Inspection on 13/07/07 for REACH Bierton Road

This inspection was carried out on 13th July 2007.

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

The inspector 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

REACH Bierton Road 07/07/08

REACH Bierton Road 20/12/06

REACH Bierton Road 23/05/06

REACH Bierton Road 02/12/05

REACH Bierton Road 07/07/05

REACH Bierton Road 05/01/05

REACH Bierton Road 15/07/04

REACH Bierton Road 20/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 REACH Bierton Road Aylesbury Bucks HP20 1EJ Lead Inspector Nancy Gates Unannounced Inspection 12th & 13th July 2007 09:30 REACH Bierton Road DS0000023044.V339576.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 REACH Bierton Road DS0000023044.V339576.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. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service REACH Bierton Road Address Aylesbury Bucks HP20 1EJ 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) 01296 429586 01296 429586 www.Reach-disabilitycare.co.uk REACH Limited Miss Amanda Follette Care Home 8 Category(ies) of Learning disability (8) registration, with number of places REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 12 September 2005 - existing residents are to be permitted to remain at 20 - 22 Bierton Road, beyond their 65th birthday. 20th December 2006 Date of last inspection Brief Description of the Service: 20-22 Bierton Road, Aylesbury, is a care home providing residential care to eight adults with learning disabilities. The home is a conversion of two mid-terraced house. The Rehabilitation Education and Community Homes Limited (REACH), an organisation specialising in residential care for adults with learning disabilities, manage the service. The home is located about half a mile from Aylesbury town centre, convenient for the facilities of the town, the specialist facilities of Manor House Hospital, which is across the road and public transport. All of the homes bedrooms are single. None have en-suite facilities. The fees at the time of this inspection were £680 to £1300 per week. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 1.30 p.m. The total number of hours spent at the home was 6 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. Four household members were in the home at the time of inspection. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. All information received by the Commission for Social Care Inspection received, since the last inspection, about this service was also taken into account when producing the key inspection report. Staff and residents were very welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. A number of records were viewed including resident’s care plans/person centred plans, staff recruitment records, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: The needs of people who may want to live at the home are checked before moving to Bierton Road. This makes sure that the staff have the right skills to support the person and also makes sure that needs of the people who already live at Bierton Road are not affected. Staff support residents following Person Centred Plan’s, making sure that individual needs are met. Reviews are conducted on a regular basis allowing for the support provided to be consistent, safe and relating to residents changing needs and wishes. Residents continue to attend a variety of social, training, and recreational activities (including holidays in the UK), which aim to meet individual needs, improve resident’s well being and maintain contact with the wider community. Residents are supported to make lifestyle choices, which recognise individuality and are enabled to take risks within these choices. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 6 Needs arising from equality and diversity are well met. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Residents are involved with staff in day to day activities in the home. This provides residents with opportunities to develop everyday living skills such as shopping, cooking and some domestic tasks. Personal support continues is provided according to needs, ensuring that people receive the assistance they require. Access to additional support from health care professionals is consistent and meets health needs. Medication is stored securely; administration is accurate, ensuring safety. Effective complaints procedures are in place to listen to the views of the people who live at the home and their representatives. Appropriate Safeguarding Adults and whistle blowing procedures are in place, The links with a local advocacy organisation remain to ensure that residents have access to independent advice and support. This continues to protect the interests of residents and supports good practice in the home. A clean, safe and well maintained environment has been created, providing people with a comfortable and homely place to live. The home is quite well located for the amenities of Aylesbury town centre and those of nearby NHS learning disability and mental health services. Residents are supported by competent and qualified staff, ensuring that needs are met, however vacancies remain. Staff have completed the necessary training in order to meet residents’ needs. The home benefits from consistent management ensuring the service is run effectively and meets care needs, however the manager has not had the opportunity to obtain the Registered Manager award. There is regular monitoring by the provider, ensuring that the service operates effectively. Due regard continues to be shown toward health and safety, to reduce the risk of accidental injury to residents, staff and visitors. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 7 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. REACH Bierton Road DS0000023044.V339576.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 REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs of potential residents continue to be assessed by experienced staff prior to admission. This ensures that the service can meet assessed needs and minimises the risk of admitting a person whose needs cannot be meet. The process continues to be conducted at a pace, which suits the potential resident, and takes account of the need for current residents and staff to get to know the new person. EVIDENCE: No new admissions have taken place since the last inspection. All eight places in the home remain occupied. REACH continues to have good systems for assessing the needs of potential residents. Referrals are assessed and considered by an experienced manager. Admission of a new resident is carefully considered alongside the needs of the people who live at the home. The process continues to include liaison with the referring care manager, the prospective resident, his or her family members, and others involved with the REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 10 person. Consideration of relevant information is made following the completion of an assessment form. Following assessment and after considering whether the service is able to meet assessed needs the prospective resident is invited to visit the home. When admission is agreed a three-month introductory placement is arranged. A review is held at the end of the period to ensure the individual and the other members of the house feel happy and comfortable with the admission. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Person Centred Plans (PCP) and personal information is written and maintained at a reasonable standard, however the structure of PCPs remains complex and may not be readily understood by many of the residents. Staff support residents following PCP’s, ensuring as far as possible that individual needs are met. Reviews are conducted on a regular basis allowing for the support provided to be consistent, safe and relating to residents changing needs and wishes. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 12 EVIDENCE: A service user plan/Person Centred Plan (PCP) remains in place for each resident. The PCP’s of three residents were looked at with permission from the person sought where possible. The PCPs continue to include assessment of the resident’s needs, a pen picture (including details of significant people such as friends and family), a list of activities, which the resident enjoys or participates in (such as clubs, shopping, particular foods), things that the person dislikes, a ‘communications passport’, and aspirations and goals and plans to achieve these. PCPs also continue to include details of personal care needs, other support requirements, and risk assessments. Risk assessment may be general, such as the level of support required when going out, or specific to individual residents, such as the risks associated with activities in the kitchen or while eating (the need to maintain supervision while eating for example). Risk assessments include the restrictions required to ensure the safety of individual residents. PCPs include dates of review and records of review meetings. Daily records are maintained in an individual notebook and include an account of how the resident has spent his or her day. Whilst the PCPs are detailed, the current format remains complex and does not facilitate the engagement of all residents in the process. Changes to the format suggested at the previous inspection have been acknowledged; reviewed and new documentation will be available in the near future. The manager stated that individuals would be supported and encouraged to engage in the process, matching format to communication needs and abilities as far as possible. However, one resident has hand written the information, which clearly relates to the wishes and goals of the individual, demonstrating respect for and acknowledgement of the persons abilities. Residents continue to be encouraged and supported by staff in making decisions. A local independent advocacy service, Aylesbury Vale Advocates, maintains involvement with some residents. Any limitations on freedom are set out in the risk assessments in PCPs (only one of the eight residents remains able to go out without staff support). REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents continue to attend a variety of social, training, and recreational activities (including holidays in the UK), which aim to meet individual needs, improve resident’s well being and maintain contact with the wider community. Residents are supported to make lifestyle choices, which recognise individuality and are enabled to take risks within these choices. EVIDENCE: The service continues to provide care for a small but diverse group of residents. PCPs include information relating to the social, emotional and communication needs of residents and the level of support required in carrying out everyday activities. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 14 At the time of inspection, three residents were on holiday in the Isle of Wight, with the remaining residents planning to go to Jersey and a holiday camp. Residents continue to go to a range of activities in the community including some courses at Aylesbury College i.e. drama and dance, an art group at a resource centre and activities at a day centre. Some residents continue to regularly attend a social club in Aylesbury. College courses are available locally but people who wish to attend must show that they are able to meet goals within a given time. This can often mean that people are unable to attend because they may need more time or additional support to meet the set goals. Whilst at home, residents continue to enjoy a range of interests which include knitting, painting, sewing, board games, TV, video and music. Some residents continue to maintain contact with their families. Residents stated that they were happy and felt that staff were kind and helped people with what they needed. Residents and staff were polite and respectful to each other, staff responding to requests when needed but also helped people to do things for themselves and others. Residents share in some light housekeeping tasks, including doing their laundry, supported by staff when needed. Residents and staff continue to do the shopping and prepare and share meals together. Breakfast consists of cereals, fruit juice, toast and tea or coffee. Lunch is a light meal, followed by fruit or yoghurt. The evening meal remains as the main meal of the day. Residents are able to choose what they like to eat, help put the menu together, and then help prepare the meal. Choices are varied and offer balanced meals including vegetables and the option of having fruit at any time. Weights are regularly checked and recorded in person centred plans. The inspector was invited to join the residents and staff for dinner, and was offered chilli and rice with vegetables with chocolate moose or fresh fruit to follow. People were given time to eat at their pace and when finished asked to clear there own dishes from the table. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal support continues is provided according to needs, ensuring that people receive the assistance they require. Access to additional support from health care professionals is consistent and meets health needs. Medication is stored securely; administration is accurate, ensuring safety. All elements of risk when dispensing medication from a portable box should be minimised to ensure safety. EVIDENCE: Personal and healthcare needs are clearly described within individuals person centred plans. The plans hold clear guidance of how people wish their personal and healthcare needs to be supported. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 16 Residents make clear choices about when to get up and go to bed, most people choosing to get up early even if there isn’t anything planned for the day. Choices around clothes and hairstyles remain with the individual; preferences are recorded within PCP’s. The staff group remains mixed in terms of gender, age, and ethnicity; the needs of individuals can be matched as far as possible to the skills knowledge of staff. No technical aids are currently required in this home because all of the residents remain mobile. The manager confirmed that reviews record changing needs and will highlight if aids or environmental adaptations are required. All residents are registered with a GP. Residents are supported in accessing other health and social care services in the community as required. This includes contact and support from the community learning disability team. Residents healthcare needs are recorded in care plans. Personal care continues to be provided in the privacy of the resident’s own room or in a bathroom. Medicines are stored in a locked portable box. Additional stock is stored in a locked metal cabinet within a lockable cupboard. Staff currently take the portable box out of the cupboard to dispense medication in the dining room. The portable box cannot currently be made secure once taken out of the cupboard; this presents an element of risk and should appropriately assessed to ensure safety. A local pharmacist supplies the home with medication stored within blister pack dispensing systems. Medication administration records are supplied by the pharmacist to support accurate administration and recording. Recording is accurate, no omissions were noted. Medicines returned to the pharmacy are recorded appropriately. The organisation provides training for staff in the administration of medicines and there are written guidelines in place on the use of all as prescribed medication. A protocol remains in place for the administration of PRN (to be taken as required) medicines for each resident. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Effective complaints procedures are in place to listen to the views of the people who live at the home and their representatives. Appropriate Safeguarding Adults and whistle blowing procedures are in place, The links with a local advocacy organisation remain to ensure that residents have access to independent advice and support. This continues to protect the interests of residents and supports good practice in the home. EVIDENCE: REACH policy and procedure guides the management of complaints. The home has received one complaint since the last inspection, response to the complaint was within 28 days, and the complaint was investigated appropriately. No formal complaints have been received at the CSCI since the last inspection. A complaints procedure is available including the details of the CSCI. The procedure detailing that the complainant can refer to the CSCI at any stage. The complaints procedure has also been made available in an alternative format. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 18 The inspector recognises that the communication needs of the people supported at Bierton Road vary and therefore the formats currently available may not meet everyone’s needs. Discussion with three residents allowed the inspector to explore whom people would talk to if they were not happy/wished to make a complaint and how staff and REACH support this. Residents were able to describe their understanding of the complaints process, “ I can talk to staff or other people, like X (advocacy service) if I don’t like something…we talk about things in meetings and I can talk to my key worker.” The service has good arrangements for Safe Guarding the people at Bierton Road. A clear policy remains in place. The registered manager has obtained a copy of the current Buckinghamshire joint agency guidelines on the protection of vulnerable adults, as recommended at the previous inspection. Protection of Vulnerable Adults/Safeguarding adults remains within the organisations induction programme and leaflets on Careline are on notice boards in the home. Staff are aware of adult protection/safeguarding and indicated confidence in managers to respond appropriately to reports of abuse. The home remains in regular contact with Aylesbury Vale Advocates. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clean, safe and well maintained environment has been created, providing people with a comfortable and homely place to live. The home is quite well located for the amenities of Aylesbury town centre and those of nearby NHS learning disability and mental health services. EVIDENCE: The home is located a mile or so from Aylesbury town centre. It is opposite Manor House Hospital (Learning Disability services) and not far from the Tindal Centre (Mental Health services). It consists of two terraced houses converted to one house. All areas were tidy, in good order and clean on day of inspection. Recent decoration of the communal areas and ongoing decoration of bedrooms is providing people with a comfortable and homely living space. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 20 The entrance hall leads to stairs to first floor, a ground floor bedroom, the lounge, dining room, and kitchen. Then further on to the staff office, a small laundry room, and a sitting area to the back of the building. There are stairs to the first floor in each half of the building. The other bedrooms are on the first floor. Bedrooms vary in size but are comfortable and has been decorated and arranged to individual tastes. One residents stated, “ I like my room, people must knock before they come in I have my own key and no-one goes in there without asking me first…I’ve got all my stuff in here, the way I want it.” This clearly demonstrates respect for individuals’ private space. The kitchen was clean and very tidy. The kitchen and dining area are in keeping with the size of the home and are usable by all household members. There are sufficient bathrooms and WCs to meet the needs of residents. All radiators are covered. The water temperature at hot water outlets is maintained at a safe temperature. The garden to rear of the house was in order with garden furniture for use for all house members. All areas of the home appeared clean and there were no unpleasant odours. It is part of the philosophy of the home that residents are supported to undertake domestic chores and gentle encouragement was overheard. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff, ensuring that needs are met, however vacancies remain. Staff have undertaken the necessary training in order to meet residents’ needs. EVIDENCE: There are currently two staff in the morning, two in the afternoon, and one waking and one ‘sleep-in’ at night who support residents. The home continues to have three staff vacancies. The manager stated that these were being covered by relief staff who were familiar with the home and its residents. Efforts continue to recruit staff to the vacant posts however continuity is assured by the use of relief staff who know the residents. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 22 The relationship between staff and residents appeared good and the overall atmosphere was calm and positive. Staff are qualified and experienced, many are qualified nurses in their own country. Issues were raised at the last inspection regarding the validity of qualifications attained outside of the UK. Staff have been able to validate their qualifications with The National Recognition Information Centre for the United Kingdom (UK NARIC). The UK NARIC is a national agency under contract to the Government Department for Education and Skills who look at whether international qualifications can be matched to qualifications required to work in a care home in the UK. The manager was able to provide documentation which demonstrated that staff have qualifications equivalent to National Vocational Qualification level 3. The proportion of staff with NVQ2 or above meets the 50 requirement for both permanent and relief staff. REACH continues to provide a range of training events over the course of the year. Courses include: ‘Non-Violent Crisis Intervention’, ‘Infection Control’, ‘Autism’, ‘Managing Medication’, ‘Moving & Handling’, ‘Health & Safety in Care Homes’, ‘Cultural Awareness’, ‘Risk Assessment’, ‘Sexuality’, ‘Food Hygiene’ and ‘Fire Prevention’, ‘Protection of Vulnerable Adults’. Staff recruitment continues to be managed by the organisation’s personnel department based at its head office in Gerrards Cross. The inspector examined three staff files and was satisfied that the organisation operates a thorough recruitment procedure to protect residents and staff. The manager confirmed that POVA first checks before staff start work at the home. This is completed alongside a CRB check. The registered manager supervises all care staff and aims to do so on a monthly basis, this exceeds the minimum standard. Staff confirmed that supervison is an opportunity to discuss ‘key-working issues/ the support of residents’, training and development needs as well as any other issues relating to their employment at Bierton Road. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home benefits from consistent management ensuring the service is run effectively and meets care needs, however the manager has not had the opportunity to obtain the Registered Manager award. There is regular monitoring by the provider, ensuring that the service operates effectively. Due regard continues to be shown toward health and safety, to reduce the risk of accidental injury to residents, staff and visitors. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager is experienced in supporting and enabling people with a learning disability and has been manager of the home since 2002. The manager reported that unforeseen funding issues have delayed the start of the Registered Managers Award (RMA). The start date is now expected to be in September 2007. During the inspection, the service made a successful appointment to the post of team leader, which should provide additional and important support to the registered manager. The home’s certificate of registration was displayed in the office and there was evidence of sufficient employer’s liability insurance as well. Reports of monthly monitoring visits by the provider are held and provide good evidence of detailed monitoring. Formal and informal review of residents’ opinions is sought on a regular basis, house meetings providing a forum for the people who live at Bierton Road to express opinions. Arrangements for safe working practices appear satisfactory. A senior manager is responsible for health and safety across the organisation. A copy of health and safety guidance and policies remains available in the manager’s office. REACH continues to ensure that new staff receive initial training during their induction and probation period in moving & handling, fire safety, first aid, food hygiene and infection control. Risk assessment processes remain well established. A fire safety audit completed in May 2007 by the fire authority records a satisfactory outcome, however suggests that the fire risk assessment should be reviewed regularly. The manager has ensured that a review of fire evacuation guidelines for each house member has been completed alongside a review of guidance and procedures. Fire alarm points, emergency lighting and fire exits are checked weekly. External contractors checked fire equipment, fire alarm points, and emergency lighting in July 2007. It was noted at the previous inspection that one fire extinguisher was free standing on the floor in the office. This has now been firmly and safely mounted on the wall and does not pose a hazard to others. The home had a current gas safety certificate and electrical appliances had been tested. Records viewed verified that the electrical supply installation at the home meets safety standards. Water temperature regulating valves are checked by maintenance monthly. The hot water was recently tested for Legionella. Showerheads continue to be descaled and disinfected monthly. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 25 Staff undertake training in control of substances hazardous to health and health and safety, as well as manual handling, food handling and first aid. Data sheets were in place for cleaning products used at the home, in case of accidental spillage or ingestion. No obvious hazards were seen during the tour of the building. COSHH materials are stored in an outside locked building. Systems are in place for recording accidents. Policies and procedures are available within the home. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 26 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 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 27 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. 1. Refer to Standard YA20 Good Practice Recommendations The manager should ensure that a risk assessment is completed for the use of a portable box to dispense medication. This should ensure that risk is minimised and should ensure safety. REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate 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 REACH Bierton Road DS0000023044.V339576.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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