Inspection on 28/06/07 for Pound Farm

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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

Pound Farm 03/03/06

Pound Farm 10/10/05

Pound Farm 08/03/05

Pound Farm 31/08/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Pound Farm Gorsley Nr Ross-on-wye Herefordshire HR9 7SL Lead Inspector Jean Littler Key Unannounced Inspection 28th June 2007 10:00 Pound Farm DS0000024729.V328200.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 Pound Farm DS0000024729.V328200.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. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pound Farm Address Gorsley Nr Ross-on-wye Herefordshire HR9 7SL 01989 720546 01989 720188 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) Salters Hill Charity Limited Mrs Gillian Hilary Sackett Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents may also have a mental disorder or a physical disability, or a sensory impairment associated with their learning disability. Date of last inspection Brief Description of the Service: Salters Hill Charity, a charity set up to provide residential care for adults with learning disabilities opened Pound Farm in 1988. Salters Hill Charity Ltd has another care home in Herefordshire and runs another service in Gloucestershire under the Supporting People arrangements. Pound Farm provides a service to 14 adults whose primary care needs arise from learning disabilities. Some people using the service also need care and support due to physical or sensory impairment or intermittent mental health needs. The emphasis at Pound Farm is on the people who live there playing an active role in the day-to-day life of the Home, ongoing learning and skill development and on enjoying a full and active life. The accommodation is provided in a farmhouse style house and adjoining barn. The buildings are linked by a covered walkway. The extensive grounds are used to grow vegetables and keep farm animals. Involvement in the care of the garden and the animals is an important element in the Homes statement of purpose, which indicates that prospective service users need to have an interest in this type of lifestyle. A small day care service is also offered to people who live at another of the group’s homes and in the local community. Information about the service is available from the Home. The fees are worked out on an individual needs basis and the current rates are between £414 and £562 per week. The residents pay a contribution towards these from benefits they receive. In addition to the basic fees the residents pay for their personal items such as toiletries and clothes, personal services such as chiropody and hairdressing, the cost of personal phone calls, and a contribution towards the TV licence and holiday costs. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on a weekday between 1pm and 5.30pm. The manager was on duty and helped with the process. The inspector looked around the house and spoke with two of the staff and some of the residents. Two residents showed the inspector their bedrooms and they talked in private about their views of the Home. Some records were looked at such as care plans, medication and money. The manager sent information about the Home to the inspector before the visit. What the service does well: The home only offers a place to someone if they can meet their needs. Each resident is fully involved in planning his or her support. The residents are supported to make decisions about their health care and medical treatment. There is enough staff and volunteers to support the residents with their chosen lifestyle. The residents choose what activities, college courses or jobs they want to do. The residents are supported to have friends and stay in touch with their families. The flats are homely, comfortable and safe. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 6 The home is well run and the residents’ views are listened to. The staff get to know the residents very well and the residents like them. The staff are trained and supported to do a good job. 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. Pound Farm DS0000024729.V328200.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 Pound Farm DS0000024729.V328200.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): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the information they need to make an informed choice about moving into the Home. Their needs and aspirations are assessed and they have the opportunity to visit and try out the service. Each resident has a contract and a statement of Terms and Conditions of Residency. EVIDENCE: A Statement of Purpose is in place and has been kept under review. There is a Service User’s Guide and each resident has a copy in a format they can understand. Each resident also has a copy of the Terms and Conditions of Residency that they have agreed to. No new residents have been admitted since 2000. Should a vacancy occur procedures are in place for the assessment process and a Community Care assessment would be obtained from the placing Social Worker. The resident and their representatives would be fully involved in the process and they would be able to visit and trial the service before agreeing to move in. The other residents would also be consulted and would have to agree before a new person moved into their flat. All residents said in the questionnaires returned to the Commission that they were given useful information before moving into the Home and they did have a choice about where they lived. