Inspection on 11/10/06 for Pinehaven

This inspection was carried out on 11th October 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinehaven 07/07/08

Pinehaven 31/07/07

Pinehaven 27/02/06

Pinehaven 07/09/05

Pinehaven 08/03/05

Pinehaven 20/12/04

Pinehaven 17/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Pinehaven 23 Parkwood Road Boscombe Bournemouth Dorset BH5 2BS Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 11 and 18th October 2006 15:00 th DS0000003946.V310984.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 DS0000003946.V310984.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. DS0000003946.V310984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinehaven Address 23 Parkwood Road Boscombe Bournemouth Dorset BH5 2BS 01202 427941 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) The Stable Family Home Trust Mr Michael Nigel Pickford Care Home 9 Category(ies) of Learning disability (9) registration, with number of places DS0000003946.V310984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service user to be accommodated in the second floor room must not be dependent on staff for means of their escape in the event of a fire. 27th February 2006 Date of last inspection Brief Description of the Service: The registered service provider is The Stable Family Home Trust [S.F.H.T] a registered charity that provides residential care, a day service and related services for adults with learning disabilities. The day and residential services are interdependent with support from specialist staff at the day service being available to the staff and service users in residential care services to provide training, guidance and help with among other things, issues such as employment; risk assessments and personal relationships. Pinehaven is a detached house converted for use as a residential care home, located in the residential area of Southbourne, fairly close to the cliff top and beach. It is within walking distance of the shopping areas and local amenities of Southbourne and Boscombe. There is good access to public transport including the railway station at Pokesdown. The accommodation provides for 9 adults and all service users have single bedrooms, which are located on the ground, first and second floor. Communal facilities include a lounge, dining room, kitchen, activity room and conservatory area. Outside there is a garden at the rear of the property and a tarmac area to the front that provides off road parking. Current fees provided on 13/11/06 are £474.60 per week; however, this does not include day care provision, which is charged separately. Fees do not include personal items such as toiletries, hairdressing, cigarettes and sweets. For further information on fee levels and fair terms of contracts you are advised to refer to the Office of Fair Trading website www.oft.gov.uk. The home keeps copies of all inspection reports that are available in the office and can be seen by service users, relatives and professionals at their request. DS0000003946.V310984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place over 2 days (11/10/06 and 18/10/06) and lasted approximately 6 ½ hours. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. This inspection was a key inspection and therefore, assessed all identified key national minimum standards for care homes for adults (18-65). The inspector initially spent time with the manager of the home and examined various records and documentation including care plans, risk assessments, staffing records and health and safety records. The inspector conducted a tour of the premises viewing all communal areas of the home and a sample of 2 service users’ bedrooms. The inspector had the opportunity to speak with seven residents both individually and in a group. They spoke positively about their experiences of living in the home including their rooms, their weekly activities, the staff and the food. The inspector also spoke with two members of staff who said they enjoyed working in the home. Additional information received by the inspector prior to the inspection was also taken into account. This included monthly monitoring visit reports from the responsible individual of the home, previous inspection reports and any incident reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. Feedback surveys were also received prior to the inspection from 9 service users and 3 relatives. Analysis of these showed feedback from service users and relatives to be very positive and included comments such as “I am very happy”, “we have been more than pleased with the care provided by the staff at Pinehaven” and “X has a very happy life and is given every opportunity to do the things he wants”. What the service does well: Pinehaven benefits from a creative and encouraging management style, which gives residents opportunities to develop and progress their aspirations. The home achieves excellent outcomes for the service users living there and there are good examples of how residents have been able to move on and accomplished new skills promoting their independence. The home works in a person centred way giving service users real choices and helping them take control of their lives. The home takes a proactive role in risk assessments using them to help service users gain new skills rather than placing unnecessary restrictions on them. All service users have opportunities to undertake educational and social activities and there are excellent links to the local community with residents DS0000003946.V310984.R01.S.doc Version 5.2 Page 6 making good use of local shops and amenities. The home makes visitors feel welcome and offers service users excellent support with their personal relationships enabling them to develop healthy social lives and maintain strong family ties. Service users are also given opportunities to make a real contribution to the home and an example of this included one service user who had taken control of the home menus, drawing up a weekly list based on other residents likes and dislikes. They were then able to help with the weekly shop purchasing the home’s requirements. The home has a committed and