Inspection on 08/01/08 for Saeeda

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saeeda 04/07/06

Saeeda 02/11/05

Saeeda 04/05/05

Saeeda 05/01/05

Saeeda 02/07/04

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 Saeeda Saeeda 17 Green Lane Redruth Cornwall TR15 1JY Lead Inspector Stephen Baber Unannounced Inspection 8th January 2008 10:00 Saeeda DS0000058449.V350314.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 Saeeda DS0000058449.V350314.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. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saeeda Address Saeeda 17 Green Lane Redruth Cornwall TR15 1JY 01209 215029 01209 215029 saeeda@swallowcourt.com 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) Swallowcourt Limited James Steven McClean Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: Saeeda is a care home providing residential accommodation to a maximum of eight adults with a learning disability. The aim of the service is to provide a good quality of care and to support service users to maximise their independence. The company are committed to achieving positive outcomes and the active participation of service users in everything that they wish to do. Service users are supported to maintain contact with their families and to be involved in the local community. The staff team fully understand the needs and aspirations of the service users and support them to achieve their goals. The home is an attractive Victorian property situated close to Redruth town centre. The home is situated within easy reach of the town of Redruth with good access to transport and all the facilities of the town. The company provide free transport for outings. Service users are provided with individual furnished bedrooms and a shared bathrooms and shower rooms. The home is undergoing major upgrading work to all areas throughout the home. At present there is a kitchen on the lower ground floor and dining room and lounge on the ground floor. The company have invested substantially in the recent months to improve the decoration and fabric of the home. The home has a small garden and there is parking for two cars. Service users attend a range of day activities, which are mainly commissioned by the Cornwall Adult Social Care Services Department. Swallowcourt employs a manager and team of staff to provide care and support for the service users living in the home. The managing director and senior manager of the company visit regularly and are available to provide additional specialist input as and when it is required. The ranges of fees are from £325 to £990 per week. Outside work activities to day centres and work placements charges are in addition to the weekly fee. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) have made changes to the way we inspect services. Known as Inspecting for Better Lives (IBL). We are now more proportionate when reporting our findings, and more focused on the experience of people using services. This was the homes fourth inspection and the purpose of the inspection was to ensure that service users needs are appropriately met, with good outcomes provided to them. This was a key inspection with one inspector, which was unannounced. It took place on the 8th and 10th January 2008 and lasted for approximately 13 hours. The purpose of the inspection was to ensure that service users needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that service users placements in the home result in good outcomes for them. The inspection included talking with the service users in the communal area of the home and with visiting relatives and professionals. There were different members of staff on duty who were interviewed and there were opportunities to directly observe aspects of service users daily lives in the home and staff interaction with them. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the manager and managing director who were present. The principle method of inspection was “case tracking”. This involves interviews with a select number of service users; staff caring for them and/or their representatives, and examination of records relating to their care. This provides a useful impression of how the home is working overall. At this inspection two service users were case-tracked, with particular reference to their individual and diverse needs relating to their age, culture and ethnicity, religion, gender, sexual orientation and disabilities. The Commission received the Annual Quality Assurance Assessment, which is an annual quality assessment that was completed by the manager. The AQAA describes the services and facilities that Saeeda provides and identifies what areas they do well in and where they want to make further improvements in the service. We were impressed by the commitment of the manager and staff who were on duty that day and would like to thank them for their very helpful manner and cooperation to complete the inspection. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 6 The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: New service users receive a detailed assessment of their needs to ensure that the home will be suitable for them. This includes full consideration of their personal; health and social care needs, including their religious, cultural and ethnic backgrounds. Where necessary, external professionals from local health and social care agencies are involved in the assessment process, service users themselves are encouraged to contribute, with input from their relatives, and external advocates if they wish. Once they are admitted to the home, they assist in drawing up detailed individual care plans with clear goals that set out how the home will meet their assessed needs. These are formally reviewed with service users and their representatives at least six monthly. Daily care records are kept to show how service users’ care plans are carried out on a day-to-day basis. Service users are encouraged to maintain existing relationships with their families and friendships and to develop new ones, with support from the home’s manager and staff. They access a variety of resources in the Community where they can meet people from outside of the home, including a weekly social club. Service users are made aware of their rights and responsibilities through the home’s service users’ guide and the individual care planning process. They are encouraged to access independent advocates from outside of the home, to oversee their best interests and the home welcomes input from their families. Service users are encouraged to maintain and develop their skills and independence by shopping and preparing their own meals or visits to the pub. All rooms are lockable