Inspection on 02/02/07 for Pinta

This inspection was carried out on 2nd February 2007.

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

The inspector found 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

Pinta 19/02/08

Pinta 15/02/06

Pinta 24/11/05

Pinta 14/03/05

Pinta 02/08/04

Similar services:

Kestrel House, St Anne`s Opportunity Centre,

The Farmhouse

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Pinta 548 Reading Road Winnersh Berkshire RG41 5HA Lead Inspector Mike Murphy Unannounced Inspection 2nd February 2007 11:00 Pinta DS0000011362.V328757.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 Pinta DS0000011362.V328757.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. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinta Address 548 Reading Road Winnersh Berkshire RG41 5HA 0118 978 3246 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) Atlas Project Team Limited Mr Grahame Lawrence Dillon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Pinta offers twenty-four hour residential care to three adult service users, of both sexes, who have learning and associated behavioural difficulties. The building is owned by a housing association and the care is provided by The Atlas Project Team Ltd. The house is a single storied building with all the accommodation on the ground floor. It is situated a few miles from the towns of Wokingham and Reading and there are shopping and leisure facilities within walking distance of the home. The home has its’ own vehicle and there is easy access to public transport, both trains and buses. Fees at the time of this inspection were £1788.69 per week. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector in February 2007. The inspection methodology consisted of discussion with managers (the home manager, two area managers, and the manager with a lead responsibility for quality) and a care worker, interaction with service users, a walk around the building and grounds, and examination of service user and staff files and other documents. The service is located in a detached bungalow, set in its own grounds in the residential area of Winnersh, a short distance from local shops, leisure and public transport facilities. The home provides safe and pleasant accommodation for three service users. Staff are available to provide support 24 hours a day. The organisation has a highly structured approach to care which is reflected in its assessment and care planning processes. The three service users who have lived together in the home for over ten years seem well supported by this. The two service users resident on the day of this inspection appeared very comfortable in the home. Service users are supported in accessing a range of facilities in the community. On the day of this inspection one service user had gone by train to London with a member of staff to celebrate his birthday, another had gone shopping with a member of staff, while the third had undertaken some exercise in the morning. In 2006 service users, either with their family or with staff, had holidays in Devon, Lanzarotte, Portugal and Cyprus. The staff work in a supportive role alongside service users, and communication boards, utilising words, pictures and symbols have been devised according to individual preferences, to facilitate communication. Liaison with local health and social care services is satisfactory. The organisation’s procedures for staff recruitment, induction, training and supervision are generally satisfactory. Its policies and procedures with regard to health and safety, complaints and the protection of vulnerable adults (POVA) are satisfactory, although some adjustment to those relating to POVA are recommended in this report. Overall, this service is providing a good level of support to its service users. Service users benefit from the provision of a safe and comfortable environment, support in accessing local amenities, participation in outings with staff, and holidays with staff and their families. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Amend the Protection of Vulnerable Adults policy to ensure that the relevant statutory authority is notified of an event at the outset of the organisation’s own investigation and include external organisation (such as CSCI) in its Whistle Blowing policy. Ensure that the records of staff working in the home include all of the information required under Schedule 2. Each of the above will strengthen the home’s existing procedures for the protection of vulnerable adults. Pinta DS0000011362.V328757.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. Pinta DS0000011362.V328757.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 Pinta DS0000011362.V328757.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): It is over ten years since an admission was made to this home so it was not possible to assess conformance to this key standard on this inspection. EVIDENCE: The three service users in this home have lived there since 1993. There were no vacancies. While the organisation has systems in place for conducting assessment of the needs of prospective users of its services, it was not possible to assess these on this inspection. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. A comprehensive care plan is in place for each resident. Care plans are well structured and include risk assessments and evidence of service user involvement. The home’s approach to care planning aim to ensure that residents’ needs are met and their independence is supported. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a care plan in place for each of the three service users. Care plans are highly structured and contain a number of checklists, assessment tools and forms for recording activity. Care plans include a photograph of the resident, communications passport, biographical information, risk assessments, and guidelines for various aspects of care (such as personal hygiene, meal times, and behaviours). Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 11 The sections on risk assessment and management include notes on the positive and negative aspects of risk i.e. the benefits and risks for the service user of participating in an activity. A checklist acts as a summary of the areas which are to be assessed and which may or may not require action. Headings include; ’Health’, ‘Communication’, ‘Social Contact’, ‘Family Contact’, ‘Accommodation’, ‘Assessment’, ‘Self-Help Programmes’, ‘Counselling’, ‘Work/Occupation’, ‘Leisure Activities’, ‘Finance’, and ‘Outside Contact’. Detailed records are maintained of service users participation in a range of activities. These include domestic activities in the house such as laying the table, clearing up, doing laundry and shopping. Participating in everyday activities in the community such as going to a pub or restaurant, walking, going to an arts activity such as a cinema or to an art gallery. Pursuing social or recreational activities such as contact with family, going out with others, participating in sports, working in the garden or listening to music or reading a book. The participation of service users is recorded and over the course of seven days a picture is built up of the service users participation in activities. This information is aggregated over time and the summary information informs care plan reviews. In addition to the notes recorded on the form, notes are also made in a diary for each resident. These simply record the activity which the service user is involved in the period preceding the entry. Such notes are made at roughly 45 to 60 minutes intervals. Service users are encouraged to participate in the process. Each service user has a communications board on which significant information is recorded in a form agreed with the user. Service users plans are reviewed monthly and summary reports are typed up. All service users have an annual multi-agency review and service users are supported in preparing for this. It was reported that one service user recently wrote up her own care plan summary in preparation for such a meeting. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Service users lead a varied lifestyle according to their individual interests, abilities and wishes. This aims to ensure that service users experience a range of social and leisure activities and form part of the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager reported that there are few appropriate educational opportunities for service users in the area. One service user used to go to college daily but the course did not develop and it is reported the service user did not feel that he was gaining any benefit from the repetitive nature of the course. One of the three service users currently goes to an arts course in Guilford once a week. The service is located in a residential area. Service users use local shops, pubs and cinemas. Each service user has at least one day out a week. On the day of this inspection one service user had gone to London for the day to celebrate his birthday with a member of staff. Earlier in the day another service user and Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 13 member of staff had gone shopping together while the third had done some cycling. Service users are members of a health spa in Bracknell and may have a Jacuzzi once a week. Some participate in trampolining once a week. Many go rambling with staff in the local countryside on a regular basis. The home has a television (new large screen LCD and clearly popular with service users on the day of this inspection), DVD, music centres, magazines and games for service user use. All are registered to vote. Service users usually have two holidays a year. In 2006 one had been to Portugal, Cyprus and on a Mediterranean cruise. Two had been on a holiday in Devon with their family and one of the two had also had a holiday in Lanzarotte. The manager reports that service users have developed friendships with others and occasionally invite friends over for tea in the home. The organisation has a draft policy (dated October 2006) to guide staff in the event of service users developing a personal relationship. Daily routines are flexible. Service users interests and participation in activities both inside and outside of the home are recorded in their ‘Keeping Tracks’ sheets. Participation in domestic activities is an important part of life in the home but is not compulsory. Service users privacy and autonomy is respected. Meals are jointly chosen by staff and service users. Breakfast is mainly cereals, porridge and hot beverages. Lunch is the main meal of the day. Dinner is a lighter meal. On the day of inspection a smoked fish pie was being prepared for lunch. A power cut led to this being deferred to dinner and to staff and a service user making cheese and salad sandwiches (using wholemeal bread). The manager said that all red meat used in the home is organic. A full fruit bowl was available for service users to help themselves as desired. Other choices for lunch on the week of this inspection included Spaghetti Bolognaise (Mon), Chicken with noodles, garlic and spinach (Wed), and Roast Pork and trimmings (Sun). Dinner dishes included Lentil Curry (Mon), Omelette and Salad (Thu) and Mixed bean salad (Sat). Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Staff provide guidance and support to service users as required. Arrangements for liaising with healthcare services in the community and for the control and administration of medicines appear satisfactory. This ensures that service users receive appropriate support in meeting their healthcare needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff provide support to service users as required. This is set out in some detail in individual care plans. Each service user has a key worker who is responsible for co-ordinating care. Service users preferences are respected. The service users in this home have lived there together for a 13 years and have established their own routines. Communication aids which include words, pictures and symbols have been developed according to service users needs and preferences. All three service users are registered with a GP. All have a six monthly dental check up which includes a session with a dental hygienist (at no additional Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 15 charge to the service user). Aromatherapy is offered to service users twice a week. Service users are weighed weekly. Service users have used opticians and podiatrists in Wokingham. All service users have a care manager (a social worker) who has responsibility for the wider aspects of their care in the community. The main contact with the Community Learning Disability Team (CLDT) is at care plan reviews. All have an annual review which is attended by the service user, staff from the home, members of the service users family, representatives of the CLDT, and the care manager. Medicines are prescribed by the service user’s GP and are dispensed by Boots Chemists. The home uses the Boots monitored dosage system (MDS). The organisation’s medicines policy was revised in 2003. All staff are required to attend in-house training before administering medicines - ‘Drug Assessment for House Supervisors’. This is detailed and competence is assessed over four observations. Some staff have attended the Boots one day training course on the use of the Boots system. Manager have attended a ‘safe handling of medicines’ course which consists of 12 or so modules and is externally accredited. The consent of service users to accept medicines is not recorded in the care plan. It is noted that service user consent is also not included in the organisations ‘Drug Assessment for House Supervisors’. Managers are of the view that this is a matter for the prescriber. Standard 20.2 refers to obtaining and recording service users consent to medicines. Such consent may of course be withdrawn at any time. The arrangements for the storage of medicines in this small home were examined and appear satisfactory. The home’s arrangements are not periodically audited by a pharmacist but correspondence from Berkshire West NHS PCT to one of the senior managers appeared to indicate that this service might be available to such homes in future. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. The home has a policy and procedure for recording and investigating complaints. It has a framework of policy and staff training with regard to the protection of vulnerable adults. Together, these aim to protect residents from abuse and to ensure that incidents are properly investigated. However, the threshold for reporting an event to statutory authorities appears high and could potentially disadvantage service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure which conforms to the standard. The contacts details for CSCI need to be updated following the recent closure of the Berkshire office and its incorporation into the ‘Northern Hub’ CSCI office which is located in Oxford. No complaints about this service have been received by the organisation or CSCI since the last inspection. No service user was in contact with an advocacy service and details of local advocacy services are not available in the home. The manager said that a resident’s family member has acted as a strong advocate for all three residents on occasions. However, the subject of ‘Advocacy and Befriending’ is included in the staff induction programme. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 17 The home is subject to the organisation’s policy on the protection of vulnerable adults (POVA). Managers said that new staff are informed of this on induction. However, the copy of the ‘Induction Training Package’ supplied to this inspection did not have this as a subject heading in the table which outlined the programme for ‘the first week’, ‘the first month’ and ‘during the first three months’. In the table for the first week there is an ‘item’ entitled ‘Policies you should know about immediately’ but since the policies are not mentioned it is difficult to know if these include POVA. The first month includes an ‘item’ on ‘How to report untoward incidents’ but again does not specify whether the reporting of suspected abuse is included under that heading. According to the training record (to December 2006) which managers supplied for the inspection, of nine staff working in the home, one had attended POVA training in 2003, three in 2004, three in 2006, and two have yet to attend training. The organisation’s policy was briefly perused in the presence of managers. The managers are confident that the policy is in line with local multi-agency procedures. A copy of the multi-agency procedure is available in the home. One important aspect of the organisation’s own procedure which is not clear is the point at which the lead local statutory authority is notified of a suspected incident. Managers are of the view that they need to establish the facts internally first and then report to the relevant authority. This could lead to a delay in initiating a multi-agency approach