enthusiastic staff team who work hard to improve the service users quality of life. A good rapport was observed between the care staff and service users and it is clear that they have an excellent knowledge of service users care needs. The home has an open and inclusive atmosphere and service users are encouraged to voice their opinions. It was evident in discussion with service users that they are confident in expressing their views and feel they are listened to. What has improved since the last inspection? What they could do better: DS0000003946.V310984.R01.S.doc Version 5.2 Page 7 As a result of this inspection two requirements and two recommendations have been made. The registered person needs to ensure that prior to agreeing any placement they obtain a copy of an assessment of the service users needs by a suitably qualified professional. The home is not currently meeting the target of 50 of care workers achieving NVQ Level 2 or above, however, progress is being made towards establishing a workforce that achieves nationally recognised care qualifications. The manager still needs to complete the Registered Managers Award and NVQ 4 in care. The inspector recommended that a record of all service users’ healthcare appointments be kept to show these are undertaken on a regular basis. It was also recommended that the times of fire drills be recorded to ensure these were taking place at various times of day. There are still some outstanding policies and procedures that are needed. However, it is appreciated that these are being prioritised and produced as quickly as possible. 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. DS0000003946.V310984.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 DS0000003946.V310984.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 at least once during a 12 month period. 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. The home has a clear admission procedure and thorough assessments are made of prospective service users’ needs to ensure they will be suitably placed in the home, however, the home must ensure they have the required documentation from placing professionals prior to accepting a new service user into the home. EVIDENCE: The home has a clear admission policy and procedure. There had been one new resident admitted to the home since the previous inspection. Records showed the manager had carried out a thorough assessment of the service user’s needs prior to admission, which had included information provided by relatives. Discussion with the manager confirmed the service user had been given opportunities to visit the home prior to admission including visits with parents and meal visits. The service user had also been given choices about the way their bedroom was decorated and the furniture they wanted. Observation during the inspection indicated the service user had settled in well in the home. The inspector could find no evidence on the service user’s file of an assessment or plan carried out by a care manager, although the manager confirmed that DS0000003946.V310984.R01.S.doc Version 5.2 Page 10 he had been liaising with the care manager prior to the placement. The registered person needs to ensure that prior to agreeing any placement they obtain a copy of an assessment of the service users needs by a suitably qualified professional. DS0000003946.V310984.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home uses person centred planning, which enables service users to be fully involved in identifying their future goals and aspirations. Improvements to care plans have ensured staff have clearer guidance about the needs of residents and the support they require. Service users feel confident about making decisions and have good opportunities to make choices in their daily lives. The home effectively implements risk management strategies to promote service users taking responsible risks thus enabling them to increase their independence by giving them opportunities to learn new skills. DS0000003946.V310984.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of 2 residents’ files was case tracked as part of the inspection. The home has adopted a person centred approach to care planning and there was clear evidence of service user participation in the process as one service user had filled in their own plan. The plan contained information about the service users likes and dislikes and their goals and aspirations. In response to a recommendation made at the last inspection an additional plan had been drawn up to give staff clearer guidance about service users basic care needs including their personal and emotional care. The manager told the inspector that the SFHT was in the process of up-dating all the care plans to establish a consistent approach throughout the organisation. These plans are designed to address service users support needs more effectively ensuring staff are aware of service users’ support needs and the assistance they require. Service users had signed written evidence that any potential limitations had been discussed with them and appropriate agreements had been reached. Examples of these included management of money and boundaries concerning behavioural issues. Observation throughout the evening evidenced many good examples of how service users are supported to make their own decisions. Service users were confident about expressing their choices and said they were supported to make decisions about personal relationships, future goals, personal appearances and the style and contents of their bedrooms. All service users have individual bank accounts and their finances are managed according to individual care plans e.g. some service users manage independently whilst others need support from staff. Further evidence of how service users were supported to make decisions included some service users having the opportunity to have their own food budget so they could purchase and prepare their own evening meals. The home has a risk management framework in place and the inspector examined a number of risk assessments that relate to individual service users. There was evidence that a number of risks had been considered such as domestic activities, accessing the community, managing finances and medication. There was evidence that this process was regularly reviewed increasing service users opportunities to learn new skills. Discussion with service users confirmed that the home effectively uses risk management strategies to promote service users independent living skills and they gave examples of these opportunities such as staying home alone, accessing the community independently, travelling on public transport and managing their own medication. DS0000003946.V310984.