Inspection on 15/09/06 for REACH Sistine Manor

This inspection was carried out on 15th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

REACH Sistine Manor 10/07/08

REACH Sistine Manor 26/07/07

REACH Sistine Manor 13/03/06

REACH Sistine Manor 30/03/05

REACH Sistine Manor 12/11/04

REACH Sistine Manor 03/03/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Sistine Manor Stoke Green Stoke Poges Bucks SL2 4HN Lead Inspector Mike Murphy Unannounced Inspection 15th September 2006 10:00 Sistine Manor DS0000023021.V304007.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 Sistine Manor DS0000023021.V304007.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. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sistine Manor Address Stoke Green Stoke Poges Bucks SL2 4HN 01753 531869 01753 511873 N/A www.Reach-disabilitycare.co.uk REACH Limited Mrs Nasrin Saeedi 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) Care Home 18 Category(ies) of Learning disability (18), Physical disability (3) registration, with number of places Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 18 service users with learning disabilities, three (3) of whom have additional physical disability 13th March 2006 Date of last inspection Brief Description of the Service: Sistine Manor is a large and spacious detached house, which offers residential care to adults with learning disabilities. The home is located on the edge of Stoke Poges village and within reach of the amenities of the village and Slough town centre. It is also conveniently situated for Wexham Park Hospital. The home is set in large enclosed grounds and there is sufficient on site parking to the front and side of the home. The home is registered for 18 service users between the ages of 18 and 65 and at the time of this inspection there were 14 service users living at the home. 16 of the 18 places are in the main home. Two places are in a separate building, the ‘Coach House’, and are considered suitable for service users who have more independent living skills. The home is run by REACH (Rehabilitation Education And Community Homes Limited) which has its head office in Gerrards Cross. The fees at the time of this inspection were between £706 to £1,414 per week. Sistine Manor DS0000023021.V304007.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 by one inspector over two visits. The methodology included discussions with the operations manager and staff, interaction with service users, observation of care, examination of documents, consideration of pre-inspection material submitted by REACH, a walk around the home over the two days, and consideration of comment cards returned by service users, relatives and health and social care professionals. The inspection finds that this service is generally well managed. It did not have a manager in post at the time of this inspection. It is hoped that REACH will be successful in making an appointment soon. The investment in improving the quality of the environment is continuing and is appreciated. The home is a large and spacious older building which is always likely to require an ongoing programme of refurbishment. On this inspection it is felt that the kitchen would benefit from some improvement in the near future. The home provides for a diverse range of needs and the quality of care of service users is generally good. This is confirmed by relatives who communicated their views to the inspection via comment cards. Three concerns arising from the inspection are an apparent reduction in opportunities for service users to benefit from education and training opportunities in the community, the lack of progress in progressing the PCP (Person Centred Plan) care plan format, and specialist training for staff. The first of these may be outside the home’s control but it does leave a significant deficit in the range of activities and has an adverse impact on the quality of life for some service users. Lack of progress on PCPs was evident through the uneven quality of care plans – some of which were excellent while others were basic with a lot of sections not completed. PCPs are more than just a paper exercise, however, and managers will need to consider what approaches might best be used to establish good practice here. It is also felt that there is a need for some specialist training for staff. The current state of the LDAF (Learning Disability Award Framework) was discussed with the operations manager. This is currently being ‘redesigned’ by Skills for Care and Valuing People Support Team. REACH offers training in ‘challenging behaviour’ and ‘culture awareness’ and is making progress on NVQs Levels 2 and 3. An earlier inspection suggested that training in autism and related subjects should be considered by senior managers. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Undertake a thorough review of activities with stakeholders to ensure that the home is exploring and utilising all avenues of community support in assisting service users develop independent living skills. Managers should address current weaknesses in Person Centred Plans (PCPs) through audit, staff training and supervision, and review of the current structure if considered necessary. It is recommended that the managers include training in autism and related subjects in the staff training programme for 2006/07/08. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sistine Manor DS0000023021.V304007.