Inspection on 05/06/07 for PIA 132 Manor Court Road

This inspection was carried out on 5th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

PIA 132 Manor Court Road 08/06/06

PIA 132 Manor Court Road 18/11/05

PIA 132 Manor Court Road 09/06/05

PIA 132 Manor Court Road 18/10/04

PIA 132 Manor Court Road 27/05/04

PIA 132 Manor Court Road 03/03/04

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 PIA 132 Manor Court Road 132 Manor Court Road Nuneaton Warwickshire CV11 5HQ Lead Inspector Kevin Ward Key Unannounced Inspection 5th June 2007 07:45a PIA 132 Manor Court Road DS0000004227.V341951.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 PIA 132 Manor Court Road DS0000004227.V341951.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. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service PIA 132 Manor Court Road Address 132 Manor Court Road Nuneaton Warwickshire CV11 5HQ 02476 383986 02476 640146 jmorrissey@people-in-action.co.uk 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) People in Action Care Home 8 Category(ies) of Learning disability (8) registration, with number of places PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2006 Brief Description of the Service: 132/134 Manor Court Road is a registered care home for eight people with learning disabilities and has been separated into two separately staffed homes that occupy the top and ground floors of two semi-detached houses. Effectively these are two group living homes. People in Action provide 24 hr personal care and support. 132 Manor Court Road is situated on the ground floor of the house and can accommodate four people with physical and learning disabilities. Each service user has their own bedroom with shared facilities of a kitchen, bathroom with W. C., separate WC and large lounge/dining room. There is a separate laundry area. 134 Manor Court Road can accommodate four people with learning disabilities and is situated on the first-floor level of the house. Each service user has their own bedroom with shared facilities of a kitchen/dining area, laundry, and bathroom with WC and lounge. There is a shared garden to the rear of the house. The property is situated close to Nuneaton town centre. Rail and public transport links are nearby. There is limited off-road parking. Individual placement fees (at 7/6/07) range between 715.62 and 775.44 per week. The people that live at the home are required to pay for personal items, such as hairdressing, toiletries, holidays, recreation, clothing and transport. PIA 132 Manor Court Road DS0000004227.V341951.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 unannounced inspection which addresses all essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for residents’. The inspection focused on assessing the main key Standards. As part of the inspection process the inspector reviewed information about the home that is held on file by us, such as notifications of accidents, allegations and incidents. The inspection included meeting with the people who live at the home. Most of the people living at the home have high communication needs and had not met the inspector before so it was not possible to gain their views on many aspects of the service. The inspection also included case tracking the needs of three people that live at the home. This involves looking at people’s care plan and health records and checking how the person’s needs are met in practice. Discussions took place with four staff on duty at the home as well as a team leader and the new manager who transferred to the home 2 months ago. A number of records, such as care plans, complaints records, staff training certificates and fire safety records were also sampled for information as part of this inspection. What the service does well: Care plans are in place for the people at the home containing information about people’s needs and preferred routines so that staff are able to support them effectively. The care plans are currently being revised into a new format, which includes pictures to help make them more interesting for people. Risk assessments and protocols are in place to help staff to support people to go about their daily lives in a safe manner. People are encouraged to take part in everyday living tasks at the home, such as preparing food and shopping. One person was seen to make his lunch with support from a member of staff at the home. There have been no complaints made to us since the last inspection and none have been made directly to the home. Staff are provided with training to recognise and report any suspicions of abuse so that people are protected from harm. Overall the home is clean and comfortable and suitably equipped to meet the needs of the people that live there. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 6 The home has satisfactory procedures in place for vetting staff before they start work at the home so that people are supported by suitably staff. Staff are provided with a good range of training to meet people’s needs and to support safe practices at the home, such as epilepsy, diabetes, communication, abuse and equality and diversity training. Staff are supported to attend National Vocational Qualification courses so that they are properly trained and equipped to carry out their work roles effectively. Procedures and risk assessments are in place for maintaining a safe living and working environment. Fire alarms and lights are tested and a contract is in place for maintaining the fire safety equipment in safe working order. What has improved since the last inspection? What they could do better: The manager agreed to arrange for the diabetes nurse specialist to sign the protocols that have been written up for a person with diabetes, to demonstrate that she is in agreement with them. One person with dysphagia (swallowing difficulties) needs more information in his care plan so that staff are clear about the level of support he needs when eating to reduce any risk of choking. The dining tables are looking old and worn and plans should be made to replace them with nicer furniture for people. The new manager has transferred to the home from another service run by People in Action and is currently in the process of being registered by us. The manager has agreed to set up a system for checking that areas of responsibility delegated to staff are carried out properly. The manager also said that she has plans to send out questionnaires to relatives and professionals that visit the home so that they can contribute to the development of the service. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 7 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. PIA 132 Manor Court Road DS0000004227.V341951.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 PIA 132 Manor Court Road DS0000004227.V341951.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the assessment procedures could compromise people settling in to the home and having their needs met properly. EVIDENCE: Since the last inspection one person has moved into the home from another service run by People in Action that was closing. The manager said that process had been rather hurried and that a written assessment had not been completed beforehand. Discussions with staff and the manager confirmed that the person concerned had opportunities to visit the home on several occasions before moving in to meet the other people at the home and to see her room and also slept overnight on one occasion. Comments by two staff confirmed that they had been given access to the person’s care plan which had transferred from the previous home and that there had been a handover of information from staff at the person’s last home. A copy of the person’s comprehensive care plan was seen at the home. The manager said that Social Services had been involved in agreeing the move but had not carried out an assessment or review of the person’s needs as part of the admission process. This is necessary for social workers to satisfy themselves that the person has been placed appropriately at the home. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 10 Admission assessments were seen on the records of people previously admitted to the home indicating that their needs had been assessed beforehand. People’s files were seen to contain accessible information telling them about the service they can expect from the home and how to raise any concerns. PIA 132 Manor Court Road DS0000004227.V341951.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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are being planned for and reviewed so that they can be supported and cared for in a safe and appropriate manner. EVIDENCE: Three people’s care plans and records were examined to see how their needs are met by the home. Overall the care plans contain good levels of information to provide staff with a picture of people and how their needs should be met. The care plans contain written summaries of people’s routines throughout the day so that staff are clear about the order and manner in which they like their needs to be met. Similarly people’s likes and dislikes are recorded. This is particularly important for people with high communication needs so that their choices and preferences are known and respected by staff. Currently the information in people’s records is spread out in various places making it difficult to find. The manager explained that the care plans and records are being reviewed to address this matter. Copies of 2 new care plans were seen. Good work is taking place to illustrate the care plans to make them PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 12 more accessible and easier to read. A team leader also explained that there are plans to carry out life story work in the coming months with some people so that they know more information about their personal histories. Risk assessments were seen covering a good range of hazards associated with individuals needs, the home environment and everyday living activities, e.g. personal care, moving and handling road safety and use of the hot tub, kitchen safety and money handling. The manager said that she would be reviewing the risk assessments very shortly. Well written protocols are in place for staff to carry out regular daily blood tests for a person with diabetes. Comments by staff and entries in the person’s notes demonstrate that a diabetes nurse specialist has been involved. The manager agreed to arrange for the nurse to sign the protocols as evidence that she has agreed them. One person’s care plan was seen to contain guidance for staff to follow when providing support with eating. The manager agreed to add more information to this document so that staff are clearer regarding how much support and supervision should be given to this person at meal times taking account of health professionals advice and any potential risks of choking. People are being encouraged to make choices and decisions in a number of ways. Comments by staff confirmed that people were recently involved in choosing the colours of the décor and new carpets in the hallway and stairs. The new manager has just re- started meetings at the home so that people are involved in making choices about everyday issues, such as activities and menus. Comments by staff and entries in people’s records confirm that they are supported to go shopping to choose clothing, personal items and some grocery shopping. PIA 132 Manor Court Road DS0000004227.V341951.