and managers would be advised to review the threshold for such reporting. This should be carried out with the relevant lead officer in statutory organisations. The organisation has a policy on whistle blowing but it is noted that the policy refers entirely to internal reporting channels and does not mention external bodies such as CSCI or local social services. Staff are trained within the first month of employment in ‘Responding to angry or upset clients’ and ‘Containing physical aggression’, and within the first three months in a ‘Therapeutic approach to Challenging Behaviour’. Some staff have also received training in ‘Strategies in Crisis Intervention and Prevention’ (SCIP). Established arrangements are in place for dealing with service users monies. Each service user has a bank account with Lloyds TSB. Facilities are in place for safe keeping of cash and other valuable. Internal accounting procedures are in place. The arrangements are subject to audit and are periodically checked by managers conducting Regulation 26 visits to the home. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The home is well located for the amenities of the local area and it provides a safe, comfortable and pleasant environment for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a pleasant detached bungalow set in its own grounds in a residential area. It is located within walking distance of Winnerish Triangle station (Reading to London Waterloo line), it is on bus routes between Reading and Wokingham, and there is parking for around four cars in the forecourt. There is a good sized garden to the rear with a patio area, lawn, shrubs and mature trees. There is a car port (with a grafitti wall for service user’s use as desired) and a large shed to the side of the house. Entry to the home is controlled by staff. All of the accommodation is on one level. The entrance hall leads to the lounge and dining room. There is a well Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 19 equipped kitchen, a small laundry room and staff office. There are three bedrooms. One bedroom was viewed with the service user. The room was of a good size and well furnished. It was decorated in accordance with the service user’s wishes. Windows were secure. This room is the only bedroom with en-suite facilities (shower and WC). A communications board which has been created with the service user was on the wall. The service user seemed happy with the room. The lounge was comfortable, well furnished and carpeted throughout. It had been decorated since the last inspection. Over the last year or so the home had acquired a large LCD television. The kitchen has been refurbished since the last inspection. It is a domestic kitchen which has fitted cupboards, cooker, refrigerator and dishwasher (from which one control button was missing). The laundry area had a washing machine which is suitable for present use. The dining room is adjacent to the kitchen and is suitably furnished for current use. The dining room has a pleasant outlook on to the garden. All areas of the home were clean and tidy. The three service users currently resident did not require any special aids to mobility. There is one bathroom with grip handles and a hair wash attachment. There is one WC. As mentioned above one bedroom has en-suite (shower and WC) facilities. Overall, the home had a pleasant ambience and seemed very suitable for the needs of current service users. The two service users present at the time of the inspection seemed quite happy living there. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. Staffing levels are satisfactory and the organisation provides training and staff development across a range of subjects. This aims to ensure that there are sufficient numbers of appropriately trained and supervised staff to meet residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The qualities and skills of staff are developed through the organisation’s policies for staff recruitment, training and development. According to information supplied by the regional manager 50 of staff had acquired NVQ2 or above – most NVQ3. Other staff were currently pursuing NVQ3 and one the LDAF (Learning Disability Award Framework). The present staffing provides for two staff in the morning, two staff in the afternoons and one waking staff member at night. The day staffing numbers are occasionally supplemented by one extra staff member. A manager is on call at all times. Staff meetings are meant to take place monthly. The most recent meeting was held in January 2007. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 21 Staff recruitment is organised from the company’s regional office in Bramshill, Hampshire. Applicants are required to complete an application form, health questionnaire, provide two referees, a CRB certificate and POVA first if appointed ahead of the CRB disclosure. Candidates are interviewed by home managers and senior managers. Interview records are made. New staff are offered the option of signing an exemption from the European Working Time Directive. Two files were examined and were generally in order with the exception of one which did not have either a POVA First or CRB certificate. Information that these have been obtained was received by telephone from the organisation’s human resources office in Devon. Such evidence must be on file for future inspections. Neither of the two files examined had a recent photograph of the staff member. All staff undertake a comprehensive ‘Induction Training Package’. This outlines the training to be undertaken over the course of the first year in post – by the first week, the first month, the first quarter, the first half year, and the first