Inspection on 20/09/05 for Roman Court (1)

This inspection was carried out on 20th September 2005.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roman Court (1) 18/08/09

Roman Court (1) 02/08/07

Roman Court (1) 12/07/06

Roman Court (1) 01/03/06

Roman Court (1) 17/03/05

Roman Court (1) 14/10/04

Roman Court (1) 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Roman Court (1) 1 Roman Court Broadfields Pewsey Wiltshire SN9 5DS Lead Inspector Tim Goadby Unannounced Inspection 20th & 21st September 2005 10:00 Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Roman Court (1) Address 1 Roman Court Broadfields Pewsey Wiltshire SN9 5DS 01672 564412 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mrs Carol Bottoms Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2005 Brief Description of the Service: Valued Lives is a private organisation, which operates 5 care homes for adults with learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered persons, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough or Devizes are within 15 minutes’ drive. Or, slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to transport service users. They contribute towards the costs of these. Most service users now cared for by the organisation have been with them for a number of years. Time may have been spent in more than one of the homes that Valued Lives operates. Valued Lives also operates the Activity, Opportunity & Development centre (AOD). This is a day care facility which most of the organisation’s service users access, for at least part of each week. They pay a small weekly sum towards this. The unit is attached to the home in Ball Road, Pewsey. Roman Court is in Broadfields, Pewsey. The home cares for up to three people. The present occupants are all male. All have single rooms, one of which is now on the ground floor. There is an upstairs bathroom, and a separate toilet downstairs. Communal areas are also downstairs. There is an enclosed garden area at the back of the house. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in September 2005. All 5 Valued Lives services were visited over the course of 2 days. There are many common features across the organisation. So, where appropriate, inspection findings have been applied to each establishment. The lead inspector was accompanied for part of the first day by the pharmacist inspector, who checked medication systems and practice. A total of 12 inspector hours were spent carrying out these unannounced visits. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; discussions with service users, staff and management; tour of the premises. What the service does well: What has improved since the last inspection? The organisation has a clear lead from Mrs Abbott. All staff understand what is expected of them. Each service works towards the same ends. This brings some strengths. However, it is also important to ensure that the individuality of service users is respected. Recent regulatory work has therefore focused on ensuring that the organisation’s approach is clearly agreed, regarding how it is Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 6 applied to each person. Progress is gradually being made on this, and further information had been put in place since the March 2005 inspections. Permissions from GPs about the giving of non-prescription medications – known as ‘homely remedies’ – were updated in June 2005. What they could do better: Clear evidence needs to be in place to show that all service users have updated individual contracts, and terms and conditions of residence. Documentation needs to be signed either by the service user themselves, or, more probably for this home, by a representative. The example seen at this inspection, dating from April 2003, was signed only on behalf of Valued Lives. One service user has significantly changing personal care needs. They are no longer able to manage the stairs at Roman Court, so are now having baths a couple of times each week at another of the organisation’s homes. Here, they are assisted by staff to go up and down the stairs, and to get in and out of the bath. No specific care plan guidelines were seen for this practice. There had also been no involvement of any relevant professionals, such as occupational and physiotherapists, to assess the support being given to the individual by staff. This would ensure that it is safe for all parties. These specialists could also advise on any adaptations or equipment that would help the individual to continue accessing bathing facilities for as long as possible. There needs to be clear guidance in place about the use of any medication which is prescribed to be given ‘as required’. Because this means that a final administration decision has to be made by staff, it is important to show that these judgements are made consistently. Guidelines should be checked with the prescribing doctor, to ensure that they are in line with the actual intentions. There are strategies in place for management of any behavioural needs. These are clear and well presented. But they date from January 2003, without evidence of subsequent review. They also need to show more clearly who has been involved in deciding on the approach taken. The organisation has yet to fully implement a quality assurance system. The tool that they have purchased needs to be adapted so that it can be applied practically to the small scale services operated by Valued Lives. The approach taken also needs to ensure that the views of service users, relatives, and other relevant people are obtained. From completion of a quality audit, the organisation needs to generate a development plan. This can focus on any identified strengths and deficits, across all areas of service delivery. Goals for improvement can then be set, against which future progress can be measured. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 7 Care plans and associated information are comprehensive, but not always easy to work through. Condensing the range of documents, and making key current issues more prominent, would be helpful for accessibility. Where people have needs that are changing quite quickly, a system that enables quick reference to the latest position is beneficial. It is also important that information about individual choices, and any restrictions felt to be necessary, is in place, and kept under review. This will demonstrate that the approach taken is agreed by all relevant persons to be suitable to each service user. Signing and dating of key documents can contribute towards showing appropriate practice. 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. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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): 3&5 Standards relating to admissions to the home were not applicable at this inspection. Service users have their needs and aspirations met by the home. Not all service users have evidence of approved current individual terms and conditions of residence in the home, placing them at risk that elements of their support may not have been confirmed to be in their best interests. EVIDENCE: There had been no admissions to the home since the previous inspection, in March 2005. All service users at Roman Court have lived within Valued Lives for a number of years. They have therefore established their routines. There has also been continuity and stability in the staff team. Many have several years’ experience. This has given them a depth of knowledge regarding service users. Service users are given assistance and support with personal care as required. They are able to access a range of health care services. Relevant professionals and therapists are involved in addressing individual needs. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 10 Education, occupation and leisure opportunities are all provided by the organisation. Valued Lives is in the process of implementing individual contracts for all service users. The documents are being signed by relevant representatives of the users, as review meetings take place. Evidence could not be found in the sampled service user file at this inspection that this had been completed. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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&9 Service users have their abilities, needs and goals reflected in their individual plans. Changes to content and presentation could make documents easier to use, and enable evidence of review to be clearly shown. Service users are supported to take risks and access opportunities. EVIDENCE: Valued Lives has developed an extensive care plan format, covering a full range of topics. Information relevant to each individual is set out under these headings. Where appropriate, risk assessments are also conducted on certain areas. Daily folders for each service user also contain a lot of relevant information. Key areas are monitored and charted. Ongoing care records contain a good level of detail about people’s health, mood, behaviour, and activities undertaken. There is evidence of consultation with other professionals, providing a clear picture of how somebody’s needs are identified and addressed. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 12 The amount of information in place means that it can be difficult to quickly identify current issues and themes for each individual. Different documents on the same topic are not necessarily filed directly next to each other. The comprehensive nature of the main care plans makes completing and updating them a major exercise. At the time of these inspections most had been removed from the individual homes, whilst Mrs Abbott was working on them. This made them unavailable for ready reference for a time. Condensing the range of current information, and making key current issues more prominent, would be helpful for accessibility. Where people have needs that are changing quite quickly, a system that enables quick reference to the latest position is beneficial. It is also important that information about individual choices, and any restrictions felt to be necessary, is in place, and kept under review. This will demonstrate that the approach taken is agreed by all relevant persons to be suitable to each service user. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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, 14 & 15 Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. EVIDENCE: Valued Lives aims to meet all of its service users’ needs. Day care is provided in the Activity, Opportunity & Development centre (AOD), which is attached to the home in Ball Road, Pewsey. Here, people are able to participate in a programme that includes a mix of craft activity, musical experience, story telling, and environmental awareness. Work includes annual projects, which result in something tangible that service users have been involved in producing. The organisation has invested in a range of materials and equipment that can be used for various sessions. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 14 The unit is facilitated by care staff. They do not have any specific training in the provision of a day service. But users appear to enjoy attending it. Additional external facilities are not routinely considered. Weekly programmes for all service users were under review, following the withdrawal of Valued Lives from another local day service facility that it had been involved with. When not attending the AOD, people have one-to-one staff time to undertake other activities. Service users from different homes will link up for this. The sessions offered are based on the known likes and preferences of each user. Physical activities, such as trampolining, are accessed at a centre near Marlborough. There is regular use of community facilities, including local shops and pubs. Further afield, people access various leisure amenities. For instance, trips to the cinema or theatre, and ten pin bowling. Once a fortnight, most users attend a local club for people with learning disability. All service users’ birthdays are marked with parties. Key events in the year, such as Easter and Christmas, are also celebrated. All service users are given the opportunity of holidays at a caravan owned by the organisation. They pay an annual contribution towards its ground rental. They are then able to use it at no further cost, other than holiday spending money. The caravan can accommodate up to 8 people at a time. But groups go in varying sizes. Length of break can also be tailored to individual needs. The caravan is also close enough to be able to bring someone home without great difficulty, if that is needed. Users may also have other holiday opportunities. Some go away with their own families. There are also regular activities in each home. Individual service users have activity boxes, containing items of interest to them. Hobbies include jigsaws, knitting, and writing. A number of people have pets. In addition, animals are regularly present in each home. The organisation believes in the beneficial therapeutic effects of such contact. Service users are supported to maintain family contact as required. Various people have regular set arrangements for this. This may be at home, or involve users being taken to visit their families. The organisation provides transport when relatives live some distance away. Users are charged fuel costs for these journeys. This is usually shared, as a number of people will be on the same trip. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 15 In addition to these planned contacts, homes keep relatives informed of any significant issues affecting their family member. Families are always invited to attend review meetings for the relevant service users. They have also been involved in developing care plans, particularly by helping to compile people’s life histories. Peer support is gained within Valued Lives, or at the local Gateway club. Contact with people without learning disability, other than staff of the organisation, is gained when people access community facilities. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 & 20 Not all appropriate guidance was in place to ensure effective personal care support to one individual, placing them at risk of harm. Service users are supported to address their health care needs effectively. Medication is handled safely in the home. However, guidelines for the use of each ‘as required’ medication must be available for staff, to ensure a consistent approach. EVIDENCE: Service users are assisted with various levels of personal care and supervision. This varies depending on their individual abilities. People have established routines, such as their preferred time for getting up. Staff guidance may be needed if people have set appointments to be ready for. Assistance is given to choose clothes on a daily basis. Staff organise shopping trips with service users to purchase new items. Each individual has an allocated keyworker. Ensuring that people have sufficient clothes and toiletries is one responsibility of this role. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 17 Valued Lives has a policy regarding any cross gender personal care. This provides suitable safeguards for both users and staff. One service user has significantly changing personal care needs, associated with a general deterioration in their health and abilities. This individual has now been provided with a ground floor bedroom. There is a downstairs toilet, which they can still access. But they are no longer able to manage the stairs at Roman Court. So they are now having baths a couple of times each week at another of the organisation’s homes, in Ball Road, Pewsey. Here, they are assisted by staff to go up and down the stairs, and to get in and out of the bath. No specific care plan guidelines were seen for this practice. There had also been no involvement of any relevant professionals, such as occupational and physiotherapists. This is needed to assess the support being given to the individual by staff, and ensure that it is safe for all parties. These specialists could also advise on any adaptations or equipment that would help the individual to continue accessing bathing facilities for as long as possible. There is a strong focus on health promotion, and also responding to any needs that do arise. All service users receive regular health monitoring. This includes dental and optical check ups. Any specialised services, such as speech therapy or occupational therapy, are also accessed as required. When significant health problems occur, it is clear that all possible steps are taken to secure treatment for these. Information about some of the main needs of individual service users is available for staff. All appointments are undertaken in private, although a staff member will give assistance as needed. Records are kept of all contacts with any health professional. Medication is stored and recorded appropriately. Staff have received training in medication handling, and in some more specialised techniques. Records are kept of medication leaving and returned to the home with service users for holidays, and home visits. A course of treatment is kept for use when required. The criteria for this must be clearly documented. GP approvals for giving medications available without prescription had been updated in June 2005. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 & 23 Service users are safeguarded by the home’s policies and procedures for complaints and protection. Service users are placed at some risk of harm, by failure to show that key intervention guidelines are regularly reviewed and updated. EVIDENCE: The organisation has various information available regarding complaints. The procedure was last updated in September 2004. A pictorial version is available within the Service User Guide. Contact details for the CSCI are included. No complaints have been received. The aim is to minimise any likelihood of this, by having strong recording systems that make all staff accountable for the actions of each particular shift period. There is also a wide range of information about adult protection issues. This includes details about multi-agency procedures within Wiltshire. A ‘Protection’ section in each individual’s care plan gives information about the various safeguards in place. These include recruitment checks, staff training, and key individual abilities and relationships that contribute to upholding someone’s welfare. Strategies for management of behavioural needs must contain appropriate guidance, show who has been involved in devising them, and be kept under regular review. Progress has previously been made on this, with some Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 19 individuals’ care managers signing up to various care plans and risk assessments. However, all guidelines seen during this inspection dated from January 2003. In most cases they did not show who wrote them. None made any reference to who else had been consulted. As key elements of the overall support to people with complex and challenging needs, it is important to demonstrate that such guidance is regularly evaluated to ensure that it remains applicable, and is the best approach for that individual at that time. Physical interventions may be used with some service users on occasions. Individual guidelines describe the holds which may be used. Staff have received appropriate training in these techniques. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 & 30 Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Roman Court is a modern semi-detached house, in a residential estate in Pewsey. It is a short walk from the centre of the village, and all local amenities. The home is domestic in scale. It is attractively decorated and furnished. There is ongoing renovation, when required. As part of this process, all windows were due to be replaced by the end of 2005. Since the previous inspection, the accommodation provided for service users has been adapted, to reflect the changing needs of one individual. This person now has a ground floor bedroom, in what was a lounge. The room vacated upstairs is used by staff when sleeping in. Communal space remains available to service users, in a smaller second lounge at the rear downstairs. The home appeared clean and hygienic in all areas seen at this unannounced inspection. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. EVIDENCE: Each home within Valued Lives has some staff specifically allocated to it. Cover is then made up by other staff, who work in more than one setting. The owner’s aim is to employ sufficient people so that, even if they are one staff member down, there are still enough to cover all the organisation’s services without needing to rely on external agencies. Roman Court has three main staff who work most of the shifts there. There is usually one person on duty. When service users go out to their planned activities, this person goes with them. At nights, one person sleeps in. An oncall manager is available, if required. There had been no staff changes since the previous inspection. There are policies which govern the organisation’s recruitment and selection practices. Staff records are held centrally, and were made available for inspection. The sample seen showed that all required checks had been carried out. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 22 When posts are advertised, interested candidates are asked to visit the home. They meet informally with service users. Shortlisted applicants attend for interview. Once appointed, new starters undertake an initial short induction. They are also on a three month probationary period. During this time they work under supervision. Sleep ins are done alongside a colleague at first, until someone is judged competent to work alone. All of the care staff who regularly work at Roman Court have achieved an NVQ in care, at Level 3. Other training is provided when necessary. Systems are in place to track when each staff member is due to undertake refresher sessions in key areas. Training materials, such as videos and written information, have been obtained on various issues. Sessions are arranged periodically on topics relevant to the care of individual service users. These have included autism, and dementia in people with Down’s Syndrome. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 The registered manager is suitably competent and experienced, and is supported by senior colleagues, so that service users benefit from a well run home. Quality assurance measures need to be implemented, to ensure the home is conducted and developed in line with service users’ needs and preferences. Effective record keeping is maintained, upholding service users’ best interests. Service users’ health and safety are protected by the systems in place. EVIDENCE: The registered person for Valued Lives is Mrs Jane Abbott. She has lengthy experience of working with people with learning disability, and has owned and operated her own services for many years. She is supported by other senior Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 24 staff within the organisation. Together, they oversee all five services currently run by Valued Lives. Mrs Carol Bottoms is registered manager for Roman Court, and also for Renwick in Manningford Bruce. Mrs Abbott and Mrs Bottoms are currently working towards the NVQ Level 4 award, as required of registered managers by the end of 2005. Mrs Abbott’s husband, Mr Steve Abbott, has obtained this qualification, and is also now undertaking the Level 4 award in care. Mrs Abbott’s brother, Mr Patrick Jones, is the registered manager of 6 Rushall Road, North Newnton. All three registered managers within the organisation can provide support to the various homes if needed. The organisation has not yet fully implemented a quality assurance system. A comprehensive tool has been purchased. But it may be difficult to apply to smaller scale homes, such as the ones that this organisation operates. At previous inspections it has been suggested that a possible approach could be to apply the full audit over a longer period – perhaps three years, instead of one. Areas of particular importance could still be focussed on more regularly. The organisation also needs to show that the views of service users, relatives, and other relevant people are obtained. From completion of a quality audit, the organisation needs to generate a development plan. This can focus on any identified strengths and deficits, across all areas of service delivery. Goals for improvement can then be set, against which future progress can be measured. Record keeping is of a good standard. Most required areas appear to be covered. As discussed elsewhere within the report, it is important to ensure that systems clearly show who has produced documents, when they have been reviewed, and when the next review is due. One staff member in the organisation has lead responsibility for health and safety issues. There are folders in each home, which contain a range of relevant policies, and risk assessments. There is evidence of monitoring of key areas, such as water and fridge temperatures. Checks are undertaken by relevant contractors, if this is felt to be more suitable. Potentially hazardous substances are stored securely. There is also product information relating to these. There are risk assessments in place for individual service users about possible hazard areas, such as use of the stairs, or accessing the kitchen. Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Roman Court (1) Score 2 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X 3 3 X DS0000028114.V251927.R01.S.doc Version 5.0 Page 26 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 YA5 Regulation Requirement Timescale for action 31/12/05 5The persons registered must 1b&c;17-2 ensure that all service users Sch4-8 have an individual costed contract that contains all information as stated within Standard 5. 2 YA18 12-1;135;15 3 YA20 12-1;13-2 3 4 YA20 YA23 17-1a Sch3-3m 12-1;136&7;151a COMMENT: Contracts need evidence that they are current, and approved by the service user, or a relevant representative. The persons registered must 30/11/05 ensure that the personal support needs of service users are assessed by relevant professionals; and that appropriate guidelines are clearly set out in individual plans. Guidelines must be available for 30/11/05 the use of all ‘as required’ medications, to ensure that they are used within the prescriber’s instructions. This part of Regulations also 30/11/05 applies to the above Requirement. 30/11/05 Strategies for management of behavioural needs must contain appropriate guidance, show who DS0000028114.V251927.R01.S.doc Version 5.0 Page 27 Roman Court (1) has been involved in devising them, and be kept under regular review. (Timescale from 23/03/04 not met) COMMENT: No further progress had been made since the previous inspection. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. 4 YA23 17-1a Sch3-3q 24 This part of Regulations also applies to the above Requirement. The persons registered must continue implementing an effective quality assurance system, ensuring that the views of all stakeholders are accessed. COMMENT: No further progress had been made since the previous inspection. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. 30/11/05 5 YA39 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Work should continue to develop the content and presentation of care plans, and associated information. COMMENT: The scale of care plans means that updates and current issues are not always easy to track. All service user documentation should be clearly signed and dated. 2 YA41 Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Roman Court (1) DS0000028114.V251927.R01.S.doc Version 5.0 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. 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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