Inspection on 18/06/08 for Little Ingestre

This inspection was carried out on 18th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Little Ingestre 30/11/06

Little Ingestre 17/01/06

Little Ingestre 29/09/05

Little Ingestre 23/03/05

Little Ingestre 07/01/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Little Ingestre Ingestre Park Near Great Haywood Stafford Staffordshire ST18 0RE Lead Inspector Pam Grace Key Unannounced Inspection 18th June 2008 13:30 Little Ingestre DS0000004973.V366451.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 Little Ingestre DS0000004973.V366451.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. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Ingestre Address Ingestre Park Near Great Haywood Stafford Staffordshire ST18 0RE 01889 270410 01189 279032 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) Platinum care Homes Ltd Mrs Alison Jane Giles Care Home 15 Category(ies) of Learning disability (3), Physical disability (15) registration, with number of places Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Service user over the age of 65 years Date of last inspection 30th November 2006 Brief Description of the Service: Little Ingestre is registered to care for 15 younger adults with physical disabilities including 3 who may have associated learning disability. The home is managed by Platinum Care Homes, based in Wolverhampton. Little Ingestre has been established for 20 years and many of the residents have lived there long term. The home caters for people with a range of disabilities, including visual impairment, epilepsy, cerebral palsy and head injury. The home is originally part of the Little Ingestre Estate and has extensive and well laid out gardens. The property has been extended and provides 13 single bedrooms, 6 with ensuite facilities and 2 double rooms, both with ensuite facilities. In addition there are assisted bathing facilities on both floors and adequate toilet facilities on both floors. A new shower room has been added to the ground floor. There are two lounge/dining areas on the ground floor, one smaller and quieter than the other. The home is situated in a rural setting on the outskirts of Great Heywood, Nr. Stafford. Access is via an un-adopted road that, despite being re-laid several times is potholed. The home does not currently have access to a mini bus, consequently there is a reliance on staff vehicles and taxi transport to access the community and attend appointments. The fees charged for the service at Little Ingestre, are from £386 - £767.00 per week. The fee information included in this report applied at the time of inspection the reader may wish to obtain more up to date information from the care service. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use the service experience good quality outcomes. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over approximately 6.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection, the care manager completed an Annual Quality Assurance Audit (AQAA) for us. There were also five “Have Your Say” questionnaires received from people who use the service. A tour of the home was undertaken. On the day of the inspection, the home was accommodating 12 people. We spoke with people who use the service, examined records, carried out indirect observation, and spoke with two staff on duty. Three care plans and three staff records were examined and observation of daily events took place. Medication procedures were inspected so that we could see how safe they were. We did not make any requirements, but made 3 recommendations as a result of this unannounced inspection. What the service does well: Observation of staff showed positive attitude and relationships with people who used the service. Staff continue to strive for high standards within the home and have supported people who use the service in a sensitive and supportive way. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 6 Staff receive a thorough induction to the home which is “Skills for Care” based. This involves the completion of a workbook by both the staff member and a senior member of staff. Each person using the service has a plan of care, which they have helped to develop. Some people living in the home need support to communicate with others. People are involved in a variety of leisure and work activities. Staff support people to identify what activities they want to be involved in on a daily basis. People are able to develop life skills, staff said they are committed to supporting people to achieve identified goals. People are supported to maintain their interests and hobbies, and to go on holidays, visits, or out for meals, or to the pub. Staff enable and support people to keep in touch with their family and friends, either by arranging visits, and or by phone or letter. What has improved since the last inspection? The Annual Quality Assurance Assessment (AQAA) document completed by the care manager, and our visit, confirmed that internal decoration of communal areas had been undertaken. Portable ramps had been purchased. People who use the service confirmed that they had gone on outings to the local theatre. New furniture had been purchased for communal areas. A personal folder has been introduced for each person to keep in their room, that contains the complaints policy, service user guide, information about the home, advocacy service, local groups and churches. Pictorial menus have been introduced, to enable people to understand the choice of food on offer. The majority of the care staff had completed their NVQ level 2,3 & 4. Little Ingestre DS0000004973.V366451.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. The summary of this inspection report can be made available in other formats on request. Little Ingestre DS0000004973.V366451.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 Little Ingestre DS0000004973.V366451.