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 9 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, 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents are enabled to be fully involved in planning and reviewing their support arrangements. They know what is written about them and they develop their own goals. The residents are supported to take reasonable risks as part of living independently. They are supported to make all decisions about their lives and are genuinely consulted about how the Home is run. EVIDENCE: Each resident has a person centred care plan, which they keep in their bedrooms. A selection of these have been seen over previous inspections. Two were sampled on this occasion, which again showed that the information is detailed and up to date. The folders contain clear information about what things are important to each resident and these are monitored each month to ensure they are happening. The residents continue to be consulted about the content of their care plans and they sign to show their agreement to what is written. The residents agree with staff each day what should be recorded in their daily diaries. The plans contain risk assessments. Those seen reconfirmed past evidence that residents are consulted and supported to take risks as part Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 10 of living lives as independently as possible e.g. using kitchen equipment in the flat without staff support. Those seen had been reviewed in Jan 07. Sensible control measures are in place to give support and to help ensure the residents’ safety. The manager should consider developing a risk assessment to give an overview of how the risks relating to having epilepsy are being managed for individual residents e.g. at night and whilst bathing. These should then be revisited if things that may affect the epilepsy risk change e.g. a reduction in medication. Keyworkers meet regularly with the residents they support to assist them to make decisions about their lives and develop their personal goals. Together they review the care plan each month and the residents can suggest changes to their current support and activity arrangements. One seen showed that the resident had decided to stop attending cooking but has now joined a computer group. The aim for the next month was to arrange a new mobile phone. Another resident had an aim to join a gym. Care reviews are being arranged on a six monthly basis and the residents are supported to hold these meetings. Computer images, photo boards and videos are all used to enable residents to develop their review reports and the agenda and to show their families and friends their achievements during the meetings. The service already works in a very person centred way but the manager is hoping to introduce person centred planning meetings (PCP). One worker has trained to facilitate these meetings but the manager is also exploring the idea of an external facilitator chairing them to help ensure they are approached objectively. The residents gave positive feedback about how they are supported to plan their lives, make choices and take risks. Very positive comments were received from residents’ relatives such as e.g. we are pleased with the care for our son and he continues to develop in the caring and loving supportive environment; we are very pleased about the effect on our daughter from the accommodation changes. The residents have monthly meetings in their flats to enable them to make decisions about how they share the space together. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 11 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, 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents have many opportunities for personal development. They make decisions about their lifestyle and the activities, further education or employment they access. Their rights are actively promoted and they are supported to be responsible adults. They are supported to develop and maintain their personal relationships. They enjoy their mealtimes and have influence over the food they eat. EVIDENCE: There was a relaxed and happy atmosphere in the home on the day of the inspection. The manager reported that the residents have settled into the new way of life after the creation of the flats. All residents have benefited from the changes and examples included; two residents are communicating more often, one verbally and one using Makaton signs. Others are socialising and enjoying each other’s company in their flats without staff input. There is a relaxed structure to daily routines particularly on weekdays because the residents all have different activity plans that include a rota for areas of shared Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 12 responsibility such as housework and the animal care. This approach enables all residents to develop their life skills, their sense of shared responsibility and also helps their self-confidence. Each flat now has a white board where activity plans and other information such as staff rotas is provided to support the residents to be well informed. More of this is going to be displayed in the format needed for any residents who do not read. Creative solutions are sought to problems so that the residents can still be independent e.g. important letters were not being shown to staff when post was decentralised. Residents have now agreed to put their letters in a box in their bedroom and show their keyworkers. One resident learned to come to her flat door when staff knock by having role play sessions. As mentioned above each resident has developed personal goals they are working towards. All those spoken with were positive about what they were doing. One resident was looking forward to going to see Cats at the theatre and another enjoyed staff taking his photograph after returning with rosettes from a horseshow. Many activity sessions are accessed and some link to the rural focus of the Home e.g. land and livestock; horticulture. Examples of leisure interests include arts and crafts, horse riding, swimming, chapel and the gym. Some residents have part time voluntary employment or attend work experience placements e.g. repairing bikes or working in a charity shop. One resident has expressed an interest in becoming a landscape gardener so enquiries are being made. Holidays are planned with the residents and they choose who they want to go with. The residents and their relatives gave positive feedback about the personalised activity plans and the varied outings that are arranged. The residents are supported to maintain and develop personal relationships with families and peers. One resident had been out for lunch with his father, which he had obviously enjoyed. The volunteer drivers help with transport for those residents whose families live further away. Staff attended a bereavement course recently and are trying to support a resident who is currently grieving for family members. The residents are now used to getting their own breakfast and light meals in their flat kitchenettes. A provisions budget is given to each flat and the residents are learning planning skills for their weekly shop. The main meals are still prepared and eaten in the communal kitchen and dining area. Residents continue to take turns to help with the preparation, which many enjoy. The manager feels residents still benefit from sharing communal meals together. The food records showed a balanced diet is offered and that residents take turns to choose meals for the menu. Special diets are catered for and one resident is very proud of the weight he has managed to lose recently. Main meals are eaten in the flats at times e.g. a group takeaway or when friends are invited over. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents are provided with personalised support in a way they prefer. Their emotional and physical health needs are being met and they are fully involved in any related decisions. The residents are supported to administer and control their own medication where possible. EVIDENCE: Each resident’s preferred ways of being supported are detailed in their care plans and they are consulted about the support they need. Goals are in place if needed to encourage independence and good personal hygiene. The care plans showed attention is paid to maintaining their privacy and dignity. The residents need different levels of support with personal care but independence is encouraged with all. When intimate care is needed the residents are consulted about who supports them e.g. someone of the same gender. The residents confirmed in their questionnaires that they feel positive about how staff treat and support them. The residents buy their own clothes and are consistently well presented when seen at inspections or in the community. Relatives’ feedback was positive about the care provided. Care plans demonstrate that there is a good understanding of the residents’ physical and emotional health needs. All residents have a health action plan Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 14 and have an annual health check with their GP. The health action plans are presented in a way that helps the residents understand the content and photographs of the specific health professionals involved in their lives have been scanned into them e.g. their psychologist. Medication is reviewed at least annually and the residents’ wishes are respected in regards to their health care and about taking medication. Specialists have been appropriately involved and residents are supported to make decisions about any treatment options. One resident is currently being supported to consider if he wants to have an eye operation. Staff have attended training related to residents’ health and care needs. The manager reported that Downs Syndrome training in 2006 was very helpful and increased staffs’ awareness of some of the residents needs. Clear records are made about any medical problems and health appointments. Medical records also contain essential information should an urgent admission to hospital be required. The providers contribute to the cost of chiropody as it is viewed as important but is very expensive. A GP gave feedback that he was always impressed with the quality of the staff and the empathy they show. The dentist’s feedback was also positive. A clinical psychologist reported that the Home does a good job of engaging residents in meaningful activities, and consults with them fully regarding changes. She felt the staff are committed to best practice but sometimes struggle when they see residents get upset or angry. Support has been accessed from the Gloucester Community Team when residents need additional support. This has had positive results and in one case it has led to a resident having a diagnosis made of her condition. Training around this was then arranged and the resident’s father attended with the staff team. Clear strategies are in place to support residents with certain behaviours. Incident reports showed staff do implement these appropriately. Following one incident the staffing arrangements were tweaked to prevent further occurrences. Medication is being managed in a flexible way. The residents keep their medication in their bedrooms in secure containers. Staff give whatever support is needed based on each residents’ risk assessment. One resident showed the inspector her medication and the form that she signs each day. She was very proud that she has been able to learn the skills to take on this new responsibility and she said her keyworker had encouraged her to try. Medication reviews have led to positive results for some residents e.g. changes for one resident increased his memory and concentration. Clear records of the changes had been made and staff had monitored his welfare throughout. The medication policy has recently been reviewed to incorporate guidance from one of the Commission’s pharmacy inspectors. All staff undertake in-house medication training. This is not an accredited course but the training plan showed this was planned for all staff in 2007. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents and their representatives feel their views are listened to and acted upon. The residents are protected from abuse and feel safe in their home. EVIDENCE: The Home has a complaints procedure and an accessible version of this is given to each resident. The residents indicated in their feedback questionnaires that they would tell their family, the manager or the staff if they had a concern. Two complaints had been recorded since the last inspection. These were from residents about a fellow resident who had upset them in some way. The complaints log showed what action had been taken to help the problem be resolved. No other complaints have been received by the Home and none have been made to the Commission. The service has a long history of enabling residents to voice their views and has always promoted self-advocacy. Feedback from relatives was positive e.g. one family said the lines of communication are so well established that issues are resolved quickly. Two families said they were not aware of the complaints procedure so the manager may want to consider sending this out again. Policies are in place relating to the protection of vulnerable adults and the staffs’ duty to report any concerns. These have been kept under review and the providers are aware of the local multi-agency protocol should an adult protection concern arise. No such concerns have been raised since the last inspection. Staff receive protection training in their induction and in a follow up course. The staff spoken with were clear of their role in protecting residents and the residents reported in their questionnaires that they feel safe at home. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 16 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, 25, 26, 27, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a homely, comfortable, clean and safe environment that meets their needs. The Home is being continually improved and the residents are consulted about any changes. EVIDENCE: The Home is situated in a rural location on the outskirts of a village. The residents look after the farm animals that are kept in the grounds and grow fruit and vegetables. The Home continues to be well maintained. There has been a high level of investment in the last few years. The Home is spread over a site and includes a large log cabin that is a meeting and entertainment place and a games room, a farmhouse that contains one flat, the main kitchen and staff facilities and an adjoining barn that contains three flats. The two residential buildings are linked by a covered walkway. In all there are fourteen single bedrooms and each flat has bathroom facilities, a lounge-diner and kitchenette. The recent building works increased the size of the smallest bedrooms and created four en-suite facilities. Each flat is shared by between two and four residents, all of whom have chosen to live together following significant involvement of an independent advocate. All rooms seen were Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 17 clean, comfortable and homely. They picked the fixtures and furnishings when the building work was finished so each room has its own distinct character. Although new carpets were laid at the time the lounge carpet in one flat was stained and in need of attention. Two residents showed the inspector around their bedrooms and flats. One resident had matching curtains and bed linen and family photos, CDs and DVDs around the room. The laundry is now located into a larger area. It is well equipped and is being used by each flat on certain days. The Home was clean and the residents follow a cleaning rota to ensure all areas are cleaned regularly. Systems are in place to minimise the risk of infection and protective clothing is provided. One family did report that sometimes when they visit there is no toilet paper and there is an unpleasant odour in one toilet. A kitchen cleaning procedure was developed following an Environmental Health inspection in Jan 07. Only two recommendations were made. The manager provided information demonstrating that all equipment has been serviced regularly. Safety records showed fire system checks are completed and all staff attend regular fire drills. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 18 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, 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents benefit from support from an established, competent and effective staff team. The staff are appropriately qualified and trained and are well supported to meet the residents’ needs. The residents are protected by the recruitment procedures. EVIDENCE: A team of support workers, four flat co-ordinators, a deputy and the manager staff the Home. Staff turnover is generally quite low. Four staff had left since the last inspection but two of these have returned. Four new staff have joined the team of fourteen during 2006. The ully staffed now and the team works flexibly to cover the shortfalls in rota due to sickness or holidays. Staff have clear job descriptions and staff at each inspection have demonstrated they have a clear understanding of their role as enablers. Those spoken with had a positive attitude towards their work and interactions seen between residents and staff were friendly, positive and respectful. Keyworking is an important part of the staffs’ role as they are responsible for leading the care planning and reviewing process as well as supporting their nominated residents with practical issues such as personal shopping. The Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 19 manager reported that staff have de-centralised their working methods since the residents split into the flats e.g. message books are now in each unit. There are a minimum of three staff on during the day, however often there is more. The providers have not been given additional funding for staff from the placing authorities to reflect the creation of four small group living areas. A worker is allocated to each flat so they can concentrate on meeting the needs of those residents. A flexible approach is taken to covering the flats at key times. Additional staff are also arranged when needed e.g. for specific activities, meetings or appointments. There are twelve volunteers who either drive or support residents with activities such as the animal care. The residents gave positive feedback about the staff through discussions and the questionnaires. All staff are liked and one said that although staff sometimes disagree with them things get sorted out and staff give loads of advice. Families were also positive e.g. one sister said that the staff are supportive and enabling for my brother and staff and residents have been very supportive of the family during difficult times. The two spoken with felt they were well supported and found the staff meetings productive and resident focused. They felt the team morale was very good and the manager and deputy approachable and helpful. Both understood the importance of the residents becoming as independent as possible. They said they are provided with staff supervisions regularly. Annual performance appraisals are also carried out. The manager has a good record of recruiting appropriate staff and ensuring they are suitable to work with