Inspection on 19/09/06 for Peddars Way

This inspection was carried out on 19th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peddars Way 24/08/09

Peddars Way 18/09/07

Peddars Way 09/02/06

Peddars Way 11/08/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Peddars Way 5a Peddars Court Peddars Way Lowestoft Suffolk NR32 4TT Lead Inspector Julie Small Unannounced Inspection 19th September 2006 14:00 Peddars Way DS0000024563.V312634.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 Peddars Way DS0000024563.V312634.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. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peddars Way Address 5a Peddars Court Peddars Way Lowestoft Suffolk NR32 4TT 01502 538746 F/P 01502 538746 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) Royal Society of Mentally Handicapped Children and Adults Michael Ullah Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 1 The care home for adults is able to accommodate three young adults in the age range 15-25 years. 2 The home is accommodating one named service user who is 15 years of age, and who will reach the age of 16 on 10.04.2006 3 The above condition no. 2 will cease once the named service user reaches 16 years of age, upon which condition no. 1 above will be amended to reflect an age range of 16-25 years 9th February 2006 Date of last inspection Brief Description of the Service: 5a Peddars Court is a home for young adults, registered to provide care, accommodation and support for three service users with profound learning and physical disabilities. Due to the complex nature of their disabilities, these service users are unable to be cared for at their family home. Each service user requires very significant care staff input in relation to meet their health; physical, and emotional and social care needs. The families of the three service users have unrestricted contact. 5a Peddars Court is a bungalow, built as part of a residential housing development in North Lowestoft. As such, it is attached to neighbouring properties, and the small development has been built in courtyard style, with neighbours on three sides. The home is located close to a range of community services including local shops and public transport. Due to the very significant levels of disability, the service users living at this home are transported using the homes own adapted minibus. The home is run by Mencap, a Voluntary Agency specialising in services for people with learning disabilities. The homes manager informed the inspector that charges were £1,754.27 per week, at the time of the inspection. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key inspection which focused on the core standards relating to young adults. The report has been written using accumulated evidence gained prior to and during the inspection. The inspection was undertaken by regulatory inspector Julie Small on Tuesday 19th September 2006 between the times 14.00 to 18.30. The homes manager, Michael Ullah facilitated the inspection process. During the inspection a manager from another Mencap home was undertaking a ‘mock’ inspection, which the homes manager said is a recently new initiative which assists with the quality assurance of the home. The homes manager said that service users were referred to as residents; this term will be used throughout the report. Two service users were met during the inspection and one resident was on home leave, due to the degree of disability of the residents it was not possible for the inspector to gain their views about the service. Staff and relatives/visitors comment cards and pre inspection questionnaire (PIQ) were sent to the home prior to the inspection. The PIQ, three staff and six relative/visitors comment cards were returned, including from placing social workers. All relatives/visitors comment cards stated that they were satisfied with the overall care provided, comments made included ‘the care ….receives at Peddars Court is wonderful’ and ‘… looked extremely well and very well looked after. Cannot thank the staff enough’. Two staff members were spoken with and a tour of the building was undertaken. Records were viewed which included residents records, accident records, fire safety records, rotas, menus and staff recruitment records, further records viewed are identified in the main body of this report. What the service does well: The homes records were well maintained. The ‘about me’ documents and person centre planning records were accessible to residents and evidenced that those working with each resident were informed of their likes and dislikes. Records viewed and discussions with staff members evidence that the home strives to meet the individual needs of each resident. The home was clean, well maintained and accessible to the residents of the home. The care provision at the home was person centred and individual residents needs were met. Interaction between staff and residents was positive and respectful. There was care taken to ensure that the residents were included in all conversations. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 6 The provision of food at the home was well balanced and there were clear records, which identified each resident’s individual needs with regards to eating and their needs. 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. Peddars Way DS0000024563.V312634.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 Peddars Way DS0000024563.V312634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality in this outcome area is good. Prospective residents can expect that their individual aspirations and needs are assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three residents have lived together in the home for a number of years. The home had originally been registered as a children’s home, the registration had been varied to allow the residents to remain together with the same staff team as they develop into adulthood. Resident’s records were viewed and evidenced that needs assessments had been undertaken when they were newly admitted into the home. There were ongoing updated needs assessments and care plans which identify how their needs would be met, throughout their placements along with their development and changing needs. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality in this outcome area is good. Residents can expect that their needs are reflected in their personal plan, they make decisions about their lives with assistance needed and they are supported to take risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were care plans in place for each resident regarding all aspects of their day to day living needs. The manager reported that care plans were completed with staff, other relevant professionals and the resident’s family. Care plans were regularly updated along with residents changing needs, where care plans had been amended staff had recorded why the change had taken place and signed and dated the document. The manager reported that they were adapting the care plan format, which would allow further writing space for the updating of the plans. Care plans included behavioural management information, including how one resident should be worked with when they hit out at staff. There were also risk assessments for this issue. Resident’s records held charts which included information on toileting, drinks and food intake, weight, and epileptic seizures which were monitored to identify any recurring patterns or triggers. Each Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 10 resident had risk assessments which identified the risks and prevention or minimisation of risks in the residents day to day living, activities in the home and in the community, self harm and harming others. A staff member was spoken with and explained how the care plans were used on a day to day basis, and was included in the shift leaders file, which was available for staff to identify how each residents needs should be met. They explained that they were a key worker to one resident and were responsible for ensuring that care plans were regularly updated. They showed the inspector key worker meetings records. They explained that these were undertaken regularly with other members of individual residents key work team and the resident. They discussed resident’s goals, progress and needs and identified any amendments required in the care plan and plans for activities which they could undertake. There was an ‘about me’ document for each resident, which included photographs of the resident and photographs of the important people and things in their life. A staff member confirmed that they had undertaken person centred planning training and following the training they had completed a person centre planning folder with the resident who they were link worker for. The folder was viewed and had photographs of the residents family, befriender/advocate and friends, likes and dislikes and any aids that they used such as a photograph of their cup, plate and fork and a photograph of their wheel chair. The pages in the folder had been laminated and were used by the resident; the staff member confirmed that it was in an accessible format. The manager reported that they had looked at the idea of producing a video of one residents care plan, because they responded better to moving pictures rather than still photographs. They were still in the early stages of exploring this possibility, which identified that the home had explored different methods of including individual residents in their care provision. The manager reported that all decisions about the care that individual residents received was discussed with the resident’s family and relevant professionals. The resident was spoken with and the manager reported that staff at the home had a good knowledge of methods each resident used to express emotions such as happiness and unhappiness. Their expression of emotions when making choices was observed. Six relatives/visitors comment cards were received, all answered yes to the question ‘If your relative/friend is not able to make decisions, are you consulted about their care?’. They all said that they were kept informed of important matters affecting the resident. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality in this outcome area is good. Residents can expect that they are able to take part in appropriate activities, maintain appropriate personal relationships, their rights are respected and that they are offered a healthy diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One resident attended full time education, and the home were investigating the possibility of day placements for the other two residents, following their transition from full time education to adulthood. A staff member said that an appropriate establishment was to be sought which would meet the individual needs. The PIQ stated that they were looking into educational activities for the two residents who do not attend school. It also listed activities as holidays, bowling, football matches, concerts and horse riding. The residents records viewed included a timetable of activities for each resident. The timetable of activities included weekly youth club, shopping, visits to local areas, eating out, walking into the town centre for coffee and tidying their bedroom. Each timetable ensured that each resident was occupied Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 12 and undertook activities in the home and in the local community. A staff member said that one resident attended a local youth club, where they could maintain contact with school friends and others in the community who were able bodied and disabled. Resident’s records evidenced that residents enjoyed regular contact with family members, friends and befrienders/advocates. There were photographs of family members in resident’s bedrooms. One resident had regular home visits which their family agreed with the home, one timetable included telephone calls to their parents. Six relatives/visitors comment cards were received and all said that staff welcomed them into the home at any time and that they could visit their relative/friend in private. There were photographs displayed in the lounge of one resident who had attended their befrienders wedding with their family. Person centred planning records and ‘about me’ documents