and we asked individual service users if we could see their rooms. All of the service users indicated that they are satisfied with the food arrangements and staff are available to help them if necessary. All of the service users appeared well groomed and smartly dressed at the time of the inspection. Service users are given copies of the home’s formal complaints procedure and this is translated into pictorial formats for them if they need it. They are also assisted to access independent advocates to help them to make formal complaints should they feel the need to do so. The new manager visits relatives with the service users and is pleased to answer any queries they have. There are regular house meetings so that service users can raise issues that affect them on a day-to-day basis before they develop into formal complaints. Staff are recruited to work in the home on the basis that they are safe to work with vulnerable adults and have ongoing training in local multi-agency Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 7 procedures to protect vulnerable adults from harm and abuse. All of the eight staff training provided by the company-training manager. The home’s recruitment policies ensure that staff are recruited on the basis of fair, safe and effective recruitment practices and records back this up. All of the service users stated that staff care for them and treat them well. The home is well managed on a day-to-day basis. The company head of learning disability and managing director support the manager on a daily basis if needed. The home’s new manager is well qualified and very experienced in the field of learning disability. There are good systems in place to enable service users to state their views individually and collectively on the quality of the care and services provided to them by the home. The new manager is in the process of improving the formal consultation methods further to inform the home’s annual development plan, which he intends to draw up once all the responses are returned from service users and their representatives. What has improved since the last inspection? The company continue to invest in the home and the service users who showed me the improvements to their rooms reinforced this. A new manager has been appointed who has many years experience of working with people with a learning disability. He has a professional approach to the care and management of people with a learning disability and supports staff to improve their knowledge and skills. The manager is also a trainer for The Cornwall Department of Adult Social Care in Safeguarding Adults. Copies of the multi-agency procedures for the protection of vulnerable adults from harm and abuse from all the local authorities placing service users in the home are now available for staff to reference, so that they have good information on what to do if they suspect a service user has been abused. Locks have been fitted to all rooms including to all the bathrooms to ensure that service users can lock them from the inside for privacy but staff can override them in emergencies, such as in the event of a fire. There are now copies of staff interview records to fully demonstrate that staff are recruited fairly and on the basis that they have the qualities that make them suitable to work with vulnerable adults in a care setting. The manager has developed relationships with a local PCT and provided service users who would benefit, with access to specialist assessments so that their needs can be better met in the future. The manager has also made Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 8 arrangements to be available to service users’ relatives at regular times so that they can contact her more easily to discuss any problems or concerns they have about how service users are being cared for, including complaints. Staff said to me that they have confidence in the manager and feel supported well to do their jobs. What they could do better: Throughout the report the manager and staff have demonstrated through evidence, discussion and observations of daily life that they have substantial strengths in the areas of delivery and managing improvements. Further improvements are required in the following areas: • One service user receives insulin injections twice daily from the staff that have been trained by the district nurse. This practice should cease as it is clearly the responsibility of the district nursing services that are covered by insurance to do it. The medication recording sheets (MARS) had gaps in them and this meant that it would be difficult to know if medication had been given or not. Risk assessments should be expanded on to elaborate on the reasons why judgements have been reached when boxes have been ticked. Information should inform and direct staff. Safeguarding Adults policy and procedure should be expanded to say that any allegation of abuse should be reported to the Department of Adult Social Care for them to make a decision on what action to take and the notification to CSCI. Complaints need to have the telephone number and contact details of the Cornwall Department of Adult Social Care should they wish to make a complaint. Care plan review sheets should be placed at the back of each recorded goal to be achieved. This will enable management and staff to audit when reviews take place. The current records evidenced signatures squeezed at the bottom of the care plan. The quality assurance when completed should produce an action plan, based on a systematic cycle of planning and review reflecting aims and outcomes for service users. • • • • • • • 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 Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 9 be made available in other formats on request. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 10 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 Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 11 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): Standards 2 and 5 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission to the home is based on detailed assessment to ensure that their needs can be met there. Specific improvements to service users’ contracts have been made so that the service users can easily understand them. This also ensures their terms and conditions are fair. EVIDENCE: Two new service users have been admitted to the home since the previous inspection. There is evidence of very clear and through assessment information on their file, including their participation in the assessment process. There are clear indications of their immediate, intermediate and long-term needs and sufficient information, from a variety of sources so that the service user and staff working with them are clear about the purpose of their placement in the home. The home’s manager has been working with one of the sister homes on the terms and conditions of residence for service users so that they can be provided with contracts for their placement in the home. The contracts have been completed in formats, language appropriate to each service user’s needs and reasonable efforts have been made to explain the contract to the service user. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 12 The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “To be investing in the structure and refurbishment of the home, to invest more in staff training and development, to be at the forefront using modern methods, person centred plans, this will ensure all at Saeeda will live the lives of their choosing, supported by staff who fully understand and practice the concepts of person centred ness, to address any areas of concern that arise quickly and efficiently, to address any areas arising from inspections or visits from CSCI”. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 13 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): Standards 6,7,9 and 10 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users participate in person centred care planning, which is followed through into their daily lives in the home. EVIDENCE: Each of the service users case tracked at this inspection has a detailed written care plan addressing their personal, social and physical care needs including needs relating to their religious, cultural and ethnic backgrounds. Care plans address their needs, risks and set out specific goals for them to achieve. Where there is a reliance on tick boxes the manager should provide staff with information on how the judgement was reached. Service users are invited to attend reviews of their care plans, at least six monthly and sign care plans as evidence of their participation and agreement. They are assisted to access independent advocates if they wish and /or it is felt to be in their best interests. Care records demonstrate how service users’ care plans are carried Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 14 out on a day-to-day basis. It is recommended that review sheets be placed at the back of each goal to be achieved. This will give the management and staff a clear record of reviews undertaken. The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “There is an extensive building plan for Saeeda over the next 12 - 18 months. This will provide everyone with better facilities. dining and social space, a more accessable kitchen, There will be provision for a flat type accomodation which will cater for more independent Service Users. This will allow for greater choice and independence”. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 15 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): Standards 12,13,15,16 and 17 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to maintain and develop positive relationships with their families and friends. There are good systems in place to ensure that service users’ rights are respected and they are made aware of their responsibilities. Service users are encouraged to eat healthily, according to their individual needs and preferences. EVIDENCE: Service users’ family, social and personal relationships are considered as part of the care planning process. Visitors are welcome to the home and service users access a variety of resources in the community where they can meet people from outside of the home, including a local social club. Records show that where necessary, specialist professional advice is sought from the local (Primary Care Teams) PCT, so that the home’s staff can appropriately support service users with difficulties. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 16 Service users are encouraged to participate in the preparation of their personal care plans. Where restrictions are necessary for their own protection, there are clear written risk assessments. The risk assessments are very reliant on ticking boxes. Where this occurs the manager and staff should provide information for staff that informs and directs them. The home’s contracts and service users’ guides set out clear information for service users and their representatives on their rights and what is expected of them. Service users are assisted to access independent advocates from outside of the home according to their individual preferences and/or needs. Staff support service users to go shopping and prepare their own meals. All of the service users interviewed said that they are satisfied with the meals they have at the home. Their dietary needs and preferences are considered as part of the formal care planning process. Staff support them to prepare healthy meals and take exercise appropriate to their ages and needs. The manager has created a snack kitchen area where service users prepare drinks and snacks. The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “All staff are registered on Learning Disability Qualification (formerly LDAF). This will equip staff to deal with every aspect of Learning Disability. Manager qualified to registered managers award More specific training around Autism, Dementia, and Person centred planning Extensive building work in due to begin in 2008. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal care needs are addressed in ways that respect their privacy and encourage them to develop their independence. The management of medication generally protects residents and there is clear written guidance for staff on the use of ‘P.R.N.required’ medication and household remedies. EVIDENCE: Service users’ personal care needs are addressed in their individual care plans. They all have individual rooms and bathrooms with suitable locking facilities to ensure they can attend to their personal care in private, with staff assistance, if necessary. Service users interviewed and/or observed at the time of the inspection appeared to be smartly dressed and well groomed. At present one resident requires support from the staff to administer her insulin twice a day. The manager said staff have been trained to do this by the district nurse but there was no evidence to substantiate this. Discussion took place with the manager about this and the comparison was used to someone living in his or her own home and then the responsibility for administering insulin would be that of the district nurse. It is required that the Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 18 manager discusses this with the district nursing service and the managing director regarding insurance liability cover. Please write to the Commission when a final decision has been made regarding the giving of insulin. The home uses the Boots Monitored Dosage system for medicines. The policy and procedure covers the required areas. Medicines are stored in a locked medicines trolley. Staff check and sign in the medicines received from the pharmacist. Records of administration were not consistently signed but appeared well maintained. Staff who administer medicines have completed a course in the safe handling of medicines. There was good guidance for PRN medication, which explains the side effects, and (P.I.L) patient information leaflets available for all staff to refer to The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “We will continue to work on care plans and Person centred planning, make more use of the health care plans, to maintain the high standard at the home, and to improve the facilities further with extensive building programme for 2008”. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 19 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. There are formal and informal systems in place to ensure that service users’ views are listened to and taken into account in the day-to-day running of the home. Robust arrangements for responding to allegations or evidence of abuse are in place to protect service users from abuse. EVIDENCE: Service users are given copies of the home’s complaints procedure, in translated formats if they need them, as part of the home’s service users’ guide. There are copies of written responses to formal complaints where they are made, to demonstrate that complaints are dealt with seriously and appropriately. Service users who request or are considered to be in need of independent advocates are provided with them and the home has good links with a local independent advocacy service. There are formal six weekly house meetings, with records kept. Where service users are able to state their views on the home and they all have individual key workers in the home so that they have someone specific to approach in respect of any concerns they have. These less formal systems ensure that service users’ day-to-day complaints can be dealt with immediately or at an early stage, before they develop into formal complaints. The complaints procedure should make reference to and have the contact details for Cornwall Department of Adult Social Care and their statutory complaints procedure. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 20 The home’s records demonstrate that staff are recruited on the basis that they are suitable and safe to work with vulnerable adults in a care setting and are provided with appropriate training. The policies and procedures have not been updated since 2005 and still say that the person in charge should investigate any suspicion of abuse. The policy and procedure should be updated so that staff have up to date information. Service users said to me that they feel safe in the home. The manager is a trainer for The Cornwall Department of Adult Social Care in Safeguarding Adults. He provides valuable knowledge and experience to the staff and provides all staff of the company with good inhouse training. Copies of the multi-agency procedures for the protection of vulnerable adults from harm and abuse from the local authorities placing service users in the home are now available for staff to reference, so that they have good information on what to do if they suspect a service user has been abused. The home has copies of multi-agency procedures for the protection of vulnerable adults from harm and abuse from all the service users’ placing authorities. The home’s internal procedures still need some updating. The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “To continue working in a positive way. To continue with training so staff are equipped to offer quality care. Staff to have more awareness of The mental capacity act and its implications, and for staff to be aware of the freedom of liberty, at which point we need to be considering the Bournwood principle for which there is a draft code of practice available, formally due for implementation in 2008”. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 21 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): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and safe so that service users can develop their skills and independence in a homely environment. They have individual bedrooms that meet their needs. EVIDENCE: The company are going to invest substantially in the home to improve the services and facilities for the service uses and also build on a two bedroomed extension. The home was well decorated and furnished throughout, and provides service users with a domestic, homely environment. It is well situated, within reach of local community resources, which are used extensively by the service users. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 22 Service users have individual bedrooms, which are lockable. Service users are able to have keys to their bedroom doors, subject to their individual risk assessments. Their bedrooms are furnished according to their individual needs and risks and they are encouraged and supported to personalise them. The home was clean and tidy throughout at the time of the unannounced inspection. There are some systems in place to prevent the risk of infection spreading. There is a laundry area set away from the thoroughfare of the home and written procedures to guide staff on how to prevent infection. The home’s manager and staff have undertaken training in infection control. Furnishings and fittings are of good quality and domestic in nature. The company will continue to undertake regular maintenance and refurbishment to provide a high standard of accommodation. The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “Extensive building work has been planned for Saeeda in 2008.” Saeeda DS0000058449.V350314.