CARE HOME ADULTS 18-65
Phoenix House 318 Station Road Holt Trowbridge Wiltshire BA14 6RD Lead Inspector
Malcolm Kippax Unannounced Inspection 16th October 2007 11:10 Phoenix House DS0000028243.V351392.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 Phoenix House DS0000028243.V351392.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. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Phoenix House Address 318 Station Road Holt Trowbridge Wiltshire BA14 6RD 01225 783127 F/P01225 783127 phoenixhouse@tiscali.co.uk londonroad@tiscali.co.uk Milbury Care Services Ltd 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) Mr Leslie Malcolm Johnson Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1), Physical disability (9), of places Physical disability over 65 years of age (1) Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Only the named male service user referred to in the application date 27 October 2004 maybe aged 65 years and over. 7th April 2006 Date of last inspection Brief Description of the Service: Phoenix House is situated in a quiet location in the village of Holt, which is near to the towns of Trowbridge and Melksham. The property is a purpose built bungalow and was designed to meet the needs of people with a physical disability. There is a garden at the rear and a parking area at the front of the home. People have their own bedrooms with en-suite facilities. The communal rooms consist of a dining room and a lounge. There is also a sensory room. One area of the kitchen has been adapted so that a person in a wheelchair can use it. A permanent staff team provides 24 hour support to the service users. Relief staff are also used on occasions. At night there are two staff members on waking duty. The home’s registered manager, Mr L. Johnson was on a six-month secondment at the time of this inspection. Mrs D. Sawyer, the deputy manager, was in the role of acting manager in Mr Johnson’s absence. Information about fee levels can be obtained from the home. Inspection reports can be seen in the home and are also available through the Commission’s website at: www.csci.org.uk Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home on 16th October 2007 between 11.10 am and 4.30 pm. A second visit was arranged with the home’s acting manager, Mrs Sawyer, in order to complete the inspection and to give feedback about the outcome. This took place on 7th November 2007 at 9.45 am. Evidence was obtained during the visits through: • • • • Time spent with the service users and with two relatives who were visiting the home. Meetings with Mrs Sawyer and with two members of staff. Observation and a tour of the home. An examination of records, including three of the service users’ personal files. Other information has been taken into account as part of this inspection: • An Annual Quality Assurance Assessment (referred to as the AQAA) that was completed by the acting manager. The AQAA is the provider’s own assessment of how well they are performing. It also provides information about what has happened in the home during the last 12 months. Surveys that were completed by four relatives, seven staff, a GP and another healthcare professional. Notifications and reports that the Commission has received about the home since the last key inspection. • • The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visits. What the service does well:
The home receives good information about a person’s needs before they move in. There is good communication with other agencies, which helps to ensure that a new service users move goes smoothly and that their needs are met. Further information is recorded after a person moves into the home. This includes an individual plan, so that staff members know what support each person needs and how this should be provided. Other guidance has been produced for staff, which helps to ensure that service users are safe in what they do and are supported in the ways that they like. Good plans are made for people to be involved in activities that they enjoy and which provide them with different experiences. A member of staff is responsible for organising activities. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 6 There is a varied menu and people receive the individual support that they need with their meals. People’s contact with their relatives and friends is well supported, which helps them to have fulfilling lives. Staff members discuss people’s care and welfare on a regular daily basis. This helps to ensure that any concerns about their health and wellbeing are identified and followed up. People receive the support that they need with their personal care needs and with their medication. The home works well with the community nursing service to ensure that people’s health needs are met. The health professionals who completed surveys commented very positively about the home and the care that people receive. People in the home are dependent on others to raise any concerns on their behalf. There are procedures in place so that their relatives and staff know what to do if they have concerns. People live in a comfortable and well maintained home environment, which meets their needs. Staff members receive guidance and training, which helps to ensure that they are competent and that service users are safe and well looked after. The home’s recruitment practices help to ensure that people are not being supported by unsuitable staff. The registered manager was on a six month secondment from the home at the time of this inspection. The deputy manager was managing Phoenix House for this period of time. This has provided good continuity and the service users are benefiting from a well run home. What has improved since the last inspection?
