Inspection on 25/09/06 for Pershore Short Term Breaks Service

This inspection was carried out on 25th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pershore Short Term Breaks... 19/09/07

Pershore Short Term Breaks... 24/01/06

Pershore Short Term Breaks... 08/03/05

Pershore Short Term Breaks... 08/09/04

Pershore Short Term Breaks... 09/02/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Pershore Short Term Breaks Service 48 Station Road Pershore Worcs WR10 1PD Lead Inspector Dianne Thompson Unannounced Inspection 25th September and 3 October 2006 15:30 rd Pershore Short Term Breaks Service DS0000037468.V313156.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 Pershore Short Term Breaks Service DS0000037468.V313156.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. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pershore Short Term Breaks Service Address 48 Station Road Pershore Worcs WR10 1PD 01386 552978 01386 553018 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.worcestershire.gov.uk Worcestershire County Council Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate people for short-term care only. Date of last inspection Brief Description of the Service: The home is situated on a service road, off the main A1041, in a pleasant residential area approximately one mile from Pershore town centre. The home is situated at the end of a building shared with a day centre and provides a short-term respite care service. Worcestershire County Council operates the home and the responsible individual is Stephen Chandler. A new manager, Mr John Masterton who commenced in July 2006 is to apply to become the registered manager with the Commission for Social Care Inspection. The main entrance to the home and car park are shared with the staff and users of the day centre. The home has its own front door and apart from the joint use of a bathroom and the garden, the accommodation is self-contained. All the accommodation used by service users is on the ground floor with staff facilities on the first floor. The home can accommodate a maximum of five service users at any particular time for short periods of care. All the people who use the service have learning and physical disabilities. The aim of the home is to offer a service based on the principles of dignity and respect in a safe, warm and friendly environment. The fees for staying at Pershore Short term Breaks service are currently £9.00 per night. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Pershore Short Breaks. A second visit was arranged so the manager could be available to discuss the development of the service. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and a tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider’s representative was used to inform this report. At the time of the inspection 15 service users, aged between 18 and 65 years, are being provided with planned respite stays - overnight in the week and at week-ends. Day care is not routinely provided during the week. On this occasion three service users were staying at the home. Time was spent with service users and staff. Comment cards were sent to relatives prior to the inspection visits, and feedback from eight cards returned will be included in the main body of this report. What the service does well: Pershore Short Term Breaks is an established service that provides care and support to 15 service users for planned short stays to give their families a break. The house is kept bright, clean and safe and has a welcoming atmosphere. The home provides a good standard of care for all service users, which has developed through getting to know individuals and how to respond to their needs. Information about the home is offered to help service users choose whether they would like to stay at the home. The home offers a choice of menu that is flexible to make sure a variety of meals are offered. Personal and healthcare needs are recorded in care plans. These plans provide information and make sure that care is provided in a way that takes into account service users preferences. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 6 Service users are protected by the home’s complaints procedure. Suitable The staff team understand their staffing levels are being maintained. responsibilities and are committed to their role. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. The home is managed with an open and positive approach. Worcestershire County Council monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. 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. Pershore Short Term Breaks Service DS0000037468.V313156.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 Pershore Short Term Breaks Service DS0000037468.V313156.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): 1, 2, 3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to the service. Information is provided about the services offered at the home to help service users make an informed choice about whether they would like to stay at Pershore Short Term Breaks Service and whether the home will meet their needs. EVIDENCE: The home has information about the service for prospective service users and their families that needs to be updated. The manager said that updating information is being carried out, and this has started with the Statement of Purpose and Service User Guide, which will also reflect the changes in management of the service. The manager said that copies of the revised Statement of Purpose and Service User Guide would be accessible to all, including visitors to the home. All service users will receive copies of relevant information during their introduction to the home, and will be offered in preferred formats, e.g. symbols and pictures. Admission procedures and assessment forms are evident for those service user files examined. One service user is currently being assessed and familiarisation visits are being arranged, towards providing planned stays at the home. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 9 An admissions policy and procedure is in place. An assessment completed for a service user recently admitted to the Service demonstrates that the home obtains information about prospective service users, their background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources including other relevant professionals, visits to homes or schools, and discussions with family members. A uniform approach should be considered to ensure consistency of care provision and information gathering. A draft agreement, which has been produced by another County Council home, is to be adapted for this service. This agreement will include a contract and statement of terms and conditions for the home. Pershore Short Term Breaks Service DS0000037468.V313156.