included photographs of important peoples in each resident’s life and of activities which they enjoyed. One included photographs of the utensils they used to eat their meal. During a tour of the building it was noted that there was a range of musical instruments, music CD’s and video and DVD films, that belonged to individuals and that the home had purchased. The home had a mini bus, which could be used to transport residents to their chosen activities. There were some makaton signs on the wall in the lounge and bathroom, which a resident used, such as drink, toilet, please and thank you. This informed staff and visitors of signs that the resident used. Staff and residents were observed playing musical instruments during the inspection, which they were enjoying. There was laughter and positive interaction. There were clear records which explained the day to day living routines of each resident, which directed staff in their care provision and the support they required. During the inspection it was observed that staff and residents enjoyed positive interaction. The staff members included the residents in all discussions. In the kitchen there was records of how each resident should be supported in eating their meals, likes and dislikes and what they could and could not eat. There were menu’s that evidenced that residents were provided with balanced and appetising meals and they met each individual’s dietary requirements. There were laminated pictures of different foods, which one staff member confirmed aided residents choice. One resident’s records identified that they were fed through a tube; two staff members confirmed that they had received relevant training. There was a bowl of fresh fruit and there was a good selection of fresh vegetables in the home. Each item of opened food had been labelled by staff identifying the date it was opened. A staff member was observed preparing the Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 13 evening meal, which smelled appetising. There was a resident present and the staff member talked through how they were preparing the meal. There was staff guidance viewed which stated that staff were expected to eat their meals with the residents. Staff were observed to provide residents with their choice of drinks throughout the day. They were observed to assist in drinking where required. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 14 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, 20 The quality in this outcome area is good. Residents can expect that they receive personal support in the way they prefer and require, their physical and emotional health needs are met and that they are protected by the homes procedures for dealing with medicines. This judgement has been made using available evidence including a visit to the service. EVIDENCE: During a tour of the building it was noted that the home had several hoists for the safe handling and lifting of individual residents. There was evidence that the hoists were regularly serviced and that staff had received training in manual handling. The manager showed the inspector a recently purchased stand aid for one resident and confirmed that the providing company demonstrated its use to the home and fitted it for the individual. Care plans viewed include information regarding the support required by each individual including personal care, likes and dislikes and their day to day routines. The manager reported that they are completed with consultation with the resident’s family and relevant professionals and that staff observed residents for displays of satisfaction and dissatisfaction with each particular activity. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 15 There was evidence that residents had received support from speech and language therapists, occupational therapists and physiotherapists, to meet individual needs. Records show dates, reasons for and outcomes of health care provision and health appointments attended. There was reports which showed how one resident had dislocated their jaw on several occasions and support the home had sought. The PIQ stated that all residents were registered with a local general practitioner and that they were provided with services from a district nurse, occupational therapist, dietician, dentist and physiotherapist. A staff member said that each resident is allocated with a key worker and a key worker team who had regular key worker meetings with the resident to ensure that their care provision continued to meet their needs. This was confirmed by information provided in the PIQ. Medication storage and records were viewed and met requirements. Records clearly indicated when one resident was on home leave. Staff training records evidenced that staff had received medication training. The types of medication taken by each resident were recorded in their personal records as well as the medication records. The administration of afternoon medication was observed and found to be appropriate, the staff member talked through all actions with the resident. Records were maintained which evidenced when medication was returned to the pharmacist and when repeat prescriptions had been made. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 16 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, 23 The quality in this outcome area is good. Residents can expect that they and their family are supported by the homes complaints procedure and policy and that they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a robust complaints procedure, which was viewed. There had been no complaints received since the last inspection. Staff comment cards received stated that they were aware of the homes complaints procedure. Four relatives/visitors comment cards said that they were aware of the homes complaints procedure, two said that they were not. Staff training records viewed evidenced that staff had been provided with child protection training and adult abuse training. The manager stated that they were in the process of identifying further protection of vulnerable adults (POVA) training. One staff member spoken with said that they were aware of identifying signs and symptoms