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 Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems for conducting assessments at the point of referral and on admission. These are designed to ensure that it does not admit someone whose needs it cannot meet, and that it is able to meet the needs of those who accept the offer of a place. EVIDENCE: The home has not admitted a new service user since the last inspection in March 2006. What follows is a description of the process the home follows in managing a referral. Referrals are made to REACH head office where the initial referral information is considered by a director and the operations or care services manager. Referrals accepted at that point are moved forward to the next stage which involves meeting the prospective service user and family, further consideration of information supplied by the referring care manager, and completion of REACH’s own assessment documentation. Where it is felt that admission to the home is a likely outcome then the home manager becomes involved in the process. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 10 The aims of the process are to ensure that the person’s needs are properly assessed and that the home does not admit someone whose needs it cannot meet. A further assessment is conducted on admission and a key worker allocated to organise the service user’s care. Key organisations in supporting the home in meeting the service user’s health needs are the GP and Community Learning Disabilities Team (CLDT). The home would expect to work closely with each as appropriate. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed and the home liaises with NHS and social care agencies as required. However, the overall standard of care planning is variable, in some cases with sections of care plans not completed at all. This may lead to service users assessed needs not being fully met. EVIDENCE: Three care plans were examined. The uneven standards found at the last inspection remain. All three care plans had sections which had not been completed even though the service users had been service user in the home for sometime. The headings of these section seemed quite significant e.g. ‘Goals’, ‘Progress to Goals’, ‘Life Path’, ‘Support Requirements’, ‘Monthly Summary Sheets’, and ‘Daily Service Record’. Progress on PCPs (Person Centred Plans) since the last inspection was not evident. In spite of this however, each of the care plans examined had a comprehensive assessment of need. The home’s own assessments were supplemented by information provided by NHS and social services professionals. The support plan based on these assessments varied. Some were detailed, well constructed Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 12 and relevant to the assessment of needs. However, one had little information to guide care and had two out of three pages left blank. It was difficult to assess the extent to which service users have been involved in drawing up their support plan. Risk assessments were generally good and covered a wide range of day to day activities. Review intervals varied but all three support plans examined showed evidence of having been reviewed in the six months prior to this inspection. Staff support service users in making day to day decisions and would assist a service user who wished to contact the ‘People’s Voices’ advocacy service in Buckinghamshire. Examples of service users participation in the running of the home includes working alongside staff in clearing tables after meals, shopping in Slough, picking apples in the garden, taking clothes to the laundry (across a courtyard), vacuuming the home’s car, and participating in the monthly house meetings (of which notes are kept). Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a varied programme of activities aimed at supporting service users in developing and maintaining social and independent living skills. However, the availability of educational and training events provided by colleges and other organisations seemed uncertain and it was not clear how this deficit was being addressed on behalf of service users. Meals are varied and appear to meet the nutritional needs of service users. EVIDENCE: Staff support service users participation in a range of activities. Two service users attended church. Two had aromatherapy and massage twice a month (for which there is an additional charge). At least six service users participated in art therapy once a week (at additional charge). All service users are invited to participate in music therapy once a fortnight. Five service users go to a farm and garden once a week. Two female service users went horse riding once a fortnight (small charge applies). Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 14 On the first morning of the inspection, seven service users were in the home, four were out horse riding (with two staff), one was in hospital, and one was on holiday with his parents. The situation with regard to service user’s attendance at college over the coming term was unclear at the time of this inspection in September 2006. The operations manager said that at least four service users would benefit from attending but the home had not yet been notified of the college’s intention to run suitable courses. It was reported that Uxbridge college had recently had its specialist courses funding withdrawn, while Langley and Chesham colleges had not yet informed the home that they would be running courses over the 2006/2007 academic year. While this is outside of the control of the home it did leave a deficit in the range of activities available to service users. It was not clear what alternatives were being explored by REACH or what representations the organisation was making to