vulnerable people. One recruitment file was sampled on this occasion. The records confirmed that a robust equal opportunity procedure had been followed. Appropriate checks had been carried out. The worker had started following receipt of a clear PoVA First check and CRB check. The providers have well organised training arrangements and encourage staff to develop professionally. A training plan is developed each year and workers have their own training record. All staff attend core safety training e.g. First Aid Appointed Person, Moving and Handling, Food hygiene. More specialised training including Autism, Bereavement, Managing Challenging Behaviours, Person Centred Planning is also provided. Staff are kept informed about changes in relevant legislation e.g. Mental Capacity Act training is planned. Seven of fourteen care staff hold an NVQ award in Care. Three of these hold the higher award of level 3. Two other staff are working towards gaining a level 2 and there are plans for two more staff to start level 2 and three to start level 3 this year. One of the Business Plan aims for 2007 is to provide all staff with at least eight paid days training a year. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 20 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, 38, 39, 40, 41, 42, 43. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a well-run home and effective leadership that continues the Charity’s person centred ethos. The residents and their representatives are fully involved in the review and development of the service. The policies and record keeping systems in place help protect the residents’ best interests. The residents’ health, safety and welfare are actively promoted. EVIDENCE: The manager continues in post. She is experienced and holds relevant qualifications. The manager has recently taken on a more senior role in the Charity and is combining this with running the Home. A deputy was appointed in November 06 from within the staff team to provide her with additional support as part of this reorganisation. He has worked in the Home for nearly three years and he has previous management experience. The manager is still based at the Home and three to four days a week are dedicated to the Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 21 management of the Home. She reported that she still attends the care review meetings. The deputy has reportedly settled into his role well and the service is running smoothly. All feedback received confirms the view that the manager is professional, committed and approachable. One worker said she is always keen for new ideas. One resident’s father said he wanted to compliment the manager and staff as the care and welfare for all is second to none. The manager keeps herself well informed about professional developments and ensures these are implemented in the Home if appropriate. The manager has some administration provided by head office staff and the Charity has recently appointed a new finance manager. The Organisation has a comprehensive set of policies and procedures. These have been kept under review and the majority have been updated in the last year. The staff are aware of these and have access to copies. Some have been developed into a format more suitable to inform the residents and there are plans to do this with others. The Organisation has recently engaged an external company to support with legal and personnel matters. Following this essential procedures have been developed into a staff handbook and each worker has been given a copy. The records seen were being well maintained and it is positive that residents have control of their own records. The Organisation has been developing their quality assurance systems over recent years. The residents, relatives and staff are asked to complete annual feedback questionnaires and the information is included in an annual report for the Charity’s Annual General Meeting. Some residents are supported to complete these by an external advocate. There has in the past been a poor response from families so the manager agreed to consider using them before review meetings are held. She also agreed to consider how feedback from external professionals can be gathered. A Business plan is developed each year from this feedback and discussed at the AGM. The residents are fully involved in the planning process and each service ends up with their own business plan as well as the overriding Charity one. These are presented in an accessible format. A newsletter for the Charity, which the residents are involved in, is periodically circulated to keep the stakeholders informed. A Quality Assurance system that monitors how well the overall service is performing has been introduced recently. The impact of the service on the environment is being reviewed and a quality award E.M.A.S. is being worked towards. As part of this policies are being reviewed e.g. recycling and energy saving. The internal Health and Safety audits are carried out to check high standards are maintained. Health and safety arrangements continue to be given priority. The Charity has recently been awarded a Kite Mark for C.H.A.S. (Contractors Health and Safety Assessment Scheme). Appropriate training is provided; risk assessments are in place and safety equipment provided. Monitoring systems are in place and kept up to date e.g. weekly fire alarm checks. All equipment has been serviced in 07. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 3 4 3 5 3 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 3 26 4 27 3 28 4 29 x 30 3 STAFFING Standard No Score 31 4 32 3 33 4 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 4 4 3 3 4 x Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NA 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. 1 Refer to Standard YA6 Good Practice Recommendations Develop a risk assessment to give an overview of how the risks relating to having epilepsy are being managed for individual residents e.g. at night, whilst bathing and during medication changes. Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Pound Farm DS0000024729.V328200.R01.S.doc Version 5.2 Page 25 - 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. 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