The home has purchased a menu planning book for use with the service users. This contains photos, which help people with limited verbal communication to identify their preferred choice of meals. New forms have been produced for recording people’s assessments and care plans. These are to be completed over time and are intended to present the information in a more ‘person centred’ way. It was reported in the home’s AQAA that one of the improvements made in the last 12 months has been the appointment by Milbury Care of a regional training and development manager. The resources for providing ‘in-house’ training have improved, which will help to ensure that staff receive the training that they need, particularly in respect of health and safety. The home has responded to some recommendations that were made about record keeping at the last inspection.
Phoenix House DS0000028243.V351392.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. Phoenix House DS0000028243.V351392.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 Phoenix House DS0000028243.V351392.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 and 2 Quality in this outcome area is adequate overall and it is poor in respect of the information that is available to people. People have their needs assessed before moving into the home. However, they are not given accurate and up to date information about some important matters. This judgement has been made using available evidence including the visits to this service. EVIDENCE: One person had moved into Phoenix House since the last inspection. Mrs Sawyer said that this person had visited the home before the move and had stayed overnight. A pre-admission assessment had been undertaken. Other information had been received from various sources before the move. This included assessment records from another care service and from the person’s placing authority. These records had been transferred to the individual’s file at Phoenix House. There was also information about specific areas of need, for example a ‘Summary of Health Needs’ assessment. The placement had been reviewed after the move. It was recorded at the review meeting that the move had gone smoothly. A physiotherapist and
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 10 occupational therapist had visited Phoenix House after the move in order to give advice. Service user’s guides had been produced. These were in a pictorial form, to make them easier to understand for people in the home. Other written information was also available, although there were no details of the arrangements in place for charging and paying for additional services. Mrs Sawyer said that this was going to be addressed. During the visits to the home it was found that service users were expected to pay for certain services and items from their own personal money. There was a Statement of Purpose’s that included information about the home’s staffing arrangements. This included the statement that, ‘The service will have six staff on duty during waking hours in addition to the full time manager, who is off rota’. However, the home was not being staffed to this consistent level. The rotas showed that the actual number of support staff on duty during the day was between three and five. Phoenix House DS0000028243.V351392.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 and 9 Quality in this outcome area is good overall. People’s needs are reflected in their individual plans. People generally benefit from the guidance that staff receive, which helps to ensure that their wishes are known and they are safe in the things they do. This judgement has been made using available evidence including the visits to this service. EVIDENCE: Information about people’s needs was contained in their personal files. The files included a range of individual plans and forms that described people’s preferences and their daily support needs. People’s files contained ‘Individual Support Requirements’ forms. These included the sections, ‘How I want staff to support me’ and ‘How I don’t want staff to support me’. This information gave a personal account of people’s needs and wishes. For example, it included guidance for staff about how people liked to get up in morning. Comments were recorded, such as ‘don’t
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 12 rush me’, ‘talk to me about what you’re doing’ and ‘don’t come in and turn on the light straight away’. Some documentation, such as ‘Communication Passports’ and ‘People Handling assessment forms’ were providing staff with guidance about specific areas of need. Dates had been added to show when the information had been reviewed. The new service user’s ‘Communication Passport’ had not yet been completed, although some relevant information had been recorded in other places. The personal files included a range of other information about individual needs that had been added to over time. Mrs Sawyer said that a new system of record keeping was to be introduced in the next few months, which would consist of a set of forms that were more closely linked. In their surveys, three relatives confirmed that the home always met people’s different needs. One relative felt that this was usually happened. People’s files contained records of risk assessments that had been undertaken. These mostly concerned tasks relating to personal care and the safety of people when physical care was being provided. The guidance generally showed that the service users required support from staff in many areas of daily living and personal care. This included support with making decisions and with making their views known. There was discussion with Mrs Sawyer about how people were supported with managing their money. Service users were paying for some items from their personal money, such as their own meals when they went out with staff for day activities. One service user had recently bought a new toilet seat from their own money, although it was not clear why this had not been paid for out of the fees. Accounts were being kept of the money spent. Staff members confirmed that they got receipts when shopping with the service users. There were no written guidelines about how service users were supported with managing their money and making decisions about how it is spent. The service users’ main personal files were kept in the home’s office. They also had individual diaries, which were kept in the hall. It was agreed with Mrs Sawyer that for reasons of confidentiality it would be appropriate to keep these diaries in a less public place. Phoenix House DS0000028243.V351392.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good overall. People are generally well supported with participating in activities that they enjoy. However the arrangements have not always ensured that support is available at the appropriate time. People are well supported with their family relationships. They are offered a varied range of meals. This judgement has been made using available evidence including the visits to this service. EVIDENCE: People’s occupation during the week included a mix of regular, planned events and other activities that were arranged on the day. Some people attended a resource centre for one or two days a week. For a large part of the week, people were supported by the home’s staff with doing different things, either on the premises or out in the community.