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, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with an acceptable range of day activities and outings so that they are provided with a satisfactory social life. People’s dietary needs are reviewed with the involvement of the dietician and so that they may be provided with a healthy diet. EVIDENCE: 6 people attend day services, including college courses, on a part-time basis during the week and two people stay at home with staff support. On the day of the site visit one person was supported to go on a trip to the zoo, which she said she had enjoyed. One person said that she likes gardening, which is part of her day service programme. Another person has been supported to join a flower arranging course at a local college and has been presented with an attractive flower arrangement for her efforts, which was on show in the home. Examples of outings and activities provided by the manager and staff, include, regular shopping trips for personal items and groceries, cafes, Coombe Abbey, parks, pub and club and bowling in addition to occasional shows at the civic PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 14 hall. One person had recently been to see the new spider man movie with staff. The manager has just introduced a new recording system for recording people’s care needs and activities. The recording system is more focused and should make it easier to find information, such as frequency of activities. Good work took place last year to install a spacious new spa pool at the home for service users to enjoy. A track hoist has been fitted to enable a person with physical disabilities to take advantage of this facility safely. Discussions with staff indicate that relatives are encouraged to visit the home and confirmed that they can visit on a flexible basis. This was verified by entries in the visitor’s book. People’s relatives are also invited to attend Birthdays and Christmas celebrations. People are also supported to maintain contact with some of their friends at occasional parties and events that are run by People In Action. The home’s menus indicate that efforts are being taken to provide people with suitably balanced diet. People’s likes and dislikes are recorded in their files. Fruit is available for people to help themselves and snack foods were also seen. The team leader explained that an increased emphasis is being placed on the purchase of low fat snack foods for people to eat between meals, such as snacker jacks, low fat yoghurts and fruit to encourage people to maintain a healthy diet and weight. Information contained in people’s files confirmed that the home makes use of advice and support from the community dietician to monitor the dietary needs of people at the home. Comments by staff indicate that measures are being taken to provide low sugar alternatives for a person with diabetes. The manager said that she has plans to develop a separate menu for this person to more accurately demonstrate how his dietary needs are being planned for and met by the home. Discussions with a team leader and entries in people’s records confirm that some people go shopping for groceries. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal care and health needs are planned for and monitored with the involvement of health professionals so that they the receive the appropriate care and support they require. EVIDENCE: Peoples care plans provide good levels of information about their preferred routines and patterns of daily living. This enables staff to be more sensitive to service users’ needs and to support them in the way they prefer. People’s care plans indicate that they have age appropriate bedtimes and this was confirmed in comments by staff at the home. People are allowed to sleep in later in the mornings if they wish to do so when they not going to day services. Staff were seen to relate to people in a friendly and respectful manner. Two staff spoken to confirmed that they had received makaton training to help them to communicate with a person at the home and demonstrated a satisfactory understanding of specific signs and gestures used by the person concerned to communicate their needs to people. People were observed to be dressed in an age appropriate manner indicating they are supported to maintain a good self image. Comments by staff and entries in people’s records confirm that people are supported to make use of PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 16 the community hairdressers to have the hair cut and are not dependent on visiting hairdressers, indicating that people are encouraged to maintain a presence in the local community where possible. A sample examination of people’s health records indicates that the home is supporting them to gain access to advice and support from relevant health professionals, such as psychiatrist, psychologist, dietician and diabetes nurse. The manager also said that a number of people have recently had dysphagia assessments to check for swallowing difficulties. People’s records contain satisfactory accounts of the outcomes of health appointments and indicate that people are supported to access well person checks, medication reviews and GP support, where required. Staff spoke in an informed manner about people’s health needs and demonstrated a good knowledge of protocols for the administration of epilepsy and insulin. Staff confirmed that they have received epilepsy and diabetes training. The new manager said that she would arrange for the diabetes nurse to sign a list of staff she provided with diabetes training to make it clear who has been trained. Comments by staff indicated that are aware of when they should trigger the support of paramedics and managers in the event that a person with diabetes goes into a coma. The person’s records show that the home has increased the frequency of blood sugar checks recently to guard against this event. The health records of a person with epilepsy indicate that action is being taken to monitor this condition with support from health professionals, which has led to a recent reduction in recorded seizures and falls. People’s medication records were sampled. The records include a record of the number of tablets recorded into the home so that staff can keep track of people’s individual medication. Similarly a stock sheet was seen that is used to record and account for any medication received into the home. Comments by two staff on duty demonstrated a good understanding of safe medication procedures. Staff confirmed that they had been provided with medication training and said that they are observed and assessed on three occasions before they are allowed to give out medication. This was verified in staff training records. The manager said that she is developing a more detailed competency assessment to check that staff have understood the medication procedures. Protocols are in place for people who receive “as required” medications in order that staff know when and how these medications are to be given properly so that they are not administered inappropriately. At the end of each shift the allocated shift leader completes a shift handover sheet that involves them re-checking the medication records to identify any errors so that they can be picked up and addressed promptly and effectively. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place for respond to people’s concerns and complaints and staff are being trained to recognise and respond to suspicions of abuse so that people are protected form harm. EVIDENCE: No complaints have been made to us since the last inspection and the new manager confirmed that no complaints have been made to the home since the last inspection. This was verified by an examination of the home’s complaints log. The log is being routinely monitored and signed by the senior manager as part of her monitoring visits to the home. Since the last inspection good work has been undertaken to arrange an advocate for a person at the home to help represent her views, following concerns about tensions with another person in the home. The Chief Executive Officer for People in Action confirmed that an incident involving an assault by one service user on another was followed up under the adult protection procedure. The manager explained that social workers appropriately identified alternative accommodation for one person with behaviour challenges to safeguard the welfare of people at the home. Three staff said that they had received prevention of adult abuse training and the information contained in staff training records confirmed that this training has been provided to the majority of staff. Comments by two staff demonstrated a good appreciation of different types of abuse that can occur and a satisfactory understanding of the procedures for reporting any concerns. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 18 Three staff spoken to confirmed that they had seen the abuse and whistleblowing procedures that are available in the home and the new manager said that she intended to re-visit a number of key polices and procedures at staff meetings (including abuse procedures) to remind staff of this information. Training records demonstrate that some staff have recently been provided with challenging behaviour training so that they are equipped to respond sensitively to any challenges that may be presented by people on rare occasions. People’s care plans contain a helpful summary of the measures that are in place for managing their personal finances. Two people’s expenditure records were sampled and found to balance correctly. Receipts are being retained to account for people’s cash and everyone’s money is checked at the end of each shift to ensure it balances correctly. This is recorded and signed as correct on a shift handover sheet. Periodic audits are carried out by the finance officer and a record of the findings are kept at the home. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being satisfactorily maintained and upgraded so that people benefit form clean and comfortable accommodation. EVIDENCE: Since the last inspection good work has taken place to re-decorate the hallways and stairs to improve the home for people. At the time of this site visit carpets were being laid throughout to complete the improvements to these areas. There are two lounges in the home. Both rooms are nicely furnished and decorated with comfortable seating for everyone. The two dining tables in the home are old and in poor condition where the varnish has worn away. People’s bedrooms have been made comfortable and contain equipment, pictures and other personal belongings that confirm they have been supported to personalise these areas in keeping with their preferences. The downstairs bathroom has hoisting equipment fitted to enable people with physical PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 20 disabilities to use the bath safely. The home has a spacious spa bath with hoisting equipment for people to use and relax in. The home has a good sized garden at the rear with a patio set, including a parasol which people were seen to sit under on the day of the service visit. A downstairs shower room is fitted with a track hoist to enable staff to provide support a wheelchair user to shower safely. The home looked clean and tidy. A cleaning schedule has devised to support cleaning the home. The home has a modern washing machine with a sluice facility and programmes capable of dealing with the small mount of continence laundry at the home. Policies are in place for managing infection control issues and aprons and gloves are situated around the home for staff to use. Staff training records indicate that staff are provided with infection control training to support safe hygiene practices in the home. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and appropriately vetted to ensure they are properly equipped for their roles and safe to work at the home. EVIDENCE: Comments by staff confirmed that the home typically has 4 staff on duty. This is often in addition to the manager / group leader. This was verified by a sample examination of recent staff rotas. The manager explained that five staff have left the home in the last year including the manager who has transferred to another home. Four new staff have started during the same period of time. Hence approximately 75 of the staff team have remained constant during this period to support consistency of a care at the home. The home employs 5 male staff and 16 females. The manager explained that the home seeks to provide gender sensitive care wherever possible. People’s preferences in this regard are recorded on their care plans. Staff training records confirm that staff are provided with Learning Disability Award Framework induction training which leads on to National Vocational Qualification training. Comments by staff and the manager