Inspection on 12/08/08 for Plean Dene

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Plean Dene 27/09/07

Plean Dene 23/02/07

Plean Dene 27/10/05

Plean Dene 21/06/05

Plean Dene 19/10/04

Plean Dene 13/05/04

Plean Dene 24/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Plean Dene 2 Luccombe Road Shanklin Isle Of Wight PO37 6RQ Lead Inspector Janet Ktomi Unannounced Inspection 12 August 2008 11.00 th Plean Dene DS0000012523.V369276.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 Plean Dene DS0000012523.V369276.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. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Plean Dene Address 2 Luccombe Road Shanklin Isle Of Wight PO37 6RQ 01983 866015 01983 867563 christina.grimes@islecare.org 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) Islecare Ltd Manager post vacant Care Home 13 Category(ies) of Learning disability (0) registration, with number of places Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 13. Date of last inspection 27th September 2007 Brief Description of the Service: Plean Dene is a registered residential home providing care and accommodation for up to thirteen people with a learning disability. The home is a large detached two-storey property set in its own grounds with a car park to the front. The town of Shanklin with its shops and amenities is a few minutes walk away. A main bus service close to the home gives access to the towns of Ventnor and Shanklin. There is a good-sized garden and patio to the rear, which are available for use by the people who live at the home. Bedrooms are single accommodation with washing facilities and one has an en-suite bathroom. There are two bedrooms on the ground floor and the rest are on the first floor. There is a large sitting room and a dining room. The building is accessible and access to the first floor is via stairs or a stair lift. The home is owned by Islecare Ltd and at the time of this inspection did not have a registered manager. The current scale of charges is from £400 - £500 per week with additional charges for transport, toiletries, chiropody, hairdressing, outings and holidays. Some people living at the home are funded for additional 1-1 hours. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This report contains information gained prior to and during a visit to the home undertaken on the 12th August 2008. All core standards and some additional standards were assessed. Compliance with the one requirement made following the previous inspection was also assessed. The visit to the home was undertaken by one inspector and lasted approximately six hours commencing at 11am and being completed at 5 p.m. The inspector was able to spend time with the manager and staff on duty and was provided with free access to all communal areas of the home, documentation requested and people who live at the home. Information from the Annual Quality Assurance Assessment (AQAA) completed by the area manager is also considered. During the visit to the home the inspector was able to meet with and talk to many of the people who live at the home. What the service does well: The people who live at Plene Dene all appeared happy, relaxed and well cared for. Interactions between the people who live at Plene Dene with care staff and the manager were warm and positive with a consistent team of care staff having a good knowledge of everyone and their individual needs. The home provides a range of in-house and community activities. These provide leisure and social opportunities that people enjoy. Most people have either had or have planned a holiday for this year. People are provided with choice about most aspects of their lives. People commented that they liked the food at the home. The home has been awarded five stars (maximum) for food hygiene by the local environmental health department. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 6 Staff are provided with training opportunities and the new manager has identified where there may be additional training needs, or where mandatory training may have been missed and has booked staff to attend these courses. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home would only admit new people whose needs could be met at the home and who were compatible with people already living there. EVIDENCE: The home has not admitted any new people since before the previous inspection when the procedures undertaken and assessments in respect of the newest person had been viewed and found to be appropriate. The manager identified the procedure that she would undertake should she be in the position of admitting a new person. This would include a thorough assessment, information from professionals involved with the person, meeting the person and if the manager felt the home could meet the persons needs she would invite them to visit the home on a number of occasions. The opinions of the people already living at the home would be sought/assessed following the visits and a final decision would be based on their views. The manager was aware of the homes registration categories and the level of need the home could meet. The manager was also aware of the need to ensure peoples needs Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 9 can continue to be met as these change due to increasing age or health conditions. There have been no previous concerns about the statement of purpose, service users guide or contracts. Therefore these non-core standards were not assessed. Plean Dene DS0000012523.V369276.