relevant agencies on behalf of service users. About six service users attended social clubs on Tuesdays (British Legion), Wednesday (‘The Wednesday Club’) and Thursday (‘Mencap’). Two to three service users went swimming occasionally. Informal outings with staff included visits to pubs or restaurants, walks in the local park, shopping in Slough or Windsor, going to the cinema in Slough, bowling in Maidenhead, a recent sports day in Stoke Poges, and this years tenth anniversary of the founding of REACH. Service users birthdays are celebrated in the house. The home has TV, DVDs, videos, a music centre, garden games, board games, books and magazines for use as desired. Staff support service users in remaining in contact with their families. Around nine out of thirteen service users were said to maintain regular contact. REACH has a policy to guide staff with regard to sexuality and relationships. Daily routines are flexible where service users are not committed to appointments in the community. It was reported that most choose to get up early for breakfast. Three service users have keys to their rooms. Staff do not open service users mail. Staff interactions with service users were observed to be supportive. The home has a dog. Service users participate in menu planning using picture menus. Meals are prepared by a cook on weekdays and by care staff at weekends. There are two dining rooms. Breakfast is served between 07.30 and 09.30 and consists of fruit juice, cereals, toast and tea or coffee. Lunch is served between 12.30 and 2.00 pm and is a snack meal. The evening meal, served between 5.00 pm and 7.00 pm, consists of two courses and is the main meal of the day. Staff reported that a significant number of service users had appeared to put on a little weight recently and that a healthier diet was under consideration. Some service users were observed to have high levels of activity over the course of Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 15 the day and staff said that small snacks would be provided between meals where required. Drinks are available at all times. Mealtimes were observed indirectly and service users were allowed time to eat at their own pace. None required assistance other than supervision. It was reported that some service users participate in preparing meals at weekends. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for the personal support and healthcare of service users appear satisfactory and ensure that service users are appropriately supported and can access NHS and other healthcare services where required. Arrangements for the storage and administration of medicines were in order and aim to ensure that medicines are administered as prescribed and to minimise the risk of errors in administration. EVIDENCE: Staff adopt a flexible approach when providing care. Support and encouragement is provided as required. Personal care is provided in service users bedrooms or bathrooms. Service users choose their own clothes and hairstyles. The multi-ethnic mix of staff and service users include individuals from the United Kingdom, Czech Republic, Colombia, Italy, Kenya, and Ukraine among others. All service users are registered with a general practitioner. Specialist learning disability and mental health services are accessed through the Community Learning Disability Team (CLDT). Dentists and opticians are accessed through referral although routine dental examinations are available six monthly. A Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 17 chiropodist visits the home very six weeks (additional charge is made). Speech therapy is accessed though the CLDT. Massage, Art and Music therapists visit regularly – an additional charge is made for such services. Psychology, Psychiatry and community psychiatric nurses (CPNs) are accessed through the GP or CLDT. The home is required to conform to REACH policy with regard to the control and administration of medicines. This was last reviewed in June 2004. Medicines are prescribed by the service users GP and dispensed by a local pharmacy. Records of medicines received to the home and returned to pharmacy are maintained. Most medicines are supplied in monitored dosage systems, are stored in a locked cabinet in a locked office, and are usually administered at mealtimes. References available to staff include the British Medical Association guide to Medicines and The Royal Pharmaceutical Society of Great Britain guidelines on the control, storage and administration of medicines in care homes. The operations manager reported that six staff had attended an ASET accredited course on medicines at East Berkshire College. This includes some distance learning using CD-ROM training materials. The arrangements for the storage of medicines appear satisfactory. Cupboards were clean and tidy and no excess stock was noted. The home has a protocol for ‘PRN’ medicines which includes additional recording. Mars sheets examined were in order. It is noted that the Regulation 26 report for August 2006 included a review of ‘Medications and Storage Record’. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is required to conform to REACH policy and procedure on complaints. The present procedure is not appropriate to the needs of service users. This may mean that complaints by service users are not recorded, or not progressed where the service user is not satisfied with the initial response of the home. Policy and procedures for the protection of vulnerable adults are satisfactory and ensure that staff are aware of the issues, that reporting systems are in place and that the chances of abuse occurring are minimised. EVIDENCE: The home is required to conform to REACH complaints policies and procedure. This has not changed since earlier inspections, where, it was felt, the requirement to put a complaint in writing was inappropriate, given that most service users will have a significant degree of impairment in communication. While there is no reason to believe that the home is not responsive to complaints REACH policy and practice needs to take account of the abilities of service users. The policy was under review at the time of this inspection. REACH has a policy on adult protection and on whistleblowing and the subjects are included in staff induction and other training events. A team leader is an approved trainer. Staff spoken to were aware of reporting systems within the organisation and had confidence that any reports of abuse would be fully investigated. Training in non-violent intervention is carried out by a senior REACH manager as part of training on ‘Positive Approaches to Challenging Behaviour’. An Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 19 advocate from the Amersham based advocacy service ‘Peoples Voices’ regularly visits the home. Systems for managing service user’s monies appear satisfactory. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is a relatively large building with a good sized garden which provides space for service users. The home is conveniently located for local services and is a relatively short distance by car for the amenities of Slough town centre. This provides opportunities for service users to access a range of facilities in the local community. A number of areas of the home have recently been refurbished which provides a pleasant and comfortable environment for service users. EVIDENCE: The home is a large detached house in the village of Stoke Poges. Slough town centre is a relatively short distance by car, bus or taxi. The home has a large and secure garden to the rear and a large pick up/drop off and car parking area to the front. Entry to the home is controlled by staff. The front gates are closed at night. The main house accommodates 16 service users and an adjacent coach house 2 service users in a first floor flat. The premises provide spacious accommodation. The home does not have a lift and there are no ramps for access to the garden or front of the house. Two service users use Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 21 wheelchairs occasionally. A service user who required a wheelchair on a more permanent basis would have to have a bedroom on the ground floor. A programme of refurbishment and redecoration has been under way for the last couple of years and evidence of this continuing was observed on this inspection. The ground floor accommodation includes a large entrance hall, kitchen, two dining rooms, a large lounge, staff work station, a sensory room and a bedroom which has recently been refurbished and which now includes en-suite facilities (shower and WC). The kitchen is of adequate size for current use. It is adequately equipped but would benefit from refurbishment in the near future. Tiles were noticed to have fallen off from a lower wall, the melamine veneer in the store cupboards and shelves had split in a number of places, the paint on many of the cupboards was washing off on cleaning. New freezers had been obtained since the last inspection but it was noted that an old rusted freezer and old cooker had not been removed from the outside store room. The kitchen was clean and tidy but containers of food stored in the fridge had not been labelled. Across a small courtyard is a games room, laundry, store area (with freezers) and entrance to a self-contained two bedroom flat. The flat was not in use at the time of this inspection. The accommodation comprises a living/dining room, two single bedrooms, kitchen, bathroom and WC. The garden is a pleasant area, large, with areas of lawn, mature shrubs and trees and which is reasonably secure. It provides plenty of space for service users. The garden was in regular use on both days of this inspection, both for a group activity (an outdoor game) and for individuals to just find space or chat to each other or with staff. Stairs lead to the first floor. This includes the manager’s office and the medicines store room. Bedrooms vary in size. Two were inspected with the service users’ permission. Both were of good size, comfortably furnished, clean and tidy and decorated in line with the wishes of the occupant. There are nine WCs and five bathroom around the home. One bedroom was being redecorated. New carpets had been laid on a stairs and landing. A new door had been fitted to the manager’s office. The lounge is large, bright and quite well furnished. It has a TV, music centre, radio, games and magazines. There are two dining rooms – one large and one small – both suitably furnished. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 22 The laundry is situated in a separate building across a courtyard. A laundry assistant is employed for 25 hours a week. Flooring appeared impermeable. The area was tidy, clean and well organised and seemed sufficient for the needs of the home. Standards of cleanliness were generally satisfactory but some bathrooms and WCs might have benefited from more frequent inspections and cleaning where needed. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are considered sufficient to meet the needs of current service users. Staff recruitment procedures are generally satisfactory but weaknesses in the status of references accepted may potentially expose services users to risk. The staff training programme provides staff with knowledge and skills required to provide care to service users. EVIDENCE: Care staff have job descriptions. Copies of job descriptions and person specifications for ‘House Manager’, ‘Team Leader’ and ‘Residential Support Worker’ were provided with other papers for this inspection. Job descriptions include reference to the achievement of the home’s aims and the promotion of service user participation in running the home. Staff are informed of the aims and values of the home through induction, supervision, training and development, and staff meetings. Staff are supplied with a copy of the GSCC codes of practice. The home does not employ volunteers other than those employed by a local advocacy organisation – ‘Peoples Voices’. At the time of this inspection the home had 15 care staff and 3 ancillary staff. Five care workers had achieved NVQ2 and one an ‘Advanced GNQ’. Three care workers were studying towards NVQ 3 and one towards NVQ 2. The staffing Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 24 also includes five care staff who are qualified as nurses in Bulgaria. Therefore, 40 of care staff had acquired NVQ 2 or above. This does not include the skills contribution of the Bulgarian qualified nurses for which NVQ equivalence has not yet been agreed for this purpose. The present staff establishment allows for 4 staff in the morning, four in the afternoon and two waking staff at night. Staff recruitment is co-ordinated by the human resource department of REACH in Gerrards Cross. Applicants are required to complete an application form, supply two references, have an enhanced CRB certificate or ‘POVA first’ and supply medical information prior to taking up post. Overseas staff supply a CV via a recruitment agency under contract to REACH. All staff are interviewed by senior managers. Three staff files were examined. Two files conformed to the standard – although in one case the offer letter of employment was dated 13 days after the person started work. While this may not be desirable the offer letter simply confirms what has been agreed between the prospective care worker and the appointing manager prior to appointment. It was noted in the third file that both references were ‘open’ i.e. not specific to REACH, Sistine Manor or the position. Staff training and development is organised from the human resources department. A copy of staff training for 2004, 2005 and 2006 was provided with other papers for this inspection. This provided details of staff attendance on training in ‘Moving & Handling’, ‘Food Hygiene’, ‘Health & Safety’, ‘First Aid’, ‘Fire Safety’, ‘Culture Awareness’, ‘Dementia Care’, ‘Challenging Behaviour’, ‘POVA’, ‘Written Records’, ‘Epilepsy’, ‘Medication’, ‘Foundation in Care Cert.’, NVQ2 and NVQ3. The issue of training in subjects specific to learning disability was discussed. The LDAF (Learning Disability Award Framework) did not appear to feature in training programmes in the sector at present (enquiries after this inspection found that the LDAF is currently being redesigned to fit with Skills for Care Common Induction Standards and NVQ levels two and three although the original LDAF Induction/Foundation units may be used until new LDAF units are available). Reach provides ‘Cultural Awareness Training’ and emphasises the importance of the principles of normalisation in its induction programme. One to one supervision of staff is established and staff files examined during the course of the inspection showed that supervision sessions are generally held monthly. All staff have an annual appraisal which is a structured process and includes consideration of training needs and objectives for the following year. Staff were observed to work alongside services users offering support and guidance where required. Staff spoken to were positive in their views on their jobs and about the home. They confirmed REACHs investment in training and Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 25 had a view of further, higher level, training they would like to undertake in the near future. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This is generally a well managed home and feedback from service users, relatives and a health care professional indicate satisfaction with the service it provides. Arrangements for health and safety are generally satisfactory although more attention appears to be required in record keeping (in health and safety records) in order to ensure that it maintains a safe environment for service users. EVIDENCE: The position of manager was vacant at the time of this inspection. The vacancy was being advertised. In the meantime the operations manager and service development manager provided managerial support and leadership to the home. A major quality assurance activity for REACH is the annual stakeholder survey. A summary report of the results for 2006 was provided for the inspection. Sistine Manor accounted for 25 of 76 questionnaires circulated and for 5 of 25 forms returned. The lead manager responsible for the survey expressed Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 27 disappointment at the return rate of 33 (25/76 questionnaires) on this occasion. Although it may not be advisable to draw too many conclusions from such a small sample and in particular to identify those which apply to Sistine Manor as distinct from the other three homes in the survey, it was felt that the results gave some indication of the level of stakeholder satisfaction with regards to the quality of notes of review meetings, providing information on complaints, menu planning, food preparation and overall satisfaction with the services. The organisation provide regular and informative Regulation 26 reports to the CSCI. Service user meetings are held monthly. Relatives views are often sought (apart from the stakeholder survey) at parties, barbeques and other informal gatherings. It was said that some relatives keep in touch with service users and staff via webcam. 