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Provision of daytime activities and links with the local community are good, which supports and enriches service users’ social, leisure and educational opportunities. The home makes visitors feel welcome and offers service users excellent support with their personal relationships enabling them to develop healthy social lives and maintain strong family ties. Routines in the home offer choice and flexibility promoting service user’s individuality and independence. The home offers choice and flexibility over meal times with service users fully participating in all aspects of menu planning and meal preparation. DS0000003946.V310984.R01.S.doc Version 5.2 Page 14 EVIDENCE: All service users take part in activities outside the home. Most service users attend the day service managed by the S.F.H.T., which provides a range of activities such as art & craft, pottery, woodwork, personal relationships, current affairs and horticulture as well as providing opportunities for work placements. The home is able to provide staffing during the day now so service users can choose to stay home and undertake activities such as home skills, budget skills, walking/gentle exercises and attending activities in the community such as music courses. Service users told the inspector they were happy with the activities provided. There was evidence that service users were able to access the community on a regular basis. The home is a short level walk from the local shopping centre and has good access to public transport routes. Service users talked about going out to the local shops and other local amenities and it was clear they visited these on a regular basis. The home welcomes visitors and family and friends can stay overnight if appropriate. Residents confirmed they could have visitors and described a range of social contacts such as going to stay with relatives, family and friends visiting them and staying for meals, overnight visits. One service user’s boyfriend visited her during the inspection and told the inspector he regularly visited the home. Service users can access the house phone to make personal calls to family and friends and residents were observed using the phone during the inspection. The organisation has a policy on Personal Relationships and service users are given support and advice on this subject. Discussion with service users demonstrated they had a good understanding of their rights in relationships and felt fully supported by staff. Observation throughout the evening showed service users were able to use the communal areas of the home freely or enjoy some privacy in their bedrooms. Staff were observed interacting closely with service users. In discussion with service users they all confirmed that their privacy is respected and that that staff knock on their doors before entering and allow them private time. Service users are able to lock their doors if they wish to and where appropriate have a key to the front door of the home. Service users are encouraged to keep the house clean and tidy and take responsibility for household chores. A rota is displayed on the notice board specifying individual’s agreed responsibilities and service users confirmed they all helped with keeping the house clean. The majority of service users have their main meal provided at the day service from Monday to Friday. A record of meals provided was kept at the home. Some service users have their own food budget and purchase and prepare DS0000003946.V310984.R01.S.doc Version 5.2 Page 15 their own evening meals. Other service users are supported by staff to prepare their own evening meal. One service user has the specific role to plan the weekly menus and consults the other residents to get their choices. Residents are also involved in the weekly shopping for the home. DS0000003946.V310984.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to have control over their personal support and their independence is promoted. Residents health care needs were being met, although details of all appointments must be recorded to show when these take place. The systems for managing medication are satisfactory and staff are familiar with the procedures for administration ensuring service users medication needs are met. EVIDENCE: The majority of service users at Pinehaven can manage their personal care independently with staff providing advice and prompting when necessary. Discussion with service users confirmed their personal care needs were met and they were comfortable asking for assistance from staff who treated them with respect. There was evidence that home was responsive to changing needs. For example one service user was currently in hospital and it was clear DS0000003946.V310984.R01.S.doc Version 5.2 Page 17 their care plan was being revised to provide the additional supported needed on their return to the home. The inspector noted improvements have been made to the way personal care needs are documented in service users care plans to give clearer guidance to staff about service users’ support needs. Discussion with staff demonstrated they had a good understanding of service users’ individual needs and their likes and preferences. Service users health care needs were noted in their personal health records (yellow books) that were seen by the inspector. These contained information about service users physical and emotional health, as well as details of their current medication. Visits to healthcare professionals were recorded such as dentists, opticians and hearing tests, although some of these seemed