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, 8 and 9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are in control of their lives and their needs direct the service. Staff are committed to supporting people to lead purposeful and fulfilling lives as independently as possible. People who live at the home make their own decisions and have the right to take risks in their daily lives. EVIDENCE: Three care/support plans were viewed. Risk assessments and the ways in which risks should be managed were seen in care/support plans. The inspector spoke with staff and the people who live at the home about people’s plans and the person centred training they have undertaken since the previous inspection. The inspector also discussed how decisions are made and observed how people who live at the home are encouraged and supported to be active and independent. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 11 At the previous inspection the inspector was shown the new person centred care planning documentation that the provider had produced and the home would be implementing. Care plans viewed on this inspection were in the new person centred format and had been completed by the person’s key worker with support from the provider’s development team. Discussions with a person who lives at the home confirmed that they had been involved in the production of their support plan. Care staff confirmed that people who live at the home were involved as far as possible in the production of their individual plans. Care staff on duty at the time of the inspection visit confirmed that they had attended person centred care training. The care/support plans viewed were individual and person centred having been completed in the new format. Care plans had been reviewed every month. Care plans contained information about, and risk/management plans in respect of, health needs as well as social and independence skills training. The home uses a key worker system. Each care plan contained risk assessments relevant to the needs identified and incorporated into the person’s care plan. Management of risk positively addressed safety issues whilst aiming for improved outcomes for people using the service in terms of skills development and independence. The level of understanding and cognitive ability of the people who currently live at the home differs from person to person. Observation during the inspection visit and discussions with people living at the home confirmed that they are able to make decisions and that these are respected and acted upon by the home. People also stated that they choose what they spend their personal money on and showed the inspector items they had purchased. The support people receive in relation to their personal finances is recorded in care/support plans and varies between the people living at the home depending on the level of support required. The inspector viewed the arrangements in respect of personal finances and the procedures and records are appropriate and well maintained. Plean Dene DS0000012523.V369276.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): 11, 12, 13, 14, 15, 16 and 17. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to live the lifestyle they choose. EVIDENCE: A list of weekly planned activities was seen in the care plans viewed. Everybody living at the home has an individual weekly programme of activities that includes a range of day services and leisure activities, intended to help develop and maintain life skills and provides opportunities for socialisation away from the home. Discussions with care staff and some people who live at the home confirmed that they enjoy these activities and had been involved in the development of their individual activity plans. The inspector also observed people doing different things within the home. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 13 During the inspection visit people were noted to be able to spend their time as they wished. The location of the home is close to the town centre of Shanklin with easy access to local services. Care staff stated there are generally sufficient staff on duty to provide the necessary support to attend community events. Whilst viewing financial records the inspector saw evidence of money spent on outings. People are involved in assisting care staff with shopping in the local shops and use local health facilities. Staff rotas confirmed staffing numbers. Care plans contained records of activities both in the home and local community that people have undertaken. Three comment cards were received from people who live at the home who stated that they could do what they wanted at all times and that activities were provided. The home has external activities providers visiting for individual and group activities including music, aromatherapy, pottery and sound beam. Evidence of craft activities undertaken by people who live at the home were seen on display in the homes communal rooms as well as peoples bedrooms. During the inspection visit three people were engaged in making cakes and others were seen playing an indoor ball game (the weather not being suitable for people to enjoy the homes garden). The home has two house cars capable of transporting people living at the home. The arrangements for the funding of the house cars were discussed with the manager and people pay for fuel dependant on the amount used. Evidence of varying fuel payments were seen in records of individual peoples personal finances. The home is in the process of obtaining island bus passes for the people who live there. People living at the home have either been or are going on holiday this year. The inspector discussed holidays with the care staff who are/had supporting people and was shown the photo albums that have been completed for people who have recently been on holiday. People are supported to celebrate life events and are able to invite friends and family to visit them at the home. A person informed the inspector that her boyfriend had visited the previous weekend and a note on the notice board stated that a persons parents were visiting on the day of the inspection. The home has a cook who prepares the main meal with care staff preparing the evening meal. Information in care plans stated what support people require in respect of meals and food preparation. People take packed lunches to day services and can then have a cooked meal in the evening. Records showed that meals are varied and nutritious. People commented that they liked the food at the home. The home has been awarded five stars (maximum) for food hygiene by the local environmental health department. Plean Dene DS0000012523.V369276.