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information provided to people about the service could be improved upon to make sure that they have the full facts about costs to enable them to make the decision about the suitability of the service and it’s ability to meet their needs. EVIDENCE: We looked at 3 care plans, and saw 3 contracts. The fees had been reviewed. Contracts were in the process of being sent out to the people who use the service. People had a copy of the Statement of Purpose and Service user Guide, which has now been included in the new information pack/folder for all people who use the service. However, it is recommended that information should also include the costs for individual holidays and transport. This was highlighted and discussed at the time with the care manager. The care manager and staff confirmed that pre-admission assessments had originally been undertaken by social services and or the specialist community learning disabilities service. However, because people who use the service had been living at the home for a number of years, some records had since been archived. This was highlighted and discussed with the care manager at the Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 10 time. The care manager confirmed that a person wishing to use this service would always undergo an assessment prior to moving in. Assessment information relating to existing residents is in place, there is evidence that the manager undertakes her own pre admission assessment. She stated that her practise is to ensure that she and/or the deputy manager would go out to undertake the assessments of prospective residents, it was also clear from the information available on individual files, that the service ensures that it receives any professional/social worker assessment for the individual People who provided feedback from our surveys, and people spoken with, said that they were “asked if they wanted to move into the home”, and they “were given information before they moved into the home”. One person said “I love it here at Little Ingestre”. All five surveys received from people who use the service supported the view that they were asked if they wanted to move to this home, and four of the five said they received enough information about the home before deciding if it was the right place for them. Little Ingestre DS0000004973.V366451.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. 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 available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, provided by the care manager, confirmed the following: “Each Service users care plans are personalised to each individual, giving the service user the option of family participation. All care plans are evaluated monthly using the key-worker system with the Service user. Staffs are aware of the policy and procedure on storing and handling confidential information. Our service users are given the option of whether they participate in the person centred planning procedure. Those that participate have records of their wishes kept along with plans on how they aim to accomplish them. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 12 We provide the Service user with detailed information of risks involved in their lifestyles, and offer them the right to make/ and learn from poor choices”. We looked at three care plans, all of which contained a client profile, with person centred information. Risk assessments seen identified in detail the risks for each individual. Evidence of health services input was also seen. Each plan was individualised, and recognised the personality and needs of the person. The plans were reviewed on a regular basis; any changes to the skills achieved were recorded. Evidence contained within care plans seen pointed to there being six monthly reviews held for each person. People spoken with said that they were consulted and encouraged to be involved in their care plan. This consultation was also confirmed when we spoke with staff during the inspection. Surveys received from people who use the service said, – “I love all the sessions especially when I have beauty therapy”. People spoken with said they enjoyed living at Little Ingestre, and also said “I like going to college, and I like my room”, “I can come and go when I want to”. We saw that people were asked by staff if they wanted drinks, food and snacks, which were made available throughout the day, with a choice of options for hot or cold food and or drinks. Little Ingestre DS0000004973.V366451.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), completed by the care manager, confirmed the following: “At Little Ingestre house we provide a monthly Holy Communion service performed by the local lay preachers this meets all religious needs of our Service Users. At present we have no other Service Users requiring other religious needs, previously we have taken them to their specified church. All Service Users have their own key-worker that they have specified, enabling them to speak freely about their likes and dislikes and concerns etc. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 14 Each individual Service User is able to plan their own lifestyles via their care plans in which the Service user and their representative take part. The Service users at Little Ingestre House are encouraged to participate in planned activities to develop their skills. Our Service users with visual disabilities attend Rugeley and Stafford blind centres twice a month. Several Service users attend the ‘Towards Independent living’ courses at Stafford College. One Service user attends the Scope computer centre in Stafford. One resident produces artwork for regular exhibitions. Integrating with the local community three-day events. Residents choose their own menus during their monthly meetings.” We looked at three care plans. Information regarding triggers to any known behaviour, for example what may upset a person, or known fears were included within the care plan. Information was recorded in regard to how the person