Inspection on 16/01/07 for Reeves Court

This inspection was carried out on 16th January 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Reeves Court 09/10/09

Reeves Court 30/10/07

Reeves Court 30/11/05

Reeves Court 11/07/05

Reeves Court 28/09/04

Reeves Court 29/06/04

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

CARE HOME ADULTS 18-65 Reeves Court Reeves Court Reigate Road Leatherhead Surrey KT22 8NR Lead Inspector Helen Dickens KeyUnannounced Inspection 16th January 2007 10:00 Reeves Court DS0000036664.V325423.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 Reeves Court DS0000036664.V325423.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. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Reeves Court Address Reeves Court Reigate Road Leatherhead Surrey KT22 8NR 01372 389410 01372 389416 sparish@seeability.org Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) SeeAbility Susan Jane Parish Care Home 25 Category(ies) of Dementia (1), Learning disability (25), Sensory registration, with number impairment (25) of places Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The age/age range of the persons usually to be accommodated wil be: 18 - 65 Years The service may provide care in respect of two named individuals within the category of Dementia (DE). That the residents with dementia are accommodated on the same unit. That 5 residents may be aged up to 70 years. Date of last inspection 30th November 2005 Brief Description of the Service: Reeves Court is located in the SeeAbility complex in Leatherhead, Surrey. It is close to local facilities and amenities. It was purpose-built and divided into four units, one of which is currently empty. Day to day management of Flats 1,2 and 4 is under the supervision of 3 deputy managers, all reporting directly to the manager. To the front of the building is a small pleasant patio area. Reeves Court provides care and accommodation for up to 25 residents in the category of younger adults. Residents have learning and sensory disabilities (visual impairment) and display some degree of challenging behaviour. The basic cost of the service is £1,669 per person per week. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over seven hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager represented the establishment. A partial tour of the premises took place. Discussions were held with three residents and three staff members, and a number of other residents were conversed with during the inspection. Returned ‘comment cards’ from residents, relatives and professionals involved with the home were also used to write this report. Three resident’s care plans and a number of other documents and files, including three staff files, were examined during the day. The CSCI would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation during the inspection. What the service does well: What has improved since the last inspection? Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 6 The four Requirements made at the last inspection have all been met. A number of other improvements have included the Service User Guide and Statement of Purpose being put on audio CD to allow easier access to residents. A new training programme is now in place with extra courses including dementia, autism, person centred planning and epilepsy. The training arrangements are now very well organised and clearly documented. Medication arrangements continue to improve and daily stocktaking has been introduced for some medications. The manager has done the ‘training the trainer award’ and will be delivering medication training for the organisation. Deputy manager meetings have been introduced and these benefit residents because good practice in some units is now spread more easily across the others, and this is leading to a more consistent approach. All resident’s communication passports have now been completed and more access to college placements is being sought, with one resident having already started at a new college, and another on the waiting list. The manager stated that more dynamic birthday treats are being organised for residents including a limousine trip and a helicopter ride. Some service users are also being supported to access a night club in London. A changed interview format for new staff now includes group discussion at the outset to see them in different situations, followed by three written scenarios, and service users get to meet applicants and then give feedback, before the interview takes place. Some decorative improvements since the last inspection have included several resident’s rooms being decorated, and new carpets being fitted on Flat 1. What they could do better: Two new Requirements were made following this inspection. There are some minor decorative issues which need attention and the staff files need to be reviewed to include the information set down in Schedule 2 of the Care Homes Regulations 2001 (as amended). Recommendations include the manager must always have copies of care manager’s assessments in advance, even where residents are admitted as an emergency; all ‘as required’ medications should have guidelines on file to accompany them; the manager should find a way to remind relatives that the complaints procedure and inspection report are available in the home; and should find a method of publishing feedback from residents. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Reeves Court DS0000036664.V325423.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 Reeves Court DS0000036664.V325423.