confirmed that staff PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 22 are provided with regular planned supervision to support them in their work. This was also verified in a sample examination of two staff files. Two staff files were examined to assess the home’s recruitment procedures. Each file contained a completed application form and evidence to demonstrate that people are interviewed and provided with proper contracts of employment. Both files contained evidence to confirm that suitable checks are carried out to ensure that people are suitable to work at the home, including Criminal Record Bureau checks and two references. Comments by four staff on duty indicate that they are provided with a satisfactory range of training opportunities. This was further verified in comments by the manager and by viewing training records and a sample of certificates. Staff are being provided with access to Health and Safety related training courses, such as food hygiene, moving and handling, first aid and adult abuse. Challenging behaviour training has also been provided earlier this year so that staff are equipped to respond with sensitivity to such challenges where they occur. Staff also attend a good range of care courses to equip them to meet the needs of the people at the home, examples include equality and diversity, epilepsy and the administration of diazepam, diabetes and insulin, makaton and communication training. People in Action employ a training officer who retains a record of staff training needs and trigger reminders for staff to attend refresher courses where necessary. PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is managed satisfactorily and staff are provided with good support and supervision to carry out their work effectively. There is scope for increasing managers monitoring checks in the home to ensure that delegated duties are carried out effectively. EVIDENCE: The organisation has recently had a management reorganisation and managers have changed the homes for which they hold responsibility. The organisation is currently in the process of applying to us to register their managers for their respective services. The new manager holds the Registered Managers Award and the National Vocational Qualification level 4 in Care. These qualifications are necessary to equip care home managers to carry out their role effectively. The new manager explained that she has just delegated various areas of responsibility to staff at the home, such as responsibility for checking that the PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 24 care plans, spa pool and protective clothing, cars, daily diary records. However there is currently no formal means of checking to ensure that these duties are carried out properly. The manager agreed to ensure that further checks are conducted by herself and the group leaders, to ensure that the delegated responsibilities are carried out properly. This is necessary so that any shortfalls can be identified and addressed promptly by the manager. As previously mentioned shift handover records involve staff checking the medication and money records each day. Monitoring visits are being carried out by the line manager for the home and the reports are being retained at the home. The manager was able to confirm the actions she was taking to address the matters highlighted in the most recent report. The manager has devised a monthly report for summarising the achievements of the home and has taken action to re-start meetings with people as a means by which they may contribute to plans and make choices. The previous manager had surveyed the views of relatives and visitors to the home during the last year and the new manager said that she would be carrying out a similar exercise shortly so that people are able to pass comment and contribute to the development of the home. Supervision notes indicate that the manager is carrying out planned supervision and supporting staff in their roles. Team meetings are taking place with staff at the home to support communication between staff and an opportunity to consider policy issues. A sample examination of the fire safety log indicates that the alarms and lights are being periodically tested to ensure they are operating effectively and a suitable contract is in place for the maintenance of fire safety equipment. Records were seen confirming that hoisting equipment is being routinely maintained to ensure it is safe to use. Certificates were seen that demonstrate that gas and electrical equipment is being checked and tested to ensure the appliances are safe to use. Hot water is being routinely tested so that it remains at a safe temperature and records indicate that shower heads are regularly flushed to prevent any risk of legionella developing at the home. PIA 132 Manor Court Road DS0000004227.V341951.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 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x PIA 132 Manor Court Road DS0000004227.V341951.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 YA2 Regulation 14 (2) Requirement Refer the new person at the home for social work review so that they can confirm that the placement is suitable and meeting their assessed needs. Timescale for action 21/07/07 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. Refer to Standard YA19 YA24 YA39 Good Practice Recommendations Arrange for the diabetes nurse to sign the protocols to confirm that she agrees with them. Make plans to upgrade the dining room tables that are old and worn so that people benefit from nicer furniture. Proceed with plans to set up a system for checking that areas of responsibility delegated to staff are carried out properly so that the service is effectively monitored by the manager. Proceed with plans to survey the views of service user, relatives and professionals involved at the home so that their views may contribute to the development of the service. 4 YA39 PIA 132 Manor Court Road DS0000004227.V341951.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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