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 14 This was evident during the first visit to the home. Two people had gone into a nearby town and had lunch out. They had bought things for a birthday party. Other people were doing things in the home, such as playing table tennis, using the sensory room and receiving visitors. A photo album was being kept which showed the different outings and entertainments that people had participated in. This had been thoughtfully put together. The album was looked at with one of the service users and it was a very good reminder for them of what they had done. Some people had been on their first holiday from the home earlier in the year. Information had been recorded which showed people’s preferred pastimes and suggestions for activities that they would enjoy and respond to positively. Records were kept of the activities undertaken, so that the frequency and range of activities could be monitored. In their survey, one of the staff commented that the home had a good activities co-ordinator who provided a wide range of activities for people. Some of people’s regular, home-based activities were of a therapeutic nature, which also helped to maintain good health and wellbeing. These included such things as hand massages, exercises and water play. Records showed that some people spent time in the kitchen and did baking. On the day before the first visit to the home it was noted that one person had not attended a resource centre, as had been planned. It was confirmed that this was because there had only been three staff members on at the time, which meant that support could not be provided with transport to the centre. Overall, staff were being deployed so that they could regularly support service users with attending activities outside the home. One person’s relatives were spoken with during the visit on 16th October. It was evident that visitors are welcomed into the home and can be met with in private. Relatives also confirmed this in their surveys. Information had been recorded about people’s likes and dislikes for particular foods. There were menu plans covering a four week period. Details of people’s individual meals were recorded in diaries. These showed a varied range of meals. Lunch was observed on a visit to the home. Some service users ate their meal independently and others received individual support from staff. A menu planning book had recently been bought for the home. This was well produced and contained photos, which meant that people with limited verbal communication could be helped to show their choice of meals. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good overall. People’s health needs are met. People receive the support that they need with their personal care needs and their medication. This judgement has been made using available evidence including the visits to this service. EVIDENCE: The main areas of personal care were described on the ‘Individual Support Requirements’ forms. The information was written from the service users’ perspectives and provided details of the personal support that people needed in different areas. Guidelines for staff had been produced in areas such as moving and handling, bathing and managing epilepsy. Mrs Sawyer said that people’s support requirements were reviewed every three months. There were forms for recording the reviews although in the examples seen this had not been done consistently. The staff spoken with confirmed that people’s support needs were regularly discussed. The staff members who completed surveys also confirmed that they were given up to date information
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 16 about the needs of the people they cared for. One staff member commented that the service users had well documented personal care plans. Other comments from staff indicated that people’s personal care needs were being met although the current staffing arrangements were affecting individual support for service users. One staff member commented ‘staff numbers seem to decrease which can put pressure on the remaining few’. Of the four relatives who completed surveys, two stated that they thought the home always gave the support or care that they expected and two stated that this was usually the case. Staff members provided personal care, except for toenail cutting, which the service users paid for privately from their own money. This arrangement was discussed with Mrs Sawyer and it was confirmed that it should be identified as an additional charge in the service user’s guide. The service users’ nursing needs were met by the District Nursing team, who visited the home on a regular basis. People’s individual records showed evidence of recent health issues and the involvement of different healthcare professionals, including physiotherapist. Information was being recorded on ‘GP/DN/Injury Notes’ forms, which showed how particular needs and health matters were being followed up. The use of these forms as short term care plans was discussed with Mrs Sawyer. The health professionals who completed surveys commented very positively about the home and the care that people receive. Comments were made that staff always contacted the District Nursing team if anything arose between their visits, and that the appropriate professionals were involved if a care plan was being questioned. No service users were able to manage their own medication. Staff members provided support with its administration and safekeeping. There were suitable storage and recording arrangements in place. One matter relating to the administration of a particular medication was discussed with Mrs Sawyer. It was agreed that the guidelines about this would be amended to include the advice that had been received from health professionals. Medication training was provided for staff. The Commission has been notified of two errors in the administration of medication since the last inspection. Neither of these was recent and Mrs Sawyer said that the staff members concerned had been reminded of the procedures to follow. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. People in the home are dependent on others to raise any concerns on their behalf. There are procedures in place that help with this. This judgement has been made using available evidence including the visits to the service. EVIDENCE: Milbury Care has produced a complaints procedure and provided some information in a pictorial version. The service users have limited communication skills and guidance has been produced for other parties in order that they know how to raise concerns. In their comment cards, three of the relatives confirmed that they were aware of the home’s complaints procedure. The home intends to develop policies in a wider range of formats. Since the last inspection the home has introduced new forms to record all concerns and compliments, in addition to recording complaints. In their survey, one relative commented ‘we have never found the need to complain about anything’. Another person reported ‘any concerns that I may have had I have been able to approach any member of staff, who will then keep me informed of the outcome’. There was guidance in the home about the prevention of abuse and the responsibilities of staff. Milbury Care has produced a policy on ‘Abuse and Whistle Blowing’.