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Care plans provide staff with relevant information about users assessed needs. They include risk assessments on how risks are to be reduced and independence promoted. Service users are enabled to make choices and decisions in their daily lives and routines. EVIDENCE: The home provides a good standard of care for all service users, which has developed through getting to know individuals and how to respond to their needs. It was not possible to communicate with the service users staying at the home at the time of the inspection visit, as communication is very limited. Staff said they would know if someone was unhappy or uncomfortable and how to respond. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 11 There were no service user photographs on the two files examined. The manager confirmed this would be rectified. Service user care plans are relevant, but the different formats and duplication of information can be confusing and does not allow new staff easy access to information to make sure that all care is provided in a consistent way. The home should develop a style to be adapted for all service users to aid consistency. Additionally where Person Centred Plans are already in use for service users, e.g. day care placements, the home should make sure that the short break service is included as part of individual plans and not completed separately. This was discussed with the home manager and the care plan for one service user (recently admitted to the home) was highlighted as an example of good practice that could be adopted within the service. Each service user is allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs. Risk assessments have been completed for individuals and include assessments where there is a risk of choking. The risk assessment for those at risk of choking that was due for review July 06 was not signed or dated. Again the filing system is confusing – examples of the same information in different parts of the file was found. An index to individual service user files that clearly identifies where information can be found would be beneficial. Pershore Short Term Breaks Service DS0000037468.V313156.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Service users receive help and encouragement to take part in activities and are supported to access facilities within the wider community. The home offers a flexible menu but needs to promote a healthy diet for the welfare of all service users. EVIDENCE: Service users attend day placements during the day. At the time of the visit two service users were relaxing in the lounge, while another service user was interacting with staff on duty. The home’s booking system supports service users to stay for evenings and weekends. There is more time available at weekends for activities such as the hydro pool, shopping, meals out and Snoezelen sessions in the day centre. The home has access to the day centre facilities at weekends. The home has a bus but not many staff can drive it. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 13 The current staff rota does not allow for full days out at weekends due to the start and finish times of shifts. The home manager says that planning ahead will be essential to allow for rota planning. Support Worker meetings are to be reinstated to assist with planning of activities. During the week service users come to the home for overnight stays, and there is less time available to organise outings or activities. Time is usually taken up with personal care, preparation and eating the evening meal. There is music, videos and television to watch or listen to. All service users are encouraged to be involved in the home’s daily routines during their stay, for example, being present during the cleaning of bedrooms although service users may be unable to do the physical task. Activities also include looking at books and magazines, doing puzzles, art and crafts. One response from the comment cards stated that ‘our daughter has short stays and arrives home happy’. The Menu record sheets show that options and choices are available and usually link in to what meals have been eaten during the day to avoid repetition. These records show the regular use of fast food such as pies, pasta, quiche and frozen vegetables. A healthy diet should be promoted which includes fresh meat, fish, and vegetables. Fresh fruit should be readily available. The manager said the home is looking to develop the menu and the range of food that is offered. The temperature probe has been calibrated and should be used where meals are being reheated. Also as an additional precaution, hot drinks should be tested with a probe. A record could be kept on the service user plan as to the safe and suitable temperature each service user’s drinks and food should be served. Pershore Short Term Breaks Service DS0000037468.V313156.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Personal and healthcare needs are identified in care plans. The plans provide information to give support for all service users in a way that they prefer, although a consistent recording system is needed. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide information about the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines, although a consistent recording system for all service users should be developed. Service users routines are known and respected, and service users were consulted about bathing or showering during the inspection visit. Staff said they are able to communicate with service users verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Staff on duty and the manager said that all personal care is given in private to promote dignity for all service users. There are hoists Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 15 and specialist chairs that the service is able to access from the adjoining day centre if necessary. One service user is relatively new to the home and the staff commented on how well he has settled into the environment. Service users health and well being is monitored during their stay at the home. During the inspection visit staff were observed encouraging a service user to drink. Staff said there were some concerns about the amount of fluids the service user was drinking. There was however, no recording system in place to monitor this. The Worcestershire Health Action Plans would be beneficial for service users to bring with them for their short stays and this has been raised with the service manager. Service users and the home are supported by emergency medical services, which includes the local GP surgery, as service users have established medical support arrangements from their own homes. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs, should they be required. Medication records were checked and all was satisfactory. The manager was advised that medication that is supplied in its original packaging would benefit from additional storage for example, in sealed plastic containers or wallets that can be individually labelled. The manager confirmed that the organisations policies and procedures would be followed should any medication error occur. Additionally these would be reported to CSCI. Pershore Short Term Breaks Service DS0000037468.V313156.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Service users are protected by the home’s complaints procedure that is available, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: Security arrangements to the home must be maintained which includes access to the front door. At the time of the first inspection visit, the doorbell was not working properly, the front door was open and the cleaner from the day services showed the inspector into the home. Another comment from a carer on the comment cards shows concern about safety at the home, in that ‘the front door is often unlocked when I arrive and able to walk in. More awareness of security needed’. The manager confirmed that the doorbell has been repaired and that security arrangements have been improved. This was demonstrated during the second visit to the home. The home has a Compliments and Complaints folder. No complaints have been made to the home or to CSCI since the previous inspection. Two ‘thank you’ cards had been received by the home from carers. There were eight responses from the comment cards to the question that asked if they were aware of the home’s complaints procedure? Four responses were aware and four were unaware of the home’s complaints procedure. The home is advised that a copy of the updated complaints policy and procedures should be sent to all families and carers. All responses indicated that they had not made a complaint to the home. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 17 The home has procedures in place for the protection of vulnerable adults. The service does not accommodate service users who may have challenging behaviour. The deputy manager has received training in protecting vulnerable adults from abuse and similar training for the staff has been requested from Social Services Training Department. Worcestershire County Guidelines on abuse and a copy of the Department of Health ‘No Secrets’ guidelines are available in the office. Service user’s money is booked in by two staff members and returned to the service user at the end of their stay. Staff sign the individual record sheets for each transaction and service users are now being supported to keep their own money in a lockable place in their bedroom. Pershore Short Term Breaks Service DS0000037468.V313156.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, 25, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Pershore Short Term Breaks Service provides accommodation for service users that meets their needs and offers a spacious and comfortable stay away from their home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: A maximum of four service users are being accommodated at any one time in single bedrooms. The fifth bedroom off the lounge continues to be appropriately used as a dining room. The ground floor of the home, where all the service users are accommodated, is warm, safe, clean and well maintained for the service users. The home accommodates people with a variety of needs and suitable specialist equipment is provided. This includes specialist beds and a pressure mattress. A tour of the home was completed and all bedrooms were seen. Bedrooms are well furnished and decorated. One room is fitted with rope lights that are Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 19 enjoyed by many of the service users who stay there. The lounge has been repainted and new curtains are ready to be fitted. There are excellent garden facilities that include a sensory area. The back garden has a lawn and decked area for service users to sit out and use in the summer. The County Council’s health and safety officer has viewed the garden and recommendations made have been completed. This included the installation of handrails to the decked and access areas. The home is clean and tidy. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available and there are suitable arrangements in place for the disposal of clinical waste. The laundry room is situated on the first floor and is suitably equipped. The home has separate staff bathing, toilet and hand washing facilities. Pershore Short Term Breaks Service DS0000037468.V313156.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, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Suitable staffing levels are being maintained, and relevant training is being arranged for staff to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The manager said that the staffing situation is becoming more settled now with a full team following the recent recruitment of staff. A copy of the rota was provided and this indicates that there are sufficient staff on duty at all times. This was observed during both inspection visits. Seven out ten members of the staff team are currently qualified to NVQ level. This meets 50 of care staff to achieve a care NVQ as required by the National Minimum Standards. Further training is planned to make sure this level is maintained. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 21 Six responses on the returned comment cards indicate that there are always sufficient numbers of staff on duty, with two comments unanswered in relation to this question. The manager confirmed that all prospective staff complete an appropriate application form and that references are obtained including one from their most recent employer. Copies of proof of identity and documentation for all candidates are taken at interview. An enhanced CRB/POVA (police) check is undertaken before their appointment is confirmed. All staff are required to work a six-month probationary period at the home. Evidence was seen of CRB and photo identification that was being processed for a new member of staff. Evidence was seen on the staff supervision overview that all staff receive supervision from the management team. Staff meetings are held regularly. Staff spoken to confirmed that they felt supported and enjoy working at the home. The manager and deputy manager are compiling a supervision planner, to ensure that all staff receive regular, planned supervision. Some gaps in staff training were identified. The manager is aware and is booking people onto identified training courses. This will include all mandatory training such as infection control, moving and handling and food hygiene. The County operates a full training programme and access to more specialist courses relevant to the home will be provided. This will include PEG Care, MAPPA, Autism and Sensory Impairment. The manager is to complete a training matrix and forward a copy to CSCI. Pershore Short Term Breaks Service DS0000037468.V313156.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 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. The home is managed with an open and positive approach. Worcestershire County Council monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The manager John Masterson has worked at the home since March 2006. He has many years experience in residential care and has completed NVQ level 4, Diploma in Management of Care Services and is an NVQ assessor. Mr Masterson says he operates an open door management style. He has undertaken a wide range of other training relevant to service users’ needs. It is evident he is knowledgeable about learning disabilities and the implications for service users themselves and their care. The manager is to submit his application for registration to CSCI. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 23 Management responsibilities in the home are shared with a deputy manager. They are involved in organising the running of the home, health & safety promotion, staff supervision and induction. An administrator also supports the home. Staff confirmed the manager is approachable. They say the staff team works closely together to help service users enjoy their stay and to make sure that all their needs are met. In respect of management support from the provider, Worcestershire County Council has Training and Human Resource Officers who are available to advise and support the home. The provider’s monthly visits are one of the ways that Worcestershire County Council monitors the service and how the home is being run. These visits include interviews with staff and service users and an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. A quality assurance programme is yet to be introduced to the service by the County Council (previous requirement). However it is noted that there are checks in place for health and safety matters. A full health and safety audit was recently completed in the home, following the fire officer’s inspection. The manager is introducing annual audits of the service and questionnaires for service users and carers. There are systems in place to maintain the health and safety of the service users and staff such as risk assessments for safe working practices and the accident book. Risk assessments such as those for lone working, infection reduction, smoking, security, and Coshh were out of date. It was difficult to track when the risk assessment reviews had been completed. Some risk assessments had been reviewed 25/01/06 but the information was not compatible with the review logs. Cans of paints stored in the office should be removed and stored securely. Responses to six of the returned comment cards indicated that relatives and friends are kept informed of important matters affecting their relative/friend. Two respondents did not answer this question. All eight respondents indicated that all are satisfied with the overall care provided in the home. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 24 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 2 2 2 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5 Requirement The draft agreement/contract must be introduced. (timescale of 31/12/05 and 31/03/06 not met) Recording systems must be in place where concerns for service users well-being have been identified. Specifically this refers to fluid intake charts. The security arrangements must be maintained at all times to ensure the safety of all service users. Specifically this refers to the access via the front door. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 39. (timescale of 31.12.05 and 30/04/06 not met) Opportunities for on going training must be available for staff, in particular NVQ’s in care and safe working practices. A training programme must be submitted to CSCI. The home manager must DS0000037468.V313156.R01.S.doc Timescale for action 30/11/06 2. YA19 12 30/11/06 3. YA23 23 31/10/06 2. YA39 24 30/11/06 3. YA42 13,18 30/11/06 4. YA43 9 15/11/06 Version 5.2 Page 26 Pershore Short Term Breaks Service complete CSCI registered manager application. 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. 2. 3. 4. 5. 6. 7. Refer to Standard YA1 YA2 YA9 YA17 YA19 YA20 YA22 Good Practice Recommendations The statement of purpose and service user guide should be updated by the new manager and copies sent to CSCI. A recording system that is consistent for all service users should be developed. An index to individual service user files should be included that clearly identifies where information can be found. A healthy diet should be promoted which includes fresh meat, fish, fruit and vegetables. Short Break service users would benefit from having health action plans. Packets of medication should be stored in individually labelled containers A copy of the updated Complaints Procedure should be sent to all parents/carers. Pershore Short Term Breaks Service DS0000037468.V313156.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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