to be overdue. The manager felt sure that appointments had taken place but had not been recorded. It is recommended that a record of all appointments be kept to show these are undertaken on a regular basis. There was evidence of liaison with other professionals such as the community nurse who had written comments in the service users healthcare record. The home had also liaised with healthcare professionals for advice when setting up plans to manage behaviour. The home has a written policy and procedure concerned with the management and administration of medication. No service users are currently selfmedicating and details were available to staff of all current medication service users are taking. The member of staff on duty gives out medication once they have been signed off as competent to administer medication, any new staff are supervised. Staff then sign to say they have witnessed the service user taking the medication and records were checked and found to be up-to-date and accurate. Members of staff confirmed they had undertaken training in the management of medication and were fully aware of the procedures for administration in the home. DS0000003946.V310984.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an ethos of openness throughout the organisation and service users were confident about how to raise complaints feeling their views would be listened to and acted upon. There is clear guidance and training in place for staff concerning the protection of vulnerable adults ensuring service users welfare is safeguarded in the home. EVIDENCE: The home has a detailed complaints procedure that meets good practice recommendations and regulations. Service users have easy access to complaints forms that have been designed in a user-friendly format. Service users confirmed they were fully aware of the procedure and how to use it. They were confident that any issues/problems raised would be resolved. The complaints log was checked during the inspection that showed no complaints had been made. The home has a number of policies concerning with the protection of vulnerable adults and these were made available to the inspector. These included Adult Protection and Dealing with Abuse, Whistleblowing, Management of Violence, Personal Relationships and Sexuality, Bullying in the Workplace, Acceptance of Gifts and Financial Procedures. Discussion with the manager confirmed his awareness of adult protection procedures and staff also receive training in adult protection and dealing with challenging behaviours. Evidence from previous inspections demonstrates adult protection investigations have been dealt with appropriately by the home. DS0000003946.V310984.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 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 satisfactorily maintained and provides residents with a comfortable and homely environment. The home is kept clean and hygienic with systems in place to ensure service users are protected from spread of infection. EVIDENCE: A tour of the premises was undertaken as part of the inspection and all communal areas of the home were viewed and a sample of 2 residents’ bedrooms. The communal areas consist of a lounge, dining room, kitchen, quiet room and conservatory area. These were generally well maintained and decorated in a homely way that was suitable for its stated purpose, i.e. providing care and support to adults with learning disabilities. Service users bedrooms were observed to be personalised to each individuals taste with plenty of space for personal possessions. DS0000003946.V310984.R01.S.doc Version 5.2 Page 20 On the evening of the inspection the home was observed to be lit, warm, clean and tidy. The home has a policy for infection control that contained guidance to staff about cleaning, spillages and clinical waste. There was further information and procedures for communicable diseases. The home has a separate laundry room that is sited away from areas where food is stored, prepared, cooked or eaten and is appropriate for the resident’s needs. DS0000003946.V310984.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is making progress towards establishing a workforce that achieves nationally recognised care qualifications and service users have confidence in the skills and experience of the care workers. Staff records are now available in the home meaning it is able to demonstrate robust recruitment procedures have been followed for vetting and recruiting staff ensuring the protection of service users living in the home. The standard of training provided is good and linked to the individual and joint needs of service users. EVIDENCE: The home currently employs 7 members of staff, two of whom have been employed since the previous inspection. None of the staff team currently hold level 2 NVQ qualifications or above, however, three members of staff are currently undertaking a NVQ or equivalent qualification. This means the home does not currently meet the target of 50 of staff holding a NVQ 2 qualification or above, however, there is evidence that the home is working towards achieving this target. DS0000003946.V310984.R01.S.doc Version 5.2 Page 22 Analysis of the rota showed that one member of staff was provided from 7.00 – 9.00 am and two members of staff from 5.00 – 10.00 pm (Mondays to Fridays) and two members of staff throughout the day at weekends. The rota is now organised to provide staffing support during the day in the home so service users have greater choice about daytime activities The inspector had the opportunity to speak to two members of staff who demonstrated a good knowledge and understanding of the residents’ individual and collective needs. Observation of practice showed there was a high level of interaction between staff and service users and it was clear positive relationships had been formed. Service users told the inspector they liked the staff and felt they were approachable. A recruitment policy is now in place setting out clear guidance about the procedure to be followed. Staffing records are kept at the SFHT Head Office and copies are now available for inspection in the home. A sample