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 18 Staff members confirmed that they received training in the protection of vulnerable adults. This was included in the home’s programme of mandatory training. Staff members were familiar with the ‘No Secrets’ booklet, which gives guidance about the reporting of suspected abuse. In their surveys, the staff members confirmed that they knew what to do if somebody had concerns about the home. Since the last inspection the home has received an ‘El-box’ (electronic learning box) which Milbury Care have produced as a training resource for staff in a number of topics. This will provide staff with additional training about abuse and safeguarding adults. There have been no adult protection referrals during the last year. The home has been involved in an adult protection investigation since the last inspection. This was discussed with Mrs Sawyer, who spoke about the learning experience that this had been for members of the staff team. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent overall. People live in a comfortable and well designed home environment, which meets their needs. This judgement has been made using available evidence including the visits to this service. EVIDENCE: Phoenix House is a purpose built care home, which provides accommodation for people with physical disabilities. Aids and facilities have been provided to meet people’s individual needs, following consultation with an occupational therapist or a physiotherapist. Each service user had their own room with an en-suite facility. There were colour schemes and decorations in the rooms that service users would find stimulating and provide them with different outlooks. In their survey, one person commented about their relative in the home: ‘they have a lovely room which is kept clean and tidy’.
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 20 Other rooms were available for communal use. The kitchen had been adapted so that one area could be used by a person in a wheelchair. During the visits, some service users enjoyed spending time in a sensory room. The lay out of the home meant that service users could move easily between the rooms and there was a good parking area outside the main entrance. There was a garden at the rear of the property. A feature of this was its division into a number of individual plots. These provided service users with their own individual gardens and seating areas. This looked like a very creative way of using the grounds. The home had two laundry areas with a separate room for storage. The accommodation looked clean and tidy. There was written guidance about infection control. Infection control was covered during the induction of new staff. It was included as a topic on the ‘El-box’, although not all staff had yet received this training. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good overall. People are supported by competent staff who undertake relevant training. Further developments in training will be beneficial. People are protected by the home’s recruitment practices. This judgement has been made using available evidence including the visits to this service. EVIDENCE: New staff members received a Learning Disability Award Framework (LDAF) accredited induction. This could then lead on to a National Vocational Qualification (NVQ) in care. Further NVQ training was being planned, which would increase the number of qualified staff. It was reported in the homes AQAA that one of the improvements made in the last 12 months had been the appointment by Milbury Care of a regional training and development manager. Mrs Sawyer had produced a staff training plan for the year ahead, based on an assessment of their needs. This primarily concerned the mandatory training that Milbury Care provided in a range of health and safety related topics.
