Inspection on 12/07/06 for Safeharbour

This inspection was carried out on 12th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Safeharbour 09/09/09

Safeharbour 14/08/07

Safeharbour 10/03/06

Safeharbour 28/09/05

Safeharbour 17/03/05

Safeharbour 06/09/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Safeharbour 52 Corbett Avenue Droitwich Spa Worcestershire WR9 7BH Lead Inspector Jean Littler Unannounced Inspection 12th July 2006 10.30 Safeharbour DS0000018672.V296042.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 Safeharbour DS0000018672.V296042.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. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Safeharbour Address 52 Corbett Avenue Droitwich Spa Worcestershire WR9 7BH 01905 796214 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) Dr Anjani Kumar Mr Geoffrey Moultire Copeland Jolene Lisa Riggs Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is for people with a learning disability but the Home may also accommodate people with an additional mental disorder. 10th March 2006 Date of last inspection Brief Description of the Service: Safeharbour is situated in a quiet residential area within a short distance of Droitwich Spa town centre and a wide range of local amenities. The premises are in keeping with the environment and the local community. There is a small patio area at the rear of the house but no garden. Accommodation is provided on two floors and all the residents have their own single bedroom. The home provides a service for six people with learning disabilities who have high support needs, some of whom may also have an additional mental disorder. Information about the service is available from the home on request. The fee for the service is £1947 per week. Additional charges are made for personal services such as hairdressing and chiropody and personal items such as clothes and toiletries. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine Key inspection was carried out on a weekday between 10am and 5.30pm. All of the six residents were at Home for part of the inspection and some were observed interacting with the staff. One showed the inspector his bedroom as part of a tour of the house. A sample of records and care plans were seen and the medication was audited. The manager assisted with the inspection and two permanent support workers were interviewed in private. The manager completed part of a pre-inspection questionnaire and provided copies of rotas as additional information on the day. The residents, their representatives and some professionals involved were given feedback questionnaires, several of which were returned. The residents’ ones were completed by their relatives on their behalf. Feedback was positive and several relatives added additional comments praising the service e.g. ‘My brother receives excellent support and any issues are dealt with appropriately’, ‘My son has the best care possible and a good quality of life. The home is run in a professional and caring manner’, ‘I have just received a revised behaviour plan, which is very good and will also be helpful for home visits’. One relative raised concerns that have been discussed between the relative and the manager. These are referred to under the complaints section of this report. Three health professional who have links with the Home returned positive feedback. The manager has been open with the Commission about any difficulties and developments in the Home since the last inspection. This information and the monthly provider’s monitoring reports have also been considered as part of the inspection process. What the service does well: The house is spacious and continues to be attractively decorated. Good quality furnishings have been provided such as double beds. Residents are supported to maintain close links with their families and staff even provide transport to enable visits to take place. Relatives said the staff are helpful and welcoming. Residents’ health needs are given priority and their personal care and support is given in a very personalised manner. An excellent variety of home cooked fresh food is provided. Staff training is promoted, team morale is good and high staffing levels are being maintained. The manager is enthusiastic and takes any complaints seriously. The providers monitor the service closely and hold the manager to account if shortfalls are found. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 7 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 Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 8 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): EVIDENCE: There are no current vacancies and no changes in the resident group so Standard 2 has not been assessed. The manager is aware of the need to complete a full assessment and demonstrate that all assessed needs can be met before admitting a new resident into the Home. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in the outcome area is good. This judgement has been made using available information and a visit to this service. The residents’ needs are reflected in their care plans and kept under review. The residents would benefit from more input from professionals in the planning process. Where possible the residents are being supported to make decisions and take risks as part of ordinary living. EVIDENCE: The care information has recently been revised and put into a new format. The manager reported that this process is nearly completed. It is positive that relatives have been helping by providing social history information and some have seen and agreed the care plan information. Two residents’ care plans were sampled. They contained detailed information and staff guidance under relevant headings such as health, communication and personal care routines. A few inaccuracies were noted that should be picked up if the manager and keyworkers review the information again. Two keyworkers who were on duty assisted the inspector to review the information and understand the residents’ needs. They both demonstrated that they have a good understanding of how to support the residents in their preferred way and enable them to make Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 10 choices where possible. They spoke about the residents in a respectful and positive manner. Daily records are made on forms that have been personalised to include each resident’s development goals. This allows staff to report on progress. Keyworkers are completing monthly summary reports from the daily records. These are being used to monitor care issues and inform the six monthly review meetings that are being held with residents’ representatives. The manager should consider if Person Centred Planning could be further developed. Staff have already attended this training. Staff reported that the team works constantly with each resident in line with their care plan. If a resident becomes anxious or distressed they try to defuse the situation by a variety of approaches depending on the individual e.g. giving them some space, offering reassurance, changing their tone of voice,. A recent internal review of one resident’s behaviour intervention strategy led to positive changes in the resident’s behaviour. Discussions were held about the approach to one resident’s behaviour at night. In an effort to manage certain behaviours he is being woken up three times a night and offered to use the toilet. When strategies are developed the impact of these on the resident’s quality of life must be considered and balanced against the need to address the behaviour. If an unusual arrangement like this is set up it should be as a short trial only and where possible with psychology input. One resident does become aggressive at times. All staff have recently attended training in breakaway techniques that included the use of physical restraint. Clear guidance needs to be developed regarding the use of restraint that includes all pre-restraint interventions and then sets a safety framework for the type of restraint permitted, by whom and for how long. If restraint is used this should be reported to the Commission. A community nurse has links with one resident and has contributed to developing his behaviour intervention strategy. Another resident has been waiting for some time for input from the local Intensive Support Team. The providers should consider the benefits of commissioning periodic input from a behavioural therapist as part of the specialist service provided. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 11 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, 16, 17. Quality in the outcome area is excellent. This judgement has been made using available information and a visit to this service. The residents are being given opportunities for personal development. They are supported to engage in a wide range of activities they enjoy, some that are community based and nonsegregated. They are supported to maintain links with their families and are provided with healthy home cooked meals. EVIDENCE: Both staff spoken with reported that residents had a good quality of life and are given opportunities to go into the community regularly. A sample of daily planning sheets were seen, which showed staff are allocated to support each resident and personalised activities. The resident’s frame of mind and health are considered during the day and the plans are changed if need be. A positive approach is taken to trying new activities and this has let to each residents timetable being very personalised. A sample seen including sessions at college, snooker, trampolining, going into Birmingham to by preferred food, swimming, snoozelem sessions and work at the allotment. Planning now also Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 12 includes the evening although free time is also built into the week and weekends are more relaxed. This years holidays was reportedly a great successes. Great effort has gone into finding accommodation that is suitable for each resident. They went to the coast in one-to-one or small groups with a high staffing ratio. The photographs have been made into personal scrapbooks and shared with the residents’ families. The residents’ rights are being promoted through normal good practice e.g. ensuring their privacy is maintained, supporting them to be independent where possible. The level of support the residents need mean they are unable to vote or exercise some normal rights e.g. going out alone. Development goals are included in the care plans and monitoring has shown some resident have developed their skills. Some communication systems are used. There are plans to increase the use of pictorial and symbol systems and the IT equipment has been purchased to support this aim. This should allow residents with limited communication skills to make more choices. . The residents are supported to keep in close contact with family members. Staff provide the transport to bring one resident’s father to the home each month so he can visit his son. Other support is also provided to enable