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,34,35 and 36 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and competent to work in a care setting. They are recruited on the basis of fair, safe and effective recruitment and selection policies and practices EVIDENCE: Staffing ratios have been improved so that service users can if they wish pursue individual interests of their choosing. One service user said she likes to go on holiday on her own, another said I like to go to the town for a cup of coffee and another said I like the staff to support me to go shopping. The company are proactive in the area of training. The documentary evidence indicates that a range of training opportunities is regularly provided for the staff. The training ranges from mandatory and specialist e.g. fire training, safe handling of medication, First Aid, Basic Food Hygiene, Induction, and NVQ level two and the LDQ (Learning Disability qualification) course that is designed for people working in learning disability settings. I talked with the staff who stated that they enjoy the training provided by the company and were looking forward to undertaking their National Vocational Training. Each member of staff has an individual training plan that is linked to supervision and the annual appraisal. Staffing ratios have been greatly Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 24 increased by the company and there are two care assistants on duty throughout the day with one sleeping in staff on duty throughout the night. There is a whole house-training matrix to demonstrate the ongoing planning of staff training in a range of subjects to protect and enhance the lives of the service users in the home. The home’s recruitment policy is clear and detailed and ensures that staff are recruited on the basis of equal opportunities and that only people who are suitable to work with vulnerable adults in a care setting are employed there. This is backed up with thorough recruitment records relating to staff working in the home. The records regarding the recruitment, selection and vetting of new staff evidence that good arrangements are in place. e.g. Photograph, proof of identification, conditions of engagement and POVA. The company use the industry standard Skills For Care Induction training for all staff. This ensures that staff possesses the necessary competencies to provide a good standard of care as well as a clear understanding about the working practices of the home. The manager leads by example and has worked hard in his first year to inform and direct staff. I spoke with the staff who said they are well supported by the manager and the company. Staff confirmed that they undergo 1:1 supervision with the home’s manager. There are regular staff meetings with minutes kept and records show dates for individual supervision sessions booked ahead for each staff member The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “To continue with our current training plan, and to have more staff trained to the LDQ level 3 To consider involving Service Users in Staff Training.” Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 25 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): Standards 37,39 and 42 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed for the benefit of the service users. The systems for resident’s consultations are reliable and quality assurance measures are in the process of being established and put in a format that can be understood by residents. Satisfactory arrangements are in place to promote the health and wellbeing of the residents and staff at the home The home’s manager is in the process of developing a formal quality assurance programme so that service users’ views can be fully accounted for in its ongoing development. EVIDENCE: The manager is in day-to-day charge of the home and he is appreciative of the support given by the learning disability manager and managing director. Regulation 37 monthly reports on the conduct of the home were seen from Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 26 October 2007. The manager is very experienced in the field of learning disability and is currently undertaking his registered manager’s award. Throughout the inspection we noted the close relationship he has with the service users who appeared very close to him. We spoke with the staff that thought very highly of him, said that he was good to work with, and provided sufficient guidance and support to help them to do their jobs well. Service users’ views are sought individually as part of the ongoing care planning system. There are regular house meetings, with records kept; Service users are consulted on matters that affect them as individual and as a group. The manager has drawn up formal questionnaires to be sent to service users, relatives and stakeholders and introduced formal sessions during which relatives can contact him to discuss any concerns they have. It is recommended that the manager consolidate the information when the quality assurance has been completed and produces an action plan, based on a systematic cycle of planning and review reflecting aims and outcomes for service users. The company have said in the AQAA (Annual quality assurance assessment) “Our plans for improvement in the next twelve months” “We have planned some extensive building work for saeeda in 2008, this will make the home environment better, we will continue to work with employees in order to achieve high standards of documentation practice. Person Centred Planning, we will do this by training our staff in all techniques in gathering the right information from service users, empowering them more in decision making.” Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 27 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 3 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 3 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 4 LIFESTYLES Standard No Score 11 x 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 4 x 3 X X 3 x Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 28 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 YA19 Regulation 13(1)(b) Requirement The registered person must consult with the district nursing service regarding the responsibility for giving insulin twice a day to a service user. Timescale for action 28/02/08 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. 2. 3. 4. 5. Refer to Standard YA6 YA9 YA22 YA23 YA39 Good Practice Recommendations The registered person should have a review sheet for each goal to be achieved for the service user. The registered person should provide information on all risk assessments for all staff that informs and directs them. The registered person should record the telephone number and contact details of the Cornwall Department of Adult Social Care in their complaints procedure. The registered person should update the policies and procedures on Adult Protection so that staff have up to date information.. The registered person should consolidate the information when the quality assurance has been completed and produces an action plan, based on a systematic cycle of DS0000058449.V350314.R01.S.doc Version 5.2 Page 29 Saeeda planning and review reflecting aims and outcomes for service users. Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Saeeda DS0000058449.V350314.R01.S.doc Version 5.2 Page 31 - 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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