Inspection on 24/04/07 for 6 Lilac Grove

This inspection was carried out on 24th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

6 Lilac Grove 01/02/06

6 Lilac Grove 17/05/05

6 Lilac Grove 06/10/04

6 Lilac Grove 07/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Lilac Grove 6 Lilac Grove Trowbridge Wiltshire BA14 0HB Lead Inspector Ms Sally Walker Key Unannounced Inspection 24th April 2007 09:15 Lilac Grove DS0000028252.V332537.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 Lilac Grove DS0000028252.V332537.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. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilac Grove Address 6 Lilac Grove Trowbridge Wiltshire BA14 0HB 01225 766200 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Victoria Caroline James Care Home 4 Category(ies) of Learning disability (4), Physical disability (4), registration, with number Sensory impairment (4) of places Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: 6 Lilac Grove provides care and support to 4 younger adults with learning disabilities, sensory impairment and physical disabilities. There is one single bedroom with an en-suite shower and toilet to the first floor and three single bedrooms on the ground floor, one of which has an ensuite toilet and washbasin. There is a large wheelchair accessible bathroom with shower, bath and toilet to the ground floor. Also on the ground floor are a sitting room, adjacent dining room, kitchen, laundry room and a separate toilet. There is a conservatory, divided into offices. All the exits have level access or ramps. There is a reasonably large enclosed garden to the rear of the property. The front garden has been covered with asphalt to alleviate the local parking problem. The interior has been decorated to take into account the needs of people with a visual impairment with dark doors, frames and light walls. All staff are expected to obtain British Sign Language qualifications. The staffing rota provides for a minimum of 3 care staff during the waking day and 1 waking night staff with 1 staff sleeping in. Staff carry out domestic tasks as well as care and support. The weekly fees for the home are between £660.00 and £1950.00 depending on assessed need. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.15am and 4.40pm. Mrs James was present during the inspection. One resident and one staff were spoken with. The care records, medication records, risk assessments and statement of purpose were inspected. As part of the inspection process the views of residents, relatives, care managers and GPs were sought. Two residents responded to comment cards in written form. The staff wrote that they had signed the questions to these residents. Newly produced photo surveys were taken to the inspection as they may be easier to access, but no response was received a the time of writing. To the question “were you asked if you wanted to move to this home?” both residents said yes. To the question “did you receive enough information about this home before you moved in so you could decide if it was the right place for you?” one resident said yes. One resident said they could make decisions about what to do each day, in the evenings and at weekends. One resident said they would speak to their friends, and indicated the staff, if they were not happy. They said the home was clean. To the questions “Do the staff treat you well?” and “Do the carers listen and act on what you say?” the resident said yes. One of the relatives said that they were very pleased with their family members progress. They said they were invited to reviews and kept up to date with any developments. They said they felt they had an honest and open relationship with the home and that notice was taken of what they said. They said their family member had gained more independence and could exercise more choice. They went on to say that the staff team seemed ‘solid and friendly’ and very supportive. Their family member was now settled for the first time in a long time. One of the care managers said that the placement for their client had been well set up. They remarked about the high staffing levels. The home consulted with the residents’ family on a regular basis. Reviews had been positive. Their client had been supported to attend the local college. The home had good communication with their client. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 6 In order to ensure that new placements are successful, the home ensures that a thorough assessment takes place prior to admission. Information is gained from the potential resident, their carers, the care manager and any healthcare specialists. The potential resident and their family make visits to the home to meet with existing residents and staff and to view the accommodation. If specialist healthcare input is needed, the home ensures that it is set up locally before the resident comes to live at the home. Comprehensive care plans are in place to ensure residents’ needs are met and regularly reviewed. Family are involved and kept up to date with developments. Significant efforts have been made to increase residents’ communication and orientation in the locality. Residents are encouraged to learn new skills. Risk assessment does not restrict residents from experiencing new activities. Residents are encouraged to make decisions. An advocacy service is available to residents. Residents’ private space is recognised by staff. Residents have a range of activities that they are involved in. The menus provide a range of healthy food as well as treats. Residents have good access to healthcare professionals. Systems are in place to ensure safe administration and control of medication. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The statement of purpose does not currently reflect the service provided. Significant efforts are made to ensure placements are successful. Information about prospective residents is gained from a variety of sources. EVIDENCE: The home had a file entitled statement of purpose. The file was a collection of information some of which was not necessarily relevant to enquirers of the service. The reason for this may be that all admissions are dealt with centrally and enquirers do not initially contact the home if a placement is sought. Mrs James said that the referrals officer would send out the organisation’s documentation with separate information about each home. Mrs James was advised to obtain a copy of the statement of purpose held centrally. Discussions were held about the information laid out in Schedule 1 of the Care Standards Regulations relating to what must be included in this document. Much information is gathered from the potential resident’s parents, care manager, previous placement and healthcare specialists in order to assess whether their needs can be met. The home carries out their own assessment with the resident and their family to establish how their current needs are being met. Once a placement is offered the home will make sure that local services are available to continue any care and support, for example, Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 9 healthcare specialists. The potential resident and their family will visit the home to meet with the other residents and staff and view the accommodation. Every effort is made to ensure that any placement is successful. The home does not take emergency admissions. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ needs and aspirations are set out in their care plans. The plans are regularly reviewed with the resident and all those involved in supporting them. Residents are encouraged to make decisions about their lives. Risk assessment does not restrict residents from experiencing new activities or developing new skills. EVIDENCE: Each resident had an individual care plan detailing all aspects of care need, including mobility, communication profile, personal care, epilepsy profile, activities and medical needs. The initial assessments include residents’ life stories and many aspects of their social history are incorporated into their care plans. Cultural needs were identified and guidance to staff on meeting those needs. Preferred daily routines for personal care giving were in place for day and night. There was good evidence of regular review and three monthly revision. All risks were identified and guidance was written into care plans. There were some areas where objects, such as a bedside lamp were not available to residents because of an identified risk. Not being able to use a key Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 11 to the front door had also been identified. These issues had been discussed with families. There was guidance from the behavioural support team with regard to some behaviours, how to recognise triggers and how to minimise or reduce the behaviours. The home had sought advice from the specialist behavioural nurse and any guidance was noted in care plans. Any behaviour monitoring forms were sent to the specialist behaviour nurse. Other risks were identified both in the home and activities in the locality. Guidance was clear to staff on their management. Risk assessments did not restrict residents from being involved in new activities or developing new skills. The care plans also identified short and long-term goals. There was good evidence of regular review of each resident care with their family and care manager as necessary. Mrs James said that she had asked residents whether they wanted an interpreter to reviews or when they visit their GP. She went on to say that residents had said they preferred staff to interpret for them as they were not comfortable with someone that they did not know. One of the staff who holds the British Sign Language Level 3 qualification will interpret for residents. This had been agreed with all the parents. An advocacy service is also available to residents. The daily reports were very detailed and related to the plan of care. Staff were recording what residents had chosen to wear, what was eaten, whether medication was taken, resident’s mood, how personal care was carried out and activities and achievements during the day. Two residents had a communication book where staff had taken photographs of a member of staff using each resident’s own sign that they used for different words. There were separate records of communication which showed evidence of residents being encouraged to use more signs and make decisions. As a matter of good practice residents were able to have private time on their own in their bedrooms at certain times during the day and there was clear guidance that they should not be disturbed by staff. The inspector advised that the files should be rationalised so that only the most up to date information was available to avoid confusion. Mrs James has held a teambuilding day recently to look at the purpose of record keeping and communication. Parents and care managers were involved in regular reviews. Parents were informed of any significant developments as they occurred. Mrs James reported good relationships with families. Residents go to bed and get up when they are ready depending on what their daily programme is. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have a good range of activities and leisure facilities both at the home and in the locality. Residents retain regular contact with family. Significant efforts have been made to improve residents’ lifestyle with extending communication and encouraging independence. Residents enjoy a healthy diet. EVIDENCE: Residents are encouraged to be involved in a range of activities both at the home and in the locality. Walks, picnics, swimming, horse riding, trips to the pub and meals out are some of the activities offered. Mrs James reported difficulties in accessing local Deaf clubs. Some residents meet friends through their college courses. Mrs James said she was looking at securing some work experience for residents who would finish their college courses later in the year. Records were kept of those activities the residents had been involved in each day. One of the residents told the inspector about what they did at Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 13 college. They also said they were happy at the home, they enjoyed the meals and had good relationships with the other residents and staff. One of the residents had gone on holiday to a theme park with the local college. Signed supporters from the college had accompanied the resident on this holiday. Other holidays have included the annual Sense holiday at an activity centre in Devon. Those residents who would not necessarily manage long periods of time in a different environment would have other days out or make day visits to the other residents on holiday. Significant efforts have been made to improve residents’ lifestyle, encouraging residents to learn new signs and use objects of reference to aid communication. Benefits to residents have included a reduction in behaviours, evidenced by the cessation of certain medication. Residents were also becoming more independent and having more control over their lives. It was clear from observations that staff were skilled at understanding residents own methods of communication. Consideration was given to residents’ cultural background and advice sought from parents and the internet. This included information about hair and skin care products. Residents who may have a visual impairment are encouraged to orientate themselves around the home. One of the staff had trained in mobility and access. They would then train the staff. This member of staff was starting a programme for visually impaired residents to map the local area to access local shops and parks. Staff had enabled residents to develop new skills, for example, one resident was now able to make toast and porridge. Residents are encouraged to be involved in some domestic tasks with staff support, for example, washing up or doing their laundry. Another resident had improved sleep through a more active programme during the day. A member of staff had recently attended training in order to support residents with exercise. A trampoline was one of the therapies advocated by this training. As well as good exercise this would encourage residents with a visual impairment to experience another sensation. Residents had been donated some money following their opening of an extension to a local supermarket. This money was being used to level the garden for the trampoline. Residents are encouraged to maintain good communication with family. Either through regular telephone calls, visits or email. Residents use the home’s own mini bus or use public transport. The weekly menu is compiled according to residents known likes and dislikes and their own contribution. One of the residents helped with the weekly shopping and would have their own list to choose items from the shelves. One of the staff was responsible for ensuring stock items were purchased each week. The fridge was well stocked and all items were dated when they were Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 14 opened. The daily menu was displayed on the fridge. There were no special diets needed. Staff said they offered a healthy diet. They went on to say that residents were not restricted from treats. One resident had a tin of chocolate and sweets in their bedroom. There was also a tin of treats in the kitchen and residents regularly asked for chocolate or sweets. Fresh fruit was also available. The main meal is taken in the evening and residents choose from a range of snacks available every day. If residents go out for a meal instead of having a meal at the home, this is paid for out of the home’s budget. Residents had their lunch as they came to the table. Those residents who may need support with eating or drinking were seen to have individual support at the resident’s own pace. Lilac Grove DS0000028252.V332537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents preferred routines for personal care giving are set out in their care plan. Residents have good access to healthcare professionals. None of the current residents were assessed as being able to administer their own medication. Systems were in place to ensure safe administration and control of residents medication. EVIDENCE: The care plans set out residents preferred personal care giving routines. Residents had good access to healthcare professionals and records were kept of regular check ups, for example, the audiologist and optometrist. Fluid charts were kept where indicated. The inspector advised that all the different drinking vessels should be measured so that daily totals could assist monitoring. One of the staff immediately addressed this. All residents were regularly weighed and food charts would be commenced if concerns were noted. The daily reports record what residents have eaten that day. One of the staff who had previously been responsible for medication showed the inspector the arrangements for administration and control of medication. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 16 Residents can administer their own medication following a risk assessment. Currently only one resident was administering their own eye drops. The medication is kept in a locked facility in a locked room. Staff can only administer medication when they have undertaken training and are deemed competent. Staff had received medication training from the supplying pharmacist. All medication was checked as it was received into the home by 2 staff who both signed the log. A record was kept of any unused or unwanted medication returned to the supplying pharmacist. Any medication that was prescribed to be taken only when required was identified in the resident’s care plan. There was a written protocol for this medication. Staff had to check first with the manager, senior staff or the on call manager if they considered this that medication was needed. If