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive personal care and support in the way they prefer and their health needs are met. Medication is appropriately managed in the home. EVIDENCE: Information about personal and health care needs and that provided was viewed in care/support plans and health action plans. Surveys received and discussions held with the people who live at the home and care staff is also considered. The arrangements for the storage and administration of medication were viewed with any related records. The home operates a key worker system. Male and female staff are employed. Times for getting up and going to bed are flexible, this being confirmed by people who live at the home and information in care plans. Interactions observed during the inspectors visit to their home indicated that people felt relaxed with care staff such that they would discuss any health concerns they may have or request support if they needed this. The home has a consistent staff team who have got to know the people who live at the home and stated Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 15 they would recognise if someone was not their usual self and may be unwell. There was discussion and records viewed in relation to people who had recently been admitted to hospital and had ongoing health needs. Everyone living at the home has a health action plan. These were viewed for the people who were case tracked. Care staff stated that support to complete health action plans had been received from members of the local community health team. Information about health needs and how these should be met were seen in care/support plans. People living at the home are registered with local GPs and support is provided from care staff to make and attend appointments. Care/support plans contained a record sheet that indicated that people are able to see chiropodists, Dentists, opticians and doctors when required. Care staff confirmed that they had been able to remain at the hospital to provide ongoing support to people who are admitted as inpatients. Care support plans contained detailed, individual information as to how people’s personal care plans should be met. Evidence of personal care is recorded on a monthly tick chart that is quick and easy for staff to complete. People stated that staff provide support when they need it. At the time of this unannounced inspection all medication was found to be stored correctly. The medication administration records were viewed and had been fully completed. Medication coming into the home is recorded on the Medication Administration records. Information about peoples prescribed medication is available and there are guidelines in place for the administration of ‘as required’ medication. The home uses a pre-dispensed system for tablets with liquid medication dispensed at the time of administration. None of the people living at the home self medicate, therefore all medication is administered by care staff who have received training and been deemed competent. The home has the necessary procedures in place should a medication administration error occur and the provider has taken the necessary action when this occurred recently. Care staff are aware of these procedures and they reported the incidents to the commission appropriately. Medication is only administered by senior staff and the manager informed the inspector that update training in medication has been provided to staff. At the time of the unannounced inspection the home did not have any controlled medication. The storage arrangements for controlled medication were discussed with the manager who would ensure that, should any controlled medication be prescribed for anyone living at the home, the necessary storage and recording procedures would be followed. Plean Dene DS0000012523.V369276.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People at the home are able to complain and protected from abuse. EVIDENCE: The provider has a complaints policy which is made available to people or their representatives. There is also information as to how to complain available around the home. The complaints policy should ensure that all complaints are appropriately investigated within twenty-eight days. The home maintains a complaints book and has received no complaints in the past twelve months. No complaints have been received at the Commission in respect of Plene Dene. Throughout the inspectors visit people who live at the home were seen responding verbally and non-verbally to staff, making requests and suggestions. Staff have a good understanding of the individual communication methods of the people who live at the home and would be in a position to realise if people were unhappy. Everyone who lives at the home has a Communication passport. Staff spoken with were aware of the procedure they should follow should a person or their representative make a complaint. People stated they would tell staff if they were unhappy about something at the home. The home has a copy of the Isle of Wight Adult Protection Policy together with the Islecare Ltd adult protection and whistle blowing policies. Staff spoken with during the inspection were aware of the adult protection policy and procedures and clear about their responsibilities to report issues of concern without delay. Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 17 The manager and staff confirmed that they have received safeguarding training. The manager showed the inspector the homes training record and plans and this confirmed training in safeguarding adults, managing challenging behaviour and autism had been attended by some staff with further training planned. People living at the home attend a variety of external day services and would be able to report concerns to staff within these settings. A representative of the provider visits the home every month and people would also be able to report concerns at this time. The commission has received a number of notifications about incidents between people who live at the home and these and care plans identify that the home aims to identify the reasons for these incidents and reduce the risk of them occurring. The provider has also taken the necessary action to safeguard the people living at the home when there were concerns that staff had placed people at risk. The personal finances and employment procedures followed should ensure that people are protected from abuse. Plean Dene DS0000012523.V369276.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a comfortable homely house suitable for their individual and collective needs. EVIDENCE: The inspector viewed the communal areas of the home and a person who lives at the home showed the inspector her bedroom. The homes AQAA did not include information about gas and electrical services. The manager informed the inspector of improvements made to the home and relevant service certificates were viewed. Three people who live at the home returned comment cards and all said that the home is always fresh and clean. The home employs a cleaner who undertakes cleaning of communal areas, bathrooms and extra cleaning of bedrooms. People who live at the home are encouraged to help their key workers to keep their bedrooms clean and tidy. The level to which people Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 19 participate in domestic activities is dependant on their level of interest and abilities. The home has a good-sized lounge and separate dining room. There is also another room available for activities with a cooking session occurring on the afternoon of the inspection visit. People were observed moving about the home and spending time where they wished. Communal rooms were reasonably well furnished. Since the previous inspection the large hall has been redecorated and has been personalised with artwork produced by the people who live at the home. The manager stated that it is planned for the landing to be redecorated. Carpets have been professionally cleaned. The home has appropriate bathing and WC facilities. The manager stating that some alternations have been made to the shower to make it safer for one person to use. Externally there have been repairs to fencing panels damaged by high winds and trees to the rear of the home have been felled or coppiced to ensure safety. On the day of the unannounced inspection gardeners were attending to areas of the garden to the front of the home. The rear gardens are safe and enclosed, being accessible to people via the homes lounge or through a conservatory that doubles as a care staff office. The home has a stair lift to enable people with mobility needs to access bedrooms on the first floor. The home has two industrial standard washing and two industrial standard drying machines located in a laundry room. Care staff confirmed these are adequate for the needs of the home. Care staff confirmed that they have adequate supplies of disposable gloves, aprons and any other infection control equipment required. On the day of the inspection visit individual antibacterial gel dispensers which can be attached to clothing arrived for all care staff. Substances hazardous to health were stored securely. Plean Dene DS0000012523.V369276.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 and 35. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported by a consistent staff team, provided in sufficient numbers and with the necessary skills to meet their individual and collective needs. EVIDENCE: People stated that they liked the care staff that they were helpful and they could ask their help with any problems. This was also the comments on the surveys completed by three people who live at the home. Interactions observed during the visit indicated that people and staff have a warm friendly relationship with people feeling able to express themselves in all respects. The staffing section of the data set on the AQAA returned by the area manager had not been completed. This information was provided by the manager during the inspection. Staff rotas and discussions with staff confirmed there are five staff in the morning and six in the afternoon throughout the week and six all day at the weekends, with two awake staff at night. The manager is additional to these numbers and can cover shifts if required. The manager also provides Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 21 an on call service when not at the home. In addition the home has a cook and cleaner with maintenance and gardening support provided via Islecare Ltd. Staff spoken with felt that the staffing levels and arrangements were appropriate to meet the peoples needs and that activities relating to social and leisure are possible during the evenings and weekends. Staff are again accompanying people on their holiday this year. Both male and female staff are employed. The home has occasionally needed to use agency staff however staff usually cover each other’s annual leave and occasional sickness. Records of staff covering extra shifts were seen on duty rotas and an agency invoice was also seen. Following the previous inspection a requirement was made in respect of recruitment and that full employment histories is obtained and that references are requested from previous employers. The manager described the homes recruitment procedures and records were viewed. The procedures in place and records seen would indicate that a thorough recruitment and checking process is in place that should ensure that unsuitable people are not employed at the home. One of the recruitment files requested was not available at the home