of 3 staffing records was viewed as part of the inspection. Examination of records showed that all the required documentation is in place. The inspector suggested that it would be useful to have a checklist to ensure all the documentation was in place and also note employee details and other useful information such as the date they commenced employment. All staff receive terms and conditions and an employee handbook is also available, which contains amongst other things information on the SFHT’s grievance and disciplinary procedures. Staff are employed subject to a six month probationary period and a form completed to record the outcome of this was observed during the inspection. Service users are included on the interview panels for staff recruitment and are given training in how to carry out interviews. The home has an annual training plan identifying training needs for the whole staff team. Examination of staff files showed they had attended a number of training courses including first aid, health and safety, food hygiene, fire training, prevention of abuse, medication, manual handling and infection control. It was noted that as well as the required courses ensuring safe working practices the home promotes additional courses that reflect the home’s aims and service users needs such as Makaton, personal relationships, risk assessment and challenging behaviour. SFHT has now introduced a new in-house induction package which links to the Skills for Care guidance and LDAF. DS0000003946.V310984.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s manager is experienced and is competently meeting the home’s stated purpose, aims and objectives. The home encourages feedback about the quality of service from the residents and staff and this is included in an annual plan setting out aims and objectives for future service development. Practices in the home promote and safeguard the health, safety and welfare of the residents. DS0000003946.V310984.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager of the home is Michael Pickford. He is experienced in working with adults with learning disabilities and had begun working towards the Registered Managers Award; however, the organisation that was responsible for assessing the work had gone into receivership and therefore, he has had to re-enrol and is currently working towards the Registered Managers award and NVQ 4 in care. There was further evidence that he was up-dating his training and he had recently completed a course in “Train the Trainer in Infection Control”. Staff spoken with during the inspection felt well supported by the manager both with formal supervision and informally. The leadership style also encourages service users to develop their skills and creates opportunities for service users to work towards more independent living and future moves are being planned and supported. The manager has set up a quality assurance system to monitor certain aspects of care provided and questionnaires had been given to all residents and relatives. A plan has been produced based on the views of the service users, staff and other interested parties to review the quality of the service and set out future aims and objectives. The responsible individual undertakes regular monitoring visits and monthly reports are sent to the Commission detailing the outcome of these (Regulation 26). Progress has been made towards updating all the written policies and procedures for all the topics set out in Appendix 2 to the National Minimum Standards (2nd Edition). The Director of the organisation is producing these so a corporate identity can be achieved in all SFHT homes. The inspector examined records that showed that the home was meeting the requirements of other agencies such as Dorset Fire and Rescue Service and Environmental Health Department. Certificates were in place demonstrating that equipment and facilities were regularly serviced and maintained. Records of fridge, freezer and food temperatures were kept as well as water temperatures. A fire risk assessment was in place and staff carry out weekly visual checks on equipment. A record of fire drills and fire training records are kept. It was recommended that the times of fire drills be recorded to ensure these were taking place at various times of day. The home had clear policies and procedures relating to health and safety practices. The manager confirmed his awareness of relevant legislation and certificates were in place showing staff had attended various training courses in safe working practices. DS0000003946.V310984.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 4 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 2 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 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 2 X 2 X DS0000003946.V310984.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 14 Requirement The registered provider needs to ensure that prior to agreeing any placement they obtain a copy of an assessment of the service users needs by a suitably qualified professional. The registered provider needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. The registered manager needs to complete NVQ 4 in management and care. (This requirement is repeated from the previous inspection.) Timescale for action 01/12/06 2. YA32 18 01/05/07 3. YA37 9 01/04/07 DS0000003946.V310984.R01.S.doc Version 5.2 Page 27 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 YA42 YA40 Good Practice Recommendations It is recommended that a record of all healthcare appointments be kept to show these are undertaken on a regular basis. It was recommended that the times of fire drills be recorded to ensure these were taking place at various times of day. It is recommended that the registered provider should produce written policies and procedures for all the topics set out in Appendix 2 to the National Minimum Standards (2nd Edition). This recommendation is carried forward from 2003. DS0000003946.V310984.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000003946.V310984.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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