residents had difficulties with swallowing tablets, liquid equivalents were requested. Residents have their medication regularly reviewed with their GP. Written confirmation had been sought from each GP with regard to taking some homely remedies. The data sheets for each prescribed medication were kept on file as was the home’s medication policy. No controlled medication was prescribed. One of the relatives said that they were pleased with the outcomes for their family member of a recent reduction in medication authorised through a consultant. The recommendation that care plans should identify details of prescribed topical creams had been actioned. Lilac Grove DS0000028252.V332537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Good systems were in place to enable residents or their representatives to comment on or complain about the service. Staff had been trained in the local procedure for Safeguarding Adults. However any internal investigations are not notified to the Commission under regulation 37. EVIDENCE: The home follows the organisation’s complaints policy and procedure. This was available in different formats as well as a booklet entitled “Let’s make things better”. The home’s complaints log had no complaints recorded since 2003. A copy of the local Safeguarding Adult procedure was available and all staff had training in abuse awareness. One member of staff, who was the home’s trained trainer for Safeguarding Adults, was clear about how to report any allegations of abuse to the relevant authority. However Mrs James was reminded of the need to inform the Commission without delay of any events under Regulation 37 or the Safeguarding Adults procedure. Immediately following the inspection Mrs James informed the inspector of her action plan with regard to a recent event which was in the process of investigation by her line manager. Residents benefits are paid directly to the organisation with the personal allowance element paid into each resident’s own bank account. Only senior staff are able to act as appointees. Residents were encouraged to save in their own accounts which attracted interest. Mostly parents deal with residents finances but residents were encouraged to manage their own money. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 18 Residents can keep small amounts of cash in the home’s safe. Only senior staff and the manager have access. Records and receipts were kept of all transactions. Lilac Grove DS0000028252.V332537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a well maintained, comfortable, and clean environment. Efforts are made to ensure the environment is accessible to Deaf and visually impaired residents. EVIDENCE: All the bedrooms are single accommodation, with two having ensuite facilities. Efforts have been made to help the residents to become well orientated around the home. Doors are clearly visible in a darker colour to the walls. Door hinges have been guarded to stop residents trapping their fingers as the doors close. Some doors may be locked if they contain potential hazards to visually impaired people, for example, the laundry. There were sufficient staff on duty to allow residents to access the kitchen with support. The home has a separate laundry room. Individual residents clothing and bed linen is processed separately. Some residents do their own laundry with staff support as needed. The night staff undertake the ironing. The washing machine had a sluice facility for dealing with soiled or contaminated laundry. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 20 Some difficulties with the functioning of the central heating boiler have resulted in a request for a new one to be installed. Mrs James was considering upgrading the bathroom with the installation of a spa bath. There were also plans to level the rear garden to accommodated the trampoline in one corner. Raised beds and a seating area would be installed at the same time. Staff undertake cleaning as well as care. The waking night staff had a schedule of cleaning duties. Two of the residents cleaned their own bedrooms with staff support. The home was cleaned to a good standard. Disposable protective clothing and gloves were available to staff. Appropriate arrangements were made for the disposal of clinical waste. There were notices in the bathroom and toilets for good infection control practices. These were in English as well as sign. Lilac Grove DS0000028252.V332537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing levels enable residents to be well supported during the day and at night. Staff are expected to undertake regular relevant training. All staff have been trained in British Sign Language. Residents were excluded when staff did not sign conversations they were having with each other in public places. A robust recruitment procedure was in place. EVIDENCE: The rota provided for a minimum of 3 care staff during the waking day and one waking night staff and one member of staff sleeping in. There is also a daily rota with a photograph of each member of staff on duty put by the front door. There have been some staff changes since the last inspection with 4 new staff commencing duties. All staff were expected to learn British Sign Language. The new staff were commencing Stage 1 at the local college in September. They were undertaking Deaf awareness training that week. They had recently undertaken training in communication, challenging behaviour and adult protection. There was a robust recruitment procedure in place. Some of the administration is completed by the Sense local office. Mrs James was involved Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 22 in short listing and interviews. Potential staff were required to complete an application form and declare any convictions or cautions. No staff commenced duties without a negative Criminal Records Bureau certificate being obtained. All of the information and documents required by regulation were on file. All new staff are