of abuse and how to report concerns. They said that they had proved competence in this subject during the completion of their NVQ award. Staff comment cards received stated that they had received training on the homes abuse policy. The financial records of one resident were viewed and there were records and receipts kept of all transactions made by the residents. There was staff guidance viewed stating that staff were expected to leave their mobile telephones in their ‘pigeon hole’ during their shift. The manager confirmed that this was to prevent staff talking on their telephone when they Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 17 were working with the residents and gave reference to adult protection if individuals had a mobile telephone that takes pictures. The inspector was asked for identification on arrival at the home and recorded their times for arrival and departure in the homes visitors book. There was evidence that this was a routine procedure. Staff recruitment records were viewed and each staff member had CRB (criminal records bureau checks) and relevant references before they commenced working at the home. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 18 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, 26, 27, 30 The quality in this outcome area is good. Residents can expect that they live in a homely, comfortable and safe environment which is clean and hygienic. They cannot be assured that one bathroom meets their individual needs. This judgement was made using available evidence including a visit to the service. EVIDENCE: On arrival at the home, it was noted that the home could not be distinguished from other domestic homes in the area. The home was clean, well maintained, comfortable and homely, there were no offensive odours identified during the inspection. The registration certificate was displayed in the entrance hall. The manager confirmed that the staff team were responsible for the housekeeping of the home and cleaning rotas were viewed, which identified cleaning chores which were done throughout each day and week. During a tour of the building it was noted that the home was accessible to wheelchair users. The home was bright and airy and the decoration and furnishings were well maintained and attractive. The patio area of the home had colourful paintings on the wall. There were various items such as colourful stones and tiles which were attached to the fence posts, which could be looked at or touched by the residents. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 19 Two residents bedrooms were viewed and reflected the resident’s individuality with the décor of the home and personal belongings such as posters, photographs. There were music centres and televisions in the bedrooms which belonged to the residents. It was noted that memorabilia and pictures were positioned at an appropriate height to support the resident in looking at their belongings when they were lying in bed. The manager confirmed that the two bedrooms had recently been decorated and that they had consulted with the resident’s family regarding colours. They said that residents were consulted and their expressions of satisfaction and dissatisfaction were taken into account. There were two bathrooms at the home. The manager said that they were awaiting confirmation to go ahead with the extension of one bathroom. They said that they had been chasing up the final decision for the extension and would continue to do so. The plans for the extension were viewed and it was noted that the bathroom would almost double in size, which would assist the access and support provided to residents when bathing. The second bathroom had newly fitted flooring, which provided a more hygienic and safe flooring for residents when they used the shower. The flooring allowed water to drain away when showering and the manager confirmed that the floor was non-slip when wet. Hand washing facilities in bathrooms provided hand wash gel and disposable paper towels. There were sufficient stores of disposable gloves and aprons for staff use when undertaking personal care duties. The laundry was viewed during a tour of the building, which contained a suitable washing machine and a tumble dryer. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The quality in this outcome group is good. Residents can expect that they are supported by trained, competent and qualified staff, are supported by the homes recruitment policy and practices. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Training records were viewed which evidenced training which staff members had undertaken which included, health and safety, fire safety, epilepsy, child protection, POVA, food and hygiene, medication, manual handling, person centred planning and specific training which related to the service user group such as tube feeding. The manager confirmed that they had identified further training for the staff team, which included POVA and more in depth child protection and de-escalation of violence. The manager said that they were awaiting confirmation of the whole team to receive POVA training to support the transition from children’s to adult services. They confirmed that the MENCAP induction was accredited by the open college network and were in line with Skills for Care Induction Standards. Staff comment cards received all stated that the home had a good training and development programme to support staff and that they felt that they received sufficient training to undertake their role. Two staff members were spoken with and confirmed that they thought the training was sufficient to inform their work roles and the training courses which they had received. One staff Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 21 member said that they had an induction and their colleague had also provided mentor support to them. They said that the homes management supported them and colleagues and they had regular meetings and handovers of each staff. One staff member said that they had achieved an NVQ (National Vocational Qualification) level 3 and one staff member said that they had recently enrolled on an NVQ level 3 Social Care and Health