and the manager had to request this from the provider’s head office. This was received within twenty minutes of being requested. The person this related to had been employed at the home for several months. The recruitment file only contained one written reference with evidence that a telephone reference had been sought from the previous employer and that although there had been attempts to chase up the written reference this was still outstanding. This was discussed with the manager who stated that she would be requesting a further written reference from another previous employer. The manager also stated that she would ensure that when people commence working at the home she ensured that she had received their file from the provider’s office. The manager stated that potential applicants are invited to visit the home prior to interview to meet the people who live at the home. Interactions are observed and that the people who live at the home are asked their views on the person following the visit. The manager described the homes induction procedures and these include all new staff working supernumerary until they are deemed competent and also have undertaken essential training such as safeguarding, infection control, fire awareness, moving and handling and health and safety. The inspector spoke with a newly recruited staff member who confirmed that appropriate recruitment procedures had been undertaken and checks including CRB and references sought. The person stated that she was on a two week induction, supernumerary and shadowing another staff member. The manager provided information about NVQ numbers these showing that stated that twelve of the twenty-two care staff have at least an NVQ level 2 in care and an additional four staff are undertaking this qualification. Care staff Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 22 confirmed to the inspector that they have undertaken all update training. Comment cards returned by care staff stated that they received all the necessary training and that they felt they had the necessary skills and experience to meet people’s needs. The manager showed the inspector the training plan and records held on her computer and stated that update training had been booked where this was due. Certificates of training were seen in staff files seen. The manager stated that the provider’s office on the island has systems that ensures that she is notified when individual staff are due update training. The manager stated that should she identify a training need for the staff employed at the home this is organised by the provider who has a training manager able to facilitate or arrange any training. Plean Dene DS0000012523.V369276.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, 40, 41 and 42. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a service that is run in their best interests. EVIDENCE: At the time of the previous inspection in September 2007 the home had an acting manager. The acting manager was replaced by a new manager who was replaced by the current manager who has been in post for approximately three months. The current manager stated that she has the Registered Managers Award and an NVQ level 4 in care. The manager stated that she has commenced the registration process and is awaiting the return of her CRB check prior to sending the completed application forms to the commission. Discussions with the manager indicated that she was aware of the Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 24 responsibilities of being the registered manager. The manager is supported by a team of senior support staff and also by the provider’s management and organisational structure with an area manager being based nearby. Prior to the inspection visit the area manager completed the homes AQAA this being received at the commission in May 2008. Parts of the AQAA were well completed however many sections were either left blank or contained limited information. The second section of the AQAA contains a data set providing additional information about the service and people it supports was also incomplete. The AQAA was discussed with the manager. Throughout the inspection visit people living at the home were seen to be encouraged to give opinions and their views or wishes were respected. A representative of the provider undertakes a monthly visit to the home with the written reports of these visits being seen during the inspection visit. The manager undertakes audits within the home; these were seen during the inspection visit. The manager, who has only been in post for three months, was unsure about other quality assurance work undertaken to formally elicit the views of the people who live at the home or other stakeholders. The manager was aware that staff had been requested to complete a survey the week prior to the inspection visit. There was no information in the AQAA in relation to seeking the views of stakeholders and how this information would be used to improve the service. The section of the AQAA relating to policies and procedures had not been fully completed. The inspector discussed this with the manager who confirmed that all the necessary policies and procedures were in place and available at the home. The inspector was shown the policies/procedures file. Throughout the inspection visit a number of records were viewed. These have been identified in the relevant section of this report. Records were well maintained and appropriately stored. There were no concerns in respect of health and safety identified during the inspection visit. Plean Dene DS0000012523.V369276.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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 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 2 3 3 3 X Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Plean Dene DS0000012523.V369276.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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