inducted. Initially staff have a 3-hour induction covering the essential basic information. They then complete a workbook of care modules. The induction record covers all aspects of the work, including working with each individual resident, working with deafblind people, health and safety, conditions of service, expectations of the organisation and staff conduct. Pertinent policies were contained in the induction file. Staff have good access to training. Mrs James keeps a matrix showing mandatory training and when staff need to be updated. Staff were required to undertake training in health and safety, moving and handling, food hygiene, managing behaviours, adult protection, sexuality and relationships, values and beliefs, medication, infection control, working with deafblind people and communication. Other relevant training is available and provided by the organisation. Some training is provided for the staff group as a whole and well-known agency staff cover the home when this is taking place. One member of staff was undertaking a diploma in deafblind studies. Three staff have NVQ Level 3 and two have NVQ Level 2. One member of staff talked about their previous experience of working in care settings. They said they had had a good induction into the work and had undertaken relevant training. They were able to describe the procedure for reporting allegations of abuse. All staff had an area of management responsibility delegated to them, for example, medication, food and menus and health and safety. Staff were seen to engage with each individual resident either with British Sign Language, hand over hand signing or speaking. Residents engaged with each other not just with staff. However during a discussion with one of the residents in the communal area they signed that they did not like staff using their voices in their presence rather than signing. When the home was first set up it promoted a total communication environment. All staff had in the past used sign when talking to each other in the communal areas. This was not currently happening. Earlier one of the staff had told the inspector about their role-play experiences of reduced hearing during deaf awareness training. They said how it made them feel isolated when other people around them were talking. They said it made them feel that people were talking about them. The inspector advised that staff should think about relating training issues back to their work. Mrs James said she would discuss the issue with all the staff group. Lilac Grove DS0000028252.V332537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. Mrs James keeps herself up to date with current good practice with regular training. Residents views were taken into consideration both at the regular meetings and as part of the quality assurance audit. The organisation has systems in place for regular review of health and safety. EVIDENCE: Mrs James was registered as manager on 13th February 2006. Previously she had worked at the home in a senior role for 3 years. She has worked for Sense for 6 years. She has had previous experience of working with older people in a nursing home and care home. Mrs James said that she was undertaking NVQ 4 and the Registered Managers Award. She keeps herself up to date with current good practice by attending regular training offered by the organisation. Recent training has included: health and safety, managing Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 24 behaviours and first aid. Mrs James said that the home had discussed the implications of the Mental Capacity Act 2005 at a recent manager’s meeting. Mrs James must ensure that notifications are made to the relevant authorities when events occur as detailed in regulation 37 and the Safeguarding Adults procedure. The organisation has a quality assurance system with the manager carrying out a self-assessment document. The manager and staff are also interviewed as part of the assessment. Residents are also involved in responding to a questionnaire. When all the information is collated, the manager sets out an action plan with timescales. Regular meetings were held with residents and minutes were written up in British Sign Language (BSL) with photographs. In the minutes file there were discussion sheets in English and BSL so that residents could be prompted where necessary to talk about different issues. The organisation has systems for staff to regularly check various areas of health and safety. Generic risk assessments are in place. Staff also carry out risk assessments specific to the home’s environment, tasks and use of any equipment. The home has sent the fire risk assessment to the local fire and rescue authority for consideration. The home’s fire procedure was in English and British Sign Language. Lilac Grove DS0000028252.V332537.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation Requirement Timescale for action 24/04/07 2 YA1 37(1)(e)&(g) The person registered must ensure that the Commission is informed without delay of any events in the home set out in regulation 37 and the Safeguarding Adults procedure. 4&5 The person registered must 01/06/07 ensure that either the statement of purpose file is reviewed and rationalised so that only relevant information is available, or that a copy of the document sent out by the organisation’s central referral officer is available in the home. 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 YA41 Good Practice Recommendations The person registered should consider rationalising the care plan files to ensure that only up to date information is DS0000028252.V332537.R01.S.doc Version 5.2 Page 27 Lilac Grove 2 YA8 available to avoid confusion. The person registered should consider the feelings of exclusion for some residents when staff use their voices rather than sign when communicating with each other in communal areas. Lilac Grove DS0000028252.V332537.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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