programme. The manager said that two staff had achieved NVQ level 3 Caring for Children and Young People, one had level 3 Promoting Independence and they were undertaking their Caring for Children and Young People award, one had level 2 care, one was a student nurse, three had enrolled the week of the inspection on level 3 Social Care and Health and a further two staff had not yet achieved an NVQ or equivalent award. When those working on their awards had completed, the home would achieve the 50 target of staff to achieve a minimum of NVQ level 2. Training records viewed confirmed the staff qualifications. The manager said that there had been three staff recruited to work at the home in August 2006 and that they were awaiting the receipt of appropriate check before they can commence in their role. They said that two of the recruited staff had achieved an NVQ level 2 in care. The homes rotas were viewed. Five relative/visitors comment cards said that there were always sufficient staff on duty, one did not respond. One comment received was that a family member would like to be informed when new staff were providing care for the resident. Three staff recruitment records were viewed and evidenced that appropriate checks had been undertaken prior to the individuals commencing work at the home. Checks included satisfactory CRB’s, two written references and identification. Staff records held a photograph of each staff member in the form of an original of a photograph or copy of a passport or photo card driving license. Staff records included application forms, including a history of their work experience and interview notes. It was noted that there was a copy of the General Social Care Council codes of conduct displayed on the office wall. During the inspection interaction between staff and residents at the home was observed to be positive and respectful. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality in this outcome area is good. Residents can expect that they benefit from a well run home, their views underpin the development of the home and that their health, safety and welfare is promoted and protected. This judgement was made using available evidence including a visit to the service. EVIDENCE: The manager had appropriate qualifications, which were identified in the homes statement of purpose and in training records. Training records viewed evidenced that the manager had undertaken training courses, which maintained and updated their knowledge. The manager had proved suitability for their role through the fit person process with CSCI (Commission for Social Care Inspection). Three staff comment cards received stated that they felt that the home was well run. Resident’s records viewed included service users satisfaction questionnaires. A staff member spoken with said that they were provided to family members and visitors such as advocates and befrienders. Areas for improvement identified were discussed in staff and key worker meetings and plans for improvements Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 23 were made. They said that residents were also observed for signs of satisfaction in their care provision. The manager said that residents would require assistance in completing surveys or questionnaires. There was a recently new initiative of managers from different services within the organisation undertaking ‘mock’ inspections. One of which was being undertaken during the day of this inspection. The manager said that the exercise was to provide quality assurance throughout each service in the organisation. The manager said that the home also had regular regulation 26 visits, which provide quality assurance. Regulation 26 reports were routinely forwarded to CSCI. Staff training records were viewed and evidence that staff received food hygiene, infection control, fire safety, health and safety, first aid and manual handling training. Staff members spoken with confirmed this. The homes accident records were appropriately completed. Notification required to be forwarded to CSCI regarding accidents and illness’ were routinely forwarded to CSCI. The first aid box was viewed, which was stored in the kitchen area and it was noted to be well stocked and accessible. Fire records evidenced that regular fire safety checks were undertaken. The manager said that there was a fire and rescue audit planned for October 2006. The homes fire risk assessment was viewed. The fire procedure was explained by a staff member to the inspector upon their arrival at the home. During a tour of the building the homes locked COSHH (control of substances hazardous to health) cupboard was noted to be situated in the laundry. Health and safety records viewed evidenced that hoists were regularly maintained and electrical items and boilers were regularly checked. There were records which showed that fridge, freezer and water temperature checks were taken on a regular basis. The manager undertook monthly health and safety checks of the building, records of checks were viewed. The PIQ stated that the shift leader carried out the weekly fire alarm testing, and there were designated workers who had responsibility for health and safety, COSHH and vehicle safety. The manager said that the local council undertook repairs and that they were prompt when repairs were reported. A staff member explained the homes fire procedure to the inspector on their arrival to the home, clearly explaining how the inspector should evacuate the building in case of a fire. Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 24 Peddars Way DS0000024563.V312634.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 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 3 27 2 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 Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA27 Regulation 23 (2) (a) Requirement The plan to extend one bathroom must go ahead to enable one resident to use it in safety. This is a repeat requirement. Timescale for action 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Peddars Way DS0000024563.V312634.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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