13 comment cards were returned in connection with this inspection. Relative respondents expressed satisfaction with the overall care provided. Additional comments included ‘We are very satisfied and know that [name] is very happy at Sistine’ and ‘The environment is warm and caring and staff do try to understand my [relationship] and meet needs. Some of the staff are particularly thoughtful and creative in their approach. I have no doubt that every staff member I have met is doing the best they can. There appears to be a good team spirit there which is consciously fostered’. A healthcare professional respondent also expressed satisfaction with the service and had not received any complaints about it. All nine service user respondents indicated that they liked living in the home, felt well cared for, felt that the staff treated them well, thought that the home provided suitable activities and felt safe living there. A few expressed ambivalence about being more involved in decision making and seemed unsure as to who to speak to if unhappy. Service users may have been assisted in completing the questionnaire by staff although this is not to suggest that staff influenced the responses. The organisation has systems in place for ensuring that staff receive training in moving & handling, food hygiene, fire safety, first aid and control of infection. The home was inspected by a fire officer in July 2006 and the operations managers said that the recommendations of that visit had been implemented. A fire drill was held in March 2006 and another was due around the time of this inspection. A team leader is responsible for testing the fire alarm weekly. According to information supplied by REACH in the pre-inspection questionnaire the gas installation was checked in March 2003. All hot water outlets in areas to which service users have access are regulated. PAT (Portable Appliance Testing) was carried out by an electrician in January 2006. The bath hoist was checked in March 2006. It was noticed that the window in the manager’s office on the first floor can be opened wide. Since service users were observed to make frequent use of the office this window should be risk assessed and either have restrictors fitted or other control measures be implemented. Some records could not easily be located in the home at the Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 28 time of the inspection and managers should check that these are in order and retrievable for future reference: the gas installation (e.g. cooker and other appliances), the current waste contract, COSHH data sheets, records of Legionella testing at hot water storage points and shower heads, and fire equipment contractors check (fire alarm points, smoke and heat sensors, emergency lighting, and fire fighting equipment). REACH has a contract with Peninsula consultants for advice on health and safety matters. Processes for conducting risk assessments are good. Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 29 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 2 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 2 X 3 X X 2 x Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 30 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 Requirement Managers are required to review the home’s complaints procedure to ensure that it is appropriate to the needs of service users (earlier timescale of 28/02/06 not met) Managers are required to review the quality of the environment in the kitchen and ensure that it provides a safe environment for users. This must include replacing loose tiles and repairing or replacing damaged or worn cupboards Timescale for action 30/11/06 2 YA42 13 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA4 Good Practice Recommendations It is recommended that if the home wishes to retain the option of accepting emergency admissions, that managers draw up a policy and procedure to manage the process, taking account of the increased risk factors in such DS0000023021.V304007.R01.S.doc Version 5.2 Page 31 Sistine Manor circumstances. 2. YA35 It is recommended that managers review staff training needs. This should include training on autism and related conditions. It is recommended that managers conduct a review of the programme of activities and that this include taking account of the views of service users, staff, families, care managers, and current good practice in the specialty. It is recommended that managers consult with relevant organisations in the community to address the deficit in the range of daytime activities caused by the withdrawal of courses in training and education. It is recommended that the window in the manager’s office on the first floor either have restrictors fitted to ensure the safety of service users or that a thorough risk assessment is carried out and written up. It is recommended that the old freezer and cooker be suitably disposed of if no longer to be used. 3. YA14 4 YA12 5 YA42 6 YA24 Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sistine Manor DS0000023021.V304007.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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