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. Prospective resident’s individual needs and aspirations are assessed prior to being admitted to Reeves Court. EVIDENCE: Three existing resident’s files were examined, as well as pre-admission information and assessments for a prospective resident, due to move in later in the month. Two residents had been at the home for some years and original assessments had now been archived. However, there was plenty of evidence of ongoing assessments and of these assessments informing the care planning and reviewing process for both residents. A third resident’s file had a good record of the pre-admission assessments which had been carried out and documented. Information from the ‘transition’ period where staff from Reeves Court went to observe and engage with the resident for one week prior to admission in their previous setting was also on file. The resident had had input into this assessment and was spoken with on the day of the inspection to confirm they were settling in well. Pre-inspection questionnaires completed by residents showed the majority had received enough information prior to admission and were consulted about moving into this home. The home should ensure that in addition to their own assessments, Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 10 those admitted through care management always have written assessments from the care manager on file. Arrangements were underway for a new resident to be admitted later in the month and the home already had assessments, including documented observations and visits, to the prospective resident in their existing home on file, and had arranged and received training regarding the special communication needs of this resident. Reeves Court DS0000036664.V325423.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s assessed and changing needs and personal goals are reflected in their support plans, and they are encouraged to make decisions in their daily lives. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Three resident’s support plans were examined and found to contain sufficient information regarding resident’s needs and were signed by the resident or their representative. Progress has been made in transferring support plans into more accessible formats for residents – some had been put onto audio CD and others were being translated into widget/picture formats. Some of these plans were now being kept in resident’s own rooms, where this was their wish and where appropriate. Specialist requirements are set out in relation to cognitive ability, communication, daily living skills and the support required; food preferences and routines; continence; emotional needs; behavioural needs; medical supervision; health and safety awareness; and mobility. The support Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 12 plans take into account the visual and sensory needs of residents, and input from the SeeAbility rehabilitation workers is clearly documented. All three plans sampled had been regularly reviewed. Throughout the inspection staff were observed to encourage residents to make decisions and to provide them with relevant information. For example, those residents who agreed to show the inspector their rooms were asked by staff if they wished to make their own way to their room, or if they would like assistance. Those who opted to find their own way were allowed to do this with staff watching from a distance and only offered verbal guidance and reassurance where this was necessary. Staff were observed to encourage residents to dress as they wished, taking steps to intervene only to protect the privacy of residents. Support plans set out resident’s needs in relation to decision making and their communication needs, to ensure resident’s wishes are made known. The two ‘communication passports’ were examined and found to contain both a good overview, and detailed guidance on the assistance these residents needed with regard to communication. The manager has made contact with a local independent advocacy network to see if this service can be made available to residents who may wish to be involved. The home manager has also changed the interview format for new staff which means service users get to meet applicants and then give feedback, before the interview proper takes place. Residents are encouraged to take risks as part of an independent lifestyle and risk assessments are documented on resident’s files. Guidelines for specific activities such as attending day care, going out into the community, and night time guidelines were noted on files. The newest resident had had risk assessments formulated prior to and in the early days of admission. Risks are identified and minimised, and staff have all had health and safety training. Residents are given guidance on their personal safety in their rehabilitation work and this is reinforced by staff. Staff at this home take steps to ensure equal opportunities for residents both within and outside Reeves Court. Visual impairment is not seen as a barrier to a good quality of life and the environment, the services on offer, and staff training, have been designed around resident’s special needs in this respect. Some members of staff are currently undergoing social inclusion training which will enable them to take resident’s independence and equal access to services one step further. Reeves Court DS0000036664.V325423.