communicated. Assessments covered all aspects of daily living for example; mobility, traffic awareness, personal care. Information relating to the person’s culture and religious needs were included in the plan, and how these were to be met. People at the home are able to express their own sexuality with appropriate support. For example: one person talked about staff supporting her with her relationship with her boyfriend, and said “I like visiting my boyfriend and going out to the pub”. Personal risk assessments recorded identified risk, level of risk and how to support the person. Surveys received from people who use the service all supported the view that they can do what they want to do, during the day, evenings and at weekends. Discussion took place with people who use the service throughout the visit. This covered their daily programmes, activities, visits to the local day service and to see their families and friends. Daily activities and life continued as normal during our visit. Staff explained the inspection process to people using the service, during the inspection visit. People spoken with said that they “do shopping”, “choose their own menus”, that they “enjoyed their food very much”. “We go to the pub, and staff take us out on trips”. One person discussed his hobbies and interests with us, these included using the internet and the computer, as well as art/watercolour painting. Paintings were framed and on view for anyone visiting the home. There is an activities person employed at the home on a part time basis. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 15 Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed the following: “We provide detailed individual care plans expressing the wishes of each Service user, evaluating monthly with their key workers. All Service users have access to healthcare, including GP’s, District Nurses, Opticians, Dentists etc. there are regularly booked appointments and also emergency access when required. The medication is provided using the Boots MDS system. At present there are no service users who are physically able to control their own medication administration. The medication is ordered, stored, administered and disposed of taking into account company policies and procedures. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 17 Training with our Speech and Language therapist on communication, speech, swallowing and diet.” We looked at three health care plans, these recorded health care needs and how people were to be supported. For example: if a person had epilepsy, a record would be kept of any seizures, and actions taken. Each person was registered with a local General Practitioner (GP). There were good relationships fostered between the home, the learning disabilities service, the GP and the local pharmacist. Other specialists maintain further contact and support. For example: Speech and Language Therapist, and where necessary, district nurses were approached for advice, information and any equipment necessary. People using the service attend surgery and or clinics as appropriate to their health needs. The evidence to support this was contained within daily records, and care plans seen. Medication was stored appropriately, and correct administration of medication was observed on the day of the inspection visit. Discussion took place in relation to medication that is taken out of the home, for example when people are staying overnight with relatives or friends. Ideally, secondary dispensing should not occur, but it is understood that this can limit the spontaneity of outings and events. The general rule of thumb is understood to be 1) where the outing or activity is planned the service should approach the dispensing pharmacy to provide the required supply in a suitable container. 2) when the outing or activity is unplanned the service must have robust procedures in place for checking, recording and dispensing the medication. We noted that a separate medication form is completed with clear instruction about the medication and when and how it should be administered, this is checked with the original instructions and both the person dispensing the medication and the person receiving it check and sign to confirm accuracy. People spoken with during the inspection visit told us, “staff help me if I’m not feeling well”, “I see the doctor if I don’t feel well”, “staff take me in the car to the hospital”. Discussion with staff revealed that they knew people well, and how to support each individual. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 18 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 and 23 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure. People are protected from abuse, and have their rights protected. EVIDENCE: The Annual Quality Assurance Assessment document, which was completed by the care manager, confirmed the following: “The homes complaints procedure is available to everyone involved with Little ingestre House. Copies are on display within the home. It is available in pictorial format for the service users. The complaints procedure is explained to Service users and they are made aware that they are able to talk to any member of staff or management if they have any concerns or fears. The staffs are issued with individual training of the company complaints policy and are encouraged to report any concerns to the manager or Regional managers. Staffs are aware of the confidentiality and are assured that any concern raised will be investigated whilst confidentiality is retained. Staff receive regular supervisions where all aspects of their work is looked at and any praise issued or concern raised. All staff undertake training in all aspects of their working practise and are encouraged to discuss any gaps in their knowledge.” Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 19 The care manager and the complaints log confirmed that the service had received 4 complaints since the previous inspection. One of the complaints had been partially upheld, and 3 had not been upheld. All 4 had been documented and recorded, and had been amicably resolved. Discussion took place in regard to the introduction of a “Grumbles book”, which could be used on a daily basis for minor grumbles. The care manager said that they encourage relatives to approach them if they have a problem. It would be discussed and addressed where appropriate at a time convenient to the family. There had been no complaints and no safeguarding issues reported to us since the previous inspection. Surveys received by us from people who use the service all confirmed that they knew who to speak to if they were not happy. One person spoken with said “I am happy with everything”. People who use the service confirmed that they were very aware of whom to tell if they had a complaint. One person said “ I just speak to my key-worker or tell Alison”, another person said “Alison is the boss, we tell her about it”. Three staff recruitment records evidenced that staff are recruited following robust procedures, which included Criminal Records Bureau and Protection of Vulnerable Adults (POVA) checks prior to commencement of employment. Staff spoken with at the time of the inspection confirmed this. Staff we spoke with were very aware of the need to Protect Vulnerable Adults, and said that they had received training in respect of this. Individual training records seen confirmed that abuse awareness training had been undertaken by staff. A spot check of two people’s finances revealed that the home appropriately records and receipts all personal monies held for people who use the service. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 20 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): 24,25 and 30 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, and comfortable environment, which encourages independence. However, not all areas within the home are accessible to wheelchair users or to people who have mobility needs. EVIDENCE: The home is located in a very rural area and is set in pleasant gardens, with a fish-pond and well established shrubs, lawns and flower beds. Which are also well maintained. The Annual Quality Assurance Assessment (AQAA) document completed by the care manager commented on the following: “Internal decoration of communal areas Portable ramps Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 21 At Little Ingestre House a homely atmosphere is promoted. We also have a well maintained large garden area, with a patio and seating area. A rolling programme is in place for re-decoration. The Service users took part in the choice of furnishing during our refurbishment programme. Infection control measures are in place and all staff receives infection control training. Maintenance and regular checks are carried out weekly.” The AQAA document also confirmed that appropriate safety checks had been undertaken. Since the previous inspection, we saw that internal decoration of communal areas had been undertaken. Portable ramps had been purchased, and new furniture had been purchased for communal areas. During a tour of the building, we saw that the home provides adequate communal space in two lounge dining rooms, one has been fitted with new flooring, and the other room is carpeted. Two bedrooms are doubles. Both have en-suite facilities, as do a number, but not all of the single bedrooms. Some of the single rooms are not as spacious as others and would not meet the minimum spatial requirements required for a new service. A sample of other bedrooms shows that people have been supported to personalise them, with evidence of family memorabilia and photographs, evidence of hobbies and interests, some people have their own telephone, all had televisions and radio’s. One person discussed his love of music and films. All bedroom doors where fitted with locks, keys are provided to people who choose to have one. One person said that they “could have visitors any time, if they wanted to”, and “I can watch television any time”. Furniture in a named person’s room needs either repairing or replacing. Handles were broken to an item of furniture. This was highlighted to the care manager at the time. Surveys received from people who use the service confirmed that the home is always fresh and clean. The provider is committed to a rolling programme of refurbishment. Access to the first floor of the home is via two staircases, the home does not have a shaft or stair lift, making this area inaccessible to people who have mobility needs. The care manager confirmed that only independently mobile service users have bedrooms on the first floor. There were gates/barriers fitted to some of the staircases. These had been fitted to benefit the safety of a person who no longer resides at the home. This Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 22 was discussed with the care manager, and those gates/barriers will be removed. The laundry area on the ground floor provides ample space, a sluice and sufficient laundry equipment. The manager stated that phase 2 of the refurbishment programme will include improvements in this area. The floor needs replacing. There is a smoking area in the laundry room, the door is kept open to allow for air-flow, people can also smoke outside the room in the passageway. The kitchen is modern and large, with a separate preparation room. The preparation room worktops, floor and all fridges needed cleaning. The chest freezer is old, and the seals are no longer efficient, it is recommended that this is replaced. The walls in the kitchen needed de-greasing/heavy duty cleaning. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 23 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 and 36 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are trained, skilled and provided in sufficient numbers to support the people who use the service and to ensure the smooth running of the service. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which is completed by the care manager, confirmed the following: “Maintenance of a staff team with minimal turnover. Set procedure for recruitment. Induction to the home and Select Healthcare Common induction Standards programme. Company policy regarding training and supervision.” The AQAA confirmed the current training courses being undertaken by staff and the numbers of staff qualified to NVQ standard. These were seen to be satisfactory. New members of staff would receive a “Skills for Care” induction package, which includes a workbook that is signed off by a senior member of staff during the induction period. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 24 From our discussions with staff, the care manager, and the examination of staff recruitment and training records, we were assured that the recruitment and training provided, promoted an effective staff team. Staff spoken with confirmed that staffing levels were flexible to meet the needs of the people who use the service, and their commitment to daily activities, for example: attendance at college, transport to an appointment, or a shopping trip. The staff rota for weeks commencing 6/5/08, and 13/06/08 confirmed that staffing levels had been maintained. Three staff records were examined. They evidenced that there is a robust system of recruitment in place. Recruitment records seen included an application form, two references, and Criminal Records Bureau/POVA checks. To ensure the protection of people who use the service. 13 care staff, therefore 61 had achieved NVQ level 2 or above. We spoke with staff, and saw individual staff training records for 2008, which confirmed that mandatory and update training was current, and that they received regular supervision via their line manager. Discussion took place in relation to the introduction of a staff training matrix. Staff meetings are held wherever possible on a three monthly basis. Staff meeting minutes were available for us to view. Surveys received from people who use the service confirmed the view that staff always listen and act upon what people say. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 25 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 and 42 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The service has effective quality assurance systems which; have been developed by a qualified, competent manager. EVIDENCE: The AQAA document confirmed the following: “The Manager at Little Ingestre House has 9 years experience of managing Little Ingestre House. She has completed her NVQ level 3 & 4 in Health & Social care and the D32/33 assessor’s award. The Manager is well aware of the aims and purpose of the home and encourages staff and Service users in all areas. The home is supported by a good, stable staff team, which includes a Deputy Manager and Senior care assistant. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 26 The Regional manager is also very supportive and has many years experience. The Manager operates an open door policy at Little Ingestre House thereby encouraging greater communication by everyone who has involvement with the home. The home sends out questionnaires every 6 months to people who use the service. Monthly resident’s meetings are held. Link resident also chairs monthly meeting, feedback meetings also held so that the action plan/outcome can be discussed.” The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, did not contain enough information in certain areas. This was highlighted and discussed with the care manager at the time. People who use the service are well supported by the sensitivity, training, and experience of the staff employed by the company. Meetings for people who use the service, and for staff are held on a regular basis. People are encouraged and supported to speak out at meetings, and to take part in the recruitment process. There is evidence that the service has a robust recruitment procedure in place. This evidence came from the staff we spoke with and records we sampled. The ethos of the home was reflected in the policies and procedures, the records, attitude and competence of the staff in addition to comments received from the people who use the service. People’s citizenship and their rights, are protected by the staff and the training that they undertake. Records seen confirmed that the practice and procedure for weekly fire alarm testing and fire drills were current. The kitchen walls, fridges, and preparation areas needed cleaning, and the freezer needs replacing, in order to protect people from cross infection. There is a rolling programme of refurbishment and re-decoration, which is monitored by the care manager. The care manager quality assures the service by sending out questionnaires every 6 months to people who use the service. Monthly resident’s meetings are held. A Link resident also chairs the monthly meeting, feedback meetings are also held so that the action plan/outcome can be discussed. Regular staff meetings are also held, and outcomes of monitoring visits to the service are reported to the Commission for Social Care Inspection, under Regulation 26. Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 27 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 3 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 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations To make sure that people considering using the service are fully aware of all costs the statement of purpose and service user guide should clearly state that additional charges are made for individual holidays and transport. The preparation area surfaces and floor need cleaning, the fridges need cleaning regularly, and the kitchen walls need heavy duty clean to remove the grease. The freezer in the preparation room is old, and the seal is not efficiently working. The freezer needs to be replaced. 2. 3. YA30 YA30 Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Little Ingestre DS0000004973.V366451.R01.S.doc Version 5.2 Page 30 - 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!