year. For nurses the document includes reference to bodies which no longer exist – these having been incorporated into the Nursing and Midwifery Council (NMC) in 2002. The programme is usefully summarised in a table which for the first three months categorises the subject matter under five headings. The programme of training undertaken by staff up to December 2006 included First Aid, Fire Safety, Food Hygiene, POVA, Makaton, NVQ 3, SCIP, Basic Communications, and Communication and Autism. Personal supervision is in place and all staff have one to one supervision every two months. Sessions are planned, recorded and include responsibility and timescales for action. Appraisal is in place and staff are appraised at three months, six months and annually thereafter. The process includes selfassessment. A relatively new member of staff expressed satisfaction with the home and the job. The person confirmed that induction had taken place and that there had been a review at the end of the first week and first month. Managers were described as supportive and the person enjoyed the variety of activities which could be pursued with service users. The quality of care to service users was described as good. One to one supervision was in place. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This is a well managed home which, combined with its structured approach to care planning, appears to be providing good care outcomes for service users. Arrangements for health and safety appear thorough and aim to ensure the safety of service users staff and visitors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home manager has worked with the organisation for over four years. He has worked in the home at various times over that period and on the occasion of this inspection had been there for around ten months. The registered manager, who was on leave at the time of this inspection, is also responsible for another home and divides his time between the two Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 23 homes. Both the home manager and the registered manager are experienced, qualified and have acquired the Registered Manager’s Award (RMA). The structure for quality assurance was discussed with those managers present throughout this inspection, the home manager, the area manager and the manager with lead responsibility for quality assurance. The specific outcomes were not considered in detail. One senior manager is responsible for quality assurance in the organisation’s homes in Berkshire and Surrey. Quality audits were carried out in the home in May, June and August 2006 and January 2007. Well structured Regulation 26 reports are regularly completed by area managers and above. There is a “rolling maintenance programme” for the home. The kitchen was refurbished in 2006. The home has plans to develop the garden with a paving area, additional decking and a larger summerhouse in 2007. Managers said that service users have been involved in drawing up plans for this. Arrangements for health & safety appear satisfactory. The organisation has a Health and Safety policy. The staff training programme provides details of staff attendance on training events on fire safety, first aid, health and safety, food safety and POVA. The first month of the induction programme includes Health and Safety at Work, Emergency Procedures, Lifting and Back Care and Basic First Aid. The Housing Association, Housing Solutions, who own the building run a one day course in health and safety. The regional manager reported on a number of health and safety matters in the pre-inspection questionnaire. These included the date of the last visit by the fire authority, checks on fire safety equipment by contractors, date of most recent fire drill (Dec 2006), in-house fire safety checks, and fire training (DVD based). The regional manager reported the date of the most recent visit by the health and safety department (February 2006), by the environmental health officer (October 2005), CORGI gas engineers, portable appliance testing, fixed electrical wiring test, check on emergency lighting, and a water temperature check for Legionella (February 2006). All areas of the building, with the exception of a control button missing from the dishwasher, appeared in good condition. A couple of items in the fridge had been opened and not labelled and staff need to ensure that such items are clearly labelled and consumed within a safe period of time. Systems are in place for recording accidents. Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 2 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 3 34 3 35 3 36 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation Sch. 2 Requirement The registered manager must ensure that the records of staff working in the home include the information required under Schedule 2 Timescale for action 28/02/07 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 Refer to Standard YA23 Good Practice Recommendations It is recommended that the policy on the protection of vulnerable adults be amended to ensure that the relevant statutory authority is notified of an event at the outset of the organisation’s own investigation. It is recommended that the policy on whistle blowing be amended to include contact details of relevant external organisations (including CSCI) to whom staff can report their concerns. It is recommended that the ‘Induction Training Package’ be amended to include an introduction to the subject of the protection of vulnerable adults (POVA) in advance of further training on POVA. 2 YA23 3 YA35 Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Pinta DS0000011362.V328757.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!