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to participate in appropriate activities and are part of the local community. Family and friendship links are encouraged and resident’s rights respected. There is a healthy diet on offer and resident’s enjoy their mealtimes. EVIDENCE: Though no residents at this home currently go out to work, they are encouraged to take part in training and to participate in and experience, fulfilling activities. The three resident’s files sampled showed input from the inhouse rehabilitation officer and specific goals which resident’s had been working towards. Across the home a variety of work is being done regarding further education, independent living skills, and literacy and numeracy training. Some residents attend the Millenium Centre which is next door to Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 14 Reeves Court; there they take part in a variety of activities including embroidery, cooking, experiencing the sensory garden, and working on the allotment which is within walking distance of the home. Staff are trying to access college places at a college not used by these residents before; one resident has now started at the college, and another is on the waiting list. The manager said that more dynamic birthday treats were being organised for residents and gave examples of one resident who likes car rides who went for an outing in a stretch limousine for their birthday; another went on a helicopter flight. One Flat’s residents received an enterprise award from the SeeAbility head office – they have set up a craft room in Flat 3 (which is no longer used) making cards and other artistic items and these are being sold and the money ploughed back in for service users. Eight residents with varied abilities have been working on this project mainly designing and producing birthday and Christmas cards, and then going out with staff selling these at local events to members of the public. Staff also encourage residents to keep up and take part in suitable hobbies and this is documented on their support plans, most notably one resident enjoys the drums, and has a large drum kit in his room which he also plays with other resident’s when they have community sessions in the living room. Resident’s at this home participate in local community activities and use local facilities including doctor’s surgeries, the swimming pool and the cinema. Some residents have been going further afield and have been visiting a night club in London. Staff are very aware of resident’s rights, and equal opportunities training is given to all staff. A new external training consultant, will be delivering disability awareness training during the coming year and some staff are already undergoing social inclusion training for a special project within SeeAbility. The manager said residents are encouraged to exercise their right to vote. Residents are encouraged to have family and personal relationships and staff were knowledgeable about resident’s relatives and their level of involvement. There was evidence on some of the files examined that relatives had been involved in the care planning process and in Reviews. Residents are also enabled to maintain existing friendship links and to make new friends. Some residents go to a club in Leatherhead which is aimed at older people, not at people with learning disabilities, which gives them the opportunity to interact with others who do not have the same disability. One resident who was interviewed spoke about a friend they keep in touch with, and shared a holiday with last year; staff support this friendship through offering practical help with keeping in contact and making arrangements to meet. Resident’s rights are respected and their responsibilities recognised in their daily lives. Daily routines promote independence. Each time a staff member enters one of the Flats they ring the bell and announce themselves so that Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 15 residents know who is in their living room. Similarly, when they leave, they also announce that they are about to go. Staff members bringing visitors, also announce those visitors. Residents were addressed respectfully, and their opinions were being sought as a matter of routine throughout the day. Residents are offered nutritious meals and a varied menu. Menus sent in as part of the pre-inspection information showed a variety of foods being on offer and on the day of the inspection a very pleasant lunchtime was observed on one Flat, with residents enjoying noodles with prawns and vegetables. Those residents who needed assistance were offered help in a discreet way and all appeared to be enjoying their meal. The member of staff spoken to confirmed that staff who are involved with meal preparation have had the food handling and hygiene training. Dietician’s advice is sought as necessary and this was noted on one of the three resident’s files sampled. Resident’s input is gained into menus and food choices, and this was seen in resident’s meetings notes. Some residents have healthy eating as part of their goals, and some are involved in cookery sessions at the millennium centre. Reeves Court DS0000036664.V325423.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. 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. Residents receive personal support in the way they prefer and require, and their health needs are met. Arrangements for the administration of medication are good. EVIDENCE: Resident’s support plans have detailed information on how personal care is to be delivered and on communication needs which is crucial to establishing resident’s needs at a particular point in time. Residents were dressed very individually. Privacy screening had been made available in the lounge for incidences whereby immediate assistance might be required. Staff were observed to be protecting the privacy of residents. Reeves Court has a key working system in place which ensures consistency and continuity of support for residents. Aids and equipment were available, and especially tactile items which were used to guide residents who all have visual impairments. Specialist advice had been taken and noted on their support plans. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 17 Healthcare needs are well met at this home with residents choosing their own GPs, and health appointments and specialist assessments clearly documented on resident’s files. On the three files examined, regular medication reviews were noted and dental and ophthalmology checks had been recorded. On one file it was noted that the home had taken advice from a senior dietician who assessed the resident with regard to dietary needs and how that resident should be supported to drink. A medication administration session was observed on one Flat, and three medication records sampled. A gap monitoring system was in place to ensure all residents were given the correct medication on time. Medicines were noted to be kept securely, and the cabinets were clean and tidy. Non-blistered medication (i.e. boxes, packets and bottles) for each resident were kept in a plastic box with their written details and their photograph to ensure the administration of these medicines was as straightforward as possible. In addition, a regular stocktaking system has been implemented for these medicines which the manager stated was working very well. Guidelines were in place for the correct administration of some medicines given ‘as required’ rather than on a regular basis; a recommendation will be made that all ‘as required’ medicines have these guidelines in place. Reeves Court DS0000036664.V325423.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s views are sought, and listened to, and they are protected from abuse. EVIDENCE: The home has a formal complaints procedure with an easy-read summary in words and pictures. Those residents who completed pre-inspection comment cards all knew how to make a complaint. Each flat at Reeves Court has a complaints book with a tactile front cover to enable residents with visual impairments to identify it and take it to a member of staff to talk about their complaint. A total of 10 complaints had been received during the last 12 months and these had been recorded in the complaints book on the relevant Flat; three of these were sampled and found to have been dealt with satisfactorily. Some issues were raised on the pre-inspection comment cards returned by relatives and these were discussed with the manager including two who stated they were not aware of the complaints procedure and seven who did not realise that past inspection reports were available on the reception desk at the home. The manager stated that she would ensure all relatives were written to with this information. A copy of the Surrey multi-agency procedures for the protection of vulnerable adults is available in the home and staff have all been trained on safeguarding vulnerable people. The basic training is now given to staff during induction which is a recommendation implemented since the last inspection. Recruitment procedures include a CRB and povalist check to ensure staff taken on have not been deemed unsuitable to work with vulnerable people. One issue had been Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 19 raised in the last 12 months which was dealt with under the safeguarding adults procedure and the home followed the correct process and dealt with the matter satisfactorily. Reeves Court DS0000036664.V325423.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment which is clean and hygienic throughout. EVIDENCE: Reeves Court provides a homely environment for its residents and fixtures and fittings are domestic in character. A number of improvements since the last inspection have included some internal decoration and new carpets have been fitted. Three resident’s rooms were visited and those residents who could express a view to the inspector said they were happy with their rooms. One resident who was not able to speak with the inspector was observed to have very comfortable surroundings, with their chosen music playing, and curtains, bedcover and other decorations which staff stated that resident had helped to choose. A maintenance worker is employed to deal with health and safety and maintenance matters, and a system is in place for both reporting and monitoring the work that needs to be done. The premises are accessible to Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 21 residents both inside and out and a number of fixtures and fittings have been used to make the environment safer for residents, and to promote their independence. A Requirement will be made to deal with some minor decorative/maintenance matters including one shower which needed regrouting as fungus had formed, and a damp patch in the hallway which needed attention. The laundry facilities on one Flat were inspected and found to be clean, tidy and suitable for their intended purpose. Resident’s are encouraged, where possible, to bring their own laundry to the laundry room and to take away their clean laundry. The home was clean and hygienic throughout and there were no offensive odours. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 22 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): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s are supported by competent and qualified staff. Recruitment practises are good though more work needs to be done to meet this Standard in full. Resident’s needs are met by appropriately trained and supervised staff. EVIDENCE: SeeAbility head office uses the Residential Forum Matrix recommended by the Department of Health to calculate the resident to staff ratios – the manager stated that she informs them of the level of resident’s needs and they then calculate staff quotas. There were sufficient staff on duty on the day of the inspection to meet residents needs. There were also sufficient staff available who were able to communicate with residents; several staff were approached to assist in communicating with individual residents during the tour of the home and all found to be competent, at ease with residents, and good at interpreting their needs. Some concerns had been raised on staffing numbers by relatives on their pre-inspection comment cards; these were highlighted to the manager. One issue had already been satisfactorily dealt with. There are regular staff meetings (monthly). Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 23 Recruitment arrangements include candidates completing an application form, attending an interview and a group session at the home, as well as written exercises. The home also encourages residents to be involved and to give feedback on potential staff. The home takes up CRB checks and povalist checks on all candidates to ensure they have not been deemed unsuitable to work with vulnerable adults. Three staff files were sampled and found to be satisfactory except for the incomplete employment history of two staff members. A Requirement will be made that full information is collected for staff as set down in Schedule 2 of the Care Homes Regulations 2001 (as amended). The training programme for the year was sampled and the manager stated that there is a dedicated budget for training; she is responsible for this and it was noted that training arrangements have improved since the last inspection. Training is now more organised and better documented, and fits with the common induction standards to ensure new staff get relevant and sufficient training within the recommended timescales. Arrangements for staff supervision are excellent - three staff files were sampled and showed staff have monthly supervision sessions which exceeds the 6 sessions per year as set down in the National Minimum Standards. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home and their views are taken into account in reviewing and developing the home. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The registered manager is qualified and competent and has 10 years experience as a manager. She completed the NVQ4 and Registered Managers Award in 2004 and maintains her own ongoing training including vulnerable adults, manual handling and health and safety training in the last year. She has also completed a project management course and is a member of the Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 25 Chartered Institute of Management. All SeeAbility managers are currently attending a management development training course. The manager has overall responsibility for ensuring that the home’s objectives are met, policies and procedures followed, and that the home complies with CSCI and other legal requirements. SeeAbility has an internal quality assurance system which includes; • Annual questionnaires from head office for each resident • Resident’s meetings on each Flat • Annual Reviews of resident’s needs • An annual development/business plan • Regulation 26 visits arranged by the provider • Staff supervision and meetings, and a staff survey • Senior team meetings The information from the resident’s questionnaires is collated at head office and the manager stated that the results/feedback are then printed off and discussed at residents meetings. The manager was asked to think about how the results of these surveys might be made available to a wider audience. Resident’s views are actively sought at this home and one of the improvements since the last inspection has been the introduction of residents participating in the recruitment process. Health and safety is taken seriously at this home and a number of measures are in place to keep residents safe. For example, health and safety training and manual handling training are given to all staff. An internal health and safety audit has recently been carried out. The manager stated that they were awaiting feedback form this audit but there were no major shortfalls. The manager is responsible for health and safety though a number of tasks are delegated to other staff including the maintenance worker who oversees the water safety checks. A number of fire safety measures are in place including quarterly fire practices, a video on the first day of induction for new staff, and 2 chief fire marshals have been appointed. Fire safety notices are displayed throughout the home. The home was correctly displaying its CSCI registration certificate and an up-to-date Employers Liability Insurance certificate. Reeves Court DS0000036664.V325423.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 3 33 X 34 2 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 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 3 X 3 X X 3 x Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(b) Requirement Timescale for action 16/02/07 2. YA34 19(4)(b)(i) The premises must be kept in a good state of repair with particular reference to the shower cubicle which needs regrouting/cleaning, and one part of a corridor wall which needs redecorating. 16/02/07 The registered person shall not employ a person to work at the care home unless the employer has obtained in respect of that person the information and documents specified in paragraphs 1-9 of Schedule 2 of the Care Homes Regulations 2001 (as amended), and in particular, a full employment history. 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 YA2 Good Practice Recommendations The registered person should ensure that, in addition to DS0000036664.V325423.R01.S.doc Version 5.2 Page 28 Reeves Court 2. 3. 4. YA20 YA22 YA39 their own assessments, residents admitted via care management always have written assessments on file from the care manager. The registered manager should ensure there is guidance on file for all ‘as required’ medications, including creams and lotions dispensed by the pharmacist. The registered person should ensure that all stakeholders are reminded about the complaints procedure, and how to access CSCI reports about this home. The registered person should explore suitable methods of publishing feedback from residents. Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Reeves Court DS0000036664.V325423.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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