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 22 As part of the developments in staff training, the home had received a lap top computer, known as an ‘El-box’ or electronic learning box. This contained software that would be used in the provision of training and for record keeping purposes. Mrs Sawyer said that most training would now be provided to staff using the ‘El-box’. An exception to this would be training in first aid and moving and handling, which involved attending courses outside the home. Some staff had been booked to go on a first aid course in December 2007. There was discussion with Mrs Sawyer about the opportunities for training in other topics that were not covered by the ‘El-box’. Mrs Sawyer said training was provided in health related matters, such as managing epilepsy. Staff members had individual training records and there was evidence of different courses having been attended relating to people’s care needs. Staff members were not attending courses in disability awareness and equal opportunities, although Mrs Sawyer said that some staff would have covered these topics during their LDAF induction. The main staff employment records were kept at a Milbury Care regional office, as had been agreed previously with the Commission. Checklists were kept in the home, as a record of the recruitment process that had been undertaken. This included obtaining a disclosure from the Criminal Records Bureau and carrying out a check of the protection of vulnerable adults (POVA) list before staff start working in the home. The checklists showed evidence of safe recruitment practice, although Mrs Sawyer needed to contact the Milbury Care office to seek clarfication about one matter because the wording on the checklist did not make this clear. All the staff who completed surveys confirmed that they thought that their recruitment was done fairly and thoroughly. Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good overall. People are benefiting from the involvement of the home’s deputy manager, who is managing Phoenix House on a temporary basis. This judgement has been made using available evidence including the visits to this service. EVIDENCE: The home’s registered manager, Mr L. Johnson was on a six-month secondment at the time of this inspection. Mrs D. Sawyer, the deputy manager, was in the role of acting manager in Mr Johnson’s absence. There was nobody in the role of deputy manager to replace Mrs Sawyer. During the visits, Mrs Sawyer was able to explain the different management and administrative systems in the home and spoke about the service users and staff in a respectful way.
Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 24 The people from outside the home who completed surveys commented positively about their experience of the home. One person commented that the leadership of the home provided a very positive and enthusiastic environment. Comments made by staff during the inspection and in their surveys indicated that they felt well supported by the home’s management and were able to discuss things. However, a number of staff were concerned about the current staff vacancies and the impact that these were having. Mrs Sawyer said that the home was actively trying to recruit more staff. An operations manager from Milbury Care visited the home regularly. The organisation had produced a system of quality assurance, which included gaining feedback from different stakeholders. A scoring system was used to show the service users’ level of satisfaction with the home. The system included the production of an Annual Service Review and Development Plan. A plan for 2006 – 2007 was seen in the home. Mrs Sawyer said that a new plan was currently being produced. In the AQAA, Mrs Sawyer has identified a number of improvements that were being planned for the next 12 months. The Annual Service Review and Development Plan showed that the service users’ satisfaction levels varied between 72.2 and 80.98 . The ‘home satisfaction level’ was 77.35 . The ‘Action to be taken’ part of the plan focussed on the need to recruit staff and to address their training requirements. Mrs Sawyer had provided information in the AQAA about the arrangements being made for health and safety. Some records were seen in the home. There was a health and safety file, which contained checklists for wheelchairs, vehicles, water temperatures and first aid boxes. The home’s fire risk assessment had been reviewed in August 2007. Other risk assessments were being undertaken. Examples seen included those for showering, cooking and the use of the sensory room. Health and safety was being discussed at staff meetings. Phoenix House DS0000028243.V351392.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 1 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 6 Requirement The statement of purpose must be reviewed, and where appropriate, revised so that it gives accurate and up to date information. The service user’s guide must include the arrangements in place for charging and paying for any services additional to those mentioned in sub-paragraphs (b) and (ba), Regulation 5(1). Timescale for action 31/01/08 2. YA1 5(1)(bc) 31/01/08 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 YA7 Good Practice Recommendations That written guidelines are produced about the times when service users are expected to contribute to the costs of goods or services from their own money. This is so that there is transparency in the arrangements being made and service users will be less at risk from financial abuse.
DS0000028243.V351392.R01.S.doc Version 5.2 Page 27 Phoenix House 2. YA12 That staffing levels are maintained at a level which will ensure that service users always receive the support that they need with attending their planned day activities. That there is discussion with the service users’ placing authorities about whether it is appropriate for service users to be paying for toenail cutting and for items such as a new lavatory seat out of their own money. That the home’s training plan is developed to include the full range of training that should be available to staff. This is so that the plan better reflects the needs of service users and for staff to develop their knowledge of equality and diversity. That the home’s Annual Development Plan includes more details of the action to be taken to improve the quality of life for service users. 3. YA18 4. YA35 5. YA39 Phoenix House DS0000028243.V351392.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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