care plans of three residents were looked at during the site visit. These were detailed and personalised. Each person had a pen picture describing their likes/ dislikes; lifestyle choices etc and these were all written in the first person. ‘Essential living plans’ were also held on file for each person providing a brief description of the person’s daily care needs. These are designed for new or agency staff for ease of access. More thorough and comprehensive care plans were held on file for all residents. These provided very detailed and clear instructions regarding the level of assistance that residents needed with all aspects of their lives. Details in care plans demonstrated that independence is promoted and encouraged and that these had been produced in conjunction Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 12 with residents. In discussion with staff they were aware of residents’ care needs and confirmed that they had access to care plans. All staff had signed each care plan and risk assessment to say that they had read, understood and would implement as per instructions. The manager has started to implement ‘person centred planning’ and some good examples were seen of this. One staff member had recently attended a five-day ‘person centred’ planning course with the intention to cascade this training to all staff. In discussion with residents it was evident that care plans reflected the actual care that they received. There is a need however to ensure that plans are in an accessible and appropriate format for residents so that they can hold their own copies. Whilst some progress has been made towards achieving this, further improvements are needed. Residents were observed to be able to make their own decisions regarding how they spend their day and to make their own lifestyle choices and this was confirmed in feedback from relatives and in conversation with residents. Residents are supported to take risks as part of their everyday lives and these are very well managed. Thorough risk assessments and risk management plans have been produced for any resident assessed as being at risk from day to day activities enabling them to continue with their lives in a safe manner. These included individual fire risk assessments measuring the risk to the person in being able to recognise the danger and the level of assistance required to evacuate the building. Examples of other risk management plans included residents vulnerability around others and methods for managing challenging behaviour. These all provided very clear instructions for staff to ensure a consistent approach is adopted. This is less confusing for residents. There was plenty of evidence that these assessments and management plans had been produced with the resident and that they had been fully involved in the process. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The opportunities for residents to engage in activities and keep in contact with friends and family are good. They are free to choose how they live their lives and to engage in activities of their own choosing. Residents’ right to make choices and lead an independent life are promoted and respected. EVIDENCE: Residents are supported to take part in a range of activities both inside and outside of the home. These include, educational, social and leisure, physical, and attending day services and college courses. On the day of the visit to the home some residents were at a day centre and others went out to the local library with staff. In discussion with residents they confirmed that they were supported to use local amenities and to access the community. Residents have the opportunity to attend courses in areas such as, hair and beauty, literacy for work, job seeking, skills for working life, care, retail and computing. The inspector saw plenty of evidence in care plans and through discussion with residents and staff that residents have the opportunity to engage in a range of leisure activities including holidays. Residents commented that they enjoyed Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 14 the regular activities provided by an outside organisation. The manager reported that there had been an increase in home-related leisure activities and that she had purchased additional resources such as art and craft materials as well as providing more organised activities. A care manager remarked that they had seen an improvement in the resources and activities available in the home. They also said that they had visited the home when residents had been involved in music therapy and arts and craft sessions. The opportunity for residents to keep in contact with their friends and relatives is good. All relatives spoken with said that they could visit the home whenever they wished, that they were made to feel welcome and that they could meet with their relative in private. Comments included, “I am always made to feel welcome and offered tea and coffee”. On the day of the visit to the home one resident had their friend visiting for the day. Residents’ right to make choices and lead an independent life are promoted and respected. This was demonstrated through information recorded in care plans and daily recordings. Residents confirmed that they were free to choose whether or not to join in with an activity. Observations made during the visit showed that residents were given freedom of choice, that they are offered encouragement and that staff respect their rights’. One relative commented, “Personally I would like him to get more involved. However he is encouraged and his choice and right to make his own decisions are respected”. It was also evident from discussion with residents, staff and from documented evidence such as house meeting minutes that residents provide an input into the day to day running of the home and that they are consulted. All residents spoken with confirmed that they were happy with the food and that they had plenty of choice. Food records demonstrated that residents are encouraged to maintain a healthy diet. Documented evidence demonstrated that residents choose what food to eat, and records were appropriately maintained. Photographs of menu choices are provided to assist residents with communication difficulties to make a choice. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents are fully supported with their healthcare needs. Support with personal care is good and carried out in such a way as to ensure that residents’ independence is maintained and promoted. Residents’ medication is generally well managed however at times this is compromised by poor practice. EVIDENCE: Care plans provided very detailed descriptions and guidance regarding residents’ personal care needs. Where any resident required assistance with transferring or mobility this was described in good detail. In one case the plan was set out in pictorial format detailing the method to be used while assisting the resident to transfer. Wherever possible this information is obtained through discussion with the individual resident and through observation enabling a full assessment of their needs. This ensures that residents’ independence is maintained and promoted. There was plenty of evidence from records that residents have access to a full range of health care support including specialist teams. Healthcare needs are monitored and referrals are made appropriately and as necessary. Residents are supported to attend appointments. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 16 A care manager spoken with said that the home kept in regular contact and actively sought advice and information from them as necessary. Residents who returned a comment card responded that they saw GP’s and dentist as necessary. The medication administration records were checked for several residents during the site visit. From examination of these records it was evident that staff are following correct recording procedures. Medication was also stored safely and correctly. The home has clear written policy and procedures for the administration of medicines and staff are trained before being able to administer. Observation of staff medication practices during the visit to the home showed that staff do not always however follow correct procedures. One staff member was observed to handle medicines by popping them from the blister pack into her hand and then into a pot. Current practice is that one member of staff is solely responsible for administering medication at any given time. Medication was left on the dining table while the staff member was administering medication to a resident. Another resident was observed to be touching the blisters packs and potentially had access to the medication. The staff member did however notice this and asked the resident to refrain from touching it. The staff member was also overheard to call out to another resident asking whether wanted their ‘as required’ (PRN) medicine. This does not fully promote residents’ confidentiality. It was also noted that written PRN guidance was needed for this person. Guidance was however available for all other residents requiring PRN medicines. These issues were discussed with the manager and the staff member. The manager reported that staff knew the correct procedure and that they knew not to administer as reported. It would be advisable to have two members of staff supervising medication at any given time this would seem a much safer system and the second person would not necessarily need to be a trained member of staff as they would only be safeguarding the medication while the other trained member deals with the administration. This would also mean that the person administering the medication could approach individuals confidentially. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Satisfactory systems are in place for residents to address any concerns or complaints that they may have. Procedures are in place for the protection of residents. EVIDENCE: The home has produced an easily understandable complaints procedure and this was on display in pictorial format in the home. Evidence was seen that the complaints procedure had been discussed and explained to all residents. Minutes from residents’ meetings demonstrated that the procedure is regularly discussed. The manager showed the inspector a set of pictures that are used to explain and describe possible scenarios to residents and to promote discussion. In discussion with staff members they were all aware of the homes’ complaints procedure were clear of correct reporting procedures. During telephone interviews with relatives they all said that they had been made aware of the complaints procedure. One person commented that they would take any concerns or complaints straight to the manager and they felt confident that the manager would deal with it appropriately. Relatives commented that any issues they had raised in the past had been dealt with to their satisfaction. Residents have access to advocacy services should they require it and the manager had recently supported one resident to make complaint against another organisation. The home has satisfactory systems in place for the protection of residents. Risk assessments and risk management plans had been put in place to protect the vulnerability of both staff and residents. Residents reported that they felt safe at the home. A care manager commented that the home responded well to adult protection issues and was able to provide examples of where the home Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 18 had implemented additional measures to safeguard individual residents. In discussion with members of staff and the manager it was evident that appropriate training and guidance is provided to staff to ensure the safety of residents. The manager demonstrated that she was fully aware of reporting procedures. Satisfactory recruitment procedures are followed and this provides safeguards to residents. The home also looks after several residents’ money. A selection of these were checked and all found to be correctly receipted and safely stored. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 19 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, 25, 26, and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents live in a safe and well-maintained environment. The home is well furnished, homely and comfortable. High standards of hygiene are maintained. EVIDENCE: On taking ownership of this home the provider submitted an action plan to the Commission for Social Care Inspection detailing how they intended to improve the physical environment and address the concerns raised with the previous provider. Since taking over the home in February 2006 the following improvements have been made. • The downstairs bathroom has been made more accessible to accommodate wheelchair access. • All hot towel rails in bathrooms now have guards fitted. • The Hall and stair carpet have been replaced, as the previous carpet was unsafe. • The hallway and most bedrooms have been redecorated and new lighting has been provided throughout. • New kitchen units and flooring have been fitted and the manager said that a new fridge and freezer were on order. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 20 • • • The conservatory has been re-carpeted and furnishings replaced. Work has commenced on improving the garden. New fencing has been erected in the lower garden and handrails have been installed. The Fire exit in the hallway is now linked to the homes’ fire alarm system. Currently the lower garden is not accessible to wheelchair users. The manager explained that to compensate for this the upper terrace area was being changed into a garden area for those unable to access the lower garden. The intention is to provide screening and pots, to make an area that all residents can enjoy and can get involved in planting and gardening. Consideration should however be given to providing access to the lower grassed area to all residents. The home was found to be very clean, tidy and homely. Good standards of hygiene are maintained. Hand creams and or gels and paper towels were in all bathrooms and the kitchen to assist with infection control. All relatives contacted commented on the cleanliness of the home, the homely environment and the recent improvements that had been made. One person remarked, “ It is like a home, just as you or I would have. It is very homely”. Another commented, “ The home is always spotlessly clean”. All bedrooms seen had been personalised with the person’s own belongings and reflected their individuality. In discussion with one new resident they said that they had been able to choose the décor for their room and that they liked it very much. Residents also told the inspector that staff helped them to keep their rooms clean and tidy and that they were happy with their rooms. Residents were observed to be free to access and use all areas of the home. Some residents said that they held keys to their rooms and others did not. The manager agreed that she would discuss this with all residents and provide keys as necessary. The home appeared to be safe and well maintained. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home maintains adequate staffing levels. Staff receive appropriate support, supervision and training to ensure that residents receive a good standard of care. Robust recruitment procedures provide protection to residents. EVIDENCE: Staff training records were received prior to the visit to the home and these demonstrated that staff receive a full range of training appropriate to their role and the needs of residents. Training courses provided include, health and safety, moving and handling, managing challenging behaviour, abuse and neglect, dementia and care planning. Currently three out of the seven care staff have undertaken an NVQ level 2 and plans are in place for other staff to undertake the course in the near future. Examination of the staff rota confirmed that sufficient staffing levels were in place for the needs of the residents. On the day of the visit two care staff were on duty as well as the manager. Only five residents were at home during the day. An additional staff member came on duty at 4.00pm to coincide with the remaining residents coming home. The home has bank staff that they can draw on to cover absence. The manager reported that this meant that the use of agency staff was kept to a minimum. When however agency staff are employed records demonstrated that as far as is possible the same people are Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 22 used. This provides consistency for the residents and keeps disruptions to a minimum. Everyone spoken with as part of this inspection spoke highly of the staff team. Residents reiterated this and appeared to be relaxed and at ease with all members of the team. Residents reported that they felt that the staff treated them well. One person said, “The staff are ok they are helpful. They help you clean your room and take you out”. From observation of staff practice the inspector noted that staff related well to residents, in a friendly and supportive manner. A care professional responsible for placing a resident at the home commented that all staff had, “Embraced the resident’s needs”. They also said that whenever they contacted or visited the home there was always a senior member of staff to confer with. Staff records were checked for the most recent staff member to be employed at the home. These demonstrated that the home was following appropriate recruitment procedures, to safeguard residents. Records were also available to demonstrate that new staff follow a suitable induction period before working on shift. As part of this induction new staff have to complete a workbook covering standards and values relevant to their role. Staff receive regular supervision and in discussion they said that they felt that the level of support provided to them was good. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, and 42 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well managed and the manager has a good knowledge of residents’ needs. The value base and ethos of the management and staff team appear to be in the best interests of residents. The provider has reinvested in the home to provide a safe and comfortable environment for those living there. EVIDENCE: Feedback from people who are in regular contact with the home was positive. One person said that they considered that there had been an overall improvement in the management and organisation since the new providers had taken over the home. Relatives spoken with felt that the home was well managed. The manager has been registered since the new providers have taken over. The Manager demonstrated a good value base and knowledge of residents’ individual needs. Staff, residents, relatives and social care professionals reported that they found the new manager to be supportive and approachable. It was evident that the manager is keen to improve the service and to provide a good standard of care to the residents. The manager is at the Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 24 home for a sufficient time each week to oversee the day-to-day running of the home and reports directly to senior manager within the organisation. The value base and ethos of the management and staff team appear to be in the best interests of residents. Action had been taken as per the new providers’ action plan upon taking ownership of the home to address all issues highlighted during previous inspections of the home. Systems are in place to ascertain the views of residents and relatives. The manager undertakes regular checks on the home’s recording systems and to ensure that staff follow policy and procedures appropriately and that residents care needs are being met. Regular team and resident meetings are held and inspection reports are made available. There is however a need for the home to develop its’ quality assurance systems further to ensure that the views of all stakeholders are sought and to enable them to assess whether they are meeting their aims and objectives and to put an improvement plan in place if necessary. Health and safety is promoted. Examination of the fire logbook demonstrated that regular and thorough testing of the home’s fire detection and fire-fighting equipment was being carried out. Certificates and service contracts were seen and the inspector was satisfied that all equipment used within the home had been regularly checked and serviced. There were not any concerns with regard to safety within the home environment and staff undertake regular fire training. Records are maintained of all fire drills carried out. The manager was advised to keep record of the names of those involved. This will assist with risk assessing residents’ response to the fire alarm and identify any further staff training needs. Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 3 X Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 26 N/A 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 YA6 Regulation 15 (2) (a) Requirement Care plans must continue to be developed so that they are all in a format suitable to residents’ individual needs. Written guidance must be produced in respect of any resident prescribed PRN medication. This must be incorporated into their care plan. The registered manager must ensure that staff follow correct and safe medication procedures at all times. The registered manager must establish a quality assurance system at appropriate intervals for monitoring the services and care delivered in the home. This must be done in consultation with the service users and their relatives/ representatives to gain views and opinions. Results of quality assurance monitoring must be made available to the Commission for Social Care Inspection. Timescale for action 28/02/07 2 YA20 13 (2) 28/11/06 3 YA20 13 (2) 28/11/06 4 YA39 24 (1)(2) (3) 28/02/07 Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 27 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 would be advisable to have two members of staff supervising medication administration at any given time. It is also recommended that individually labelled pots are used. Consideration should be given to providing access to the lower area of the garden to all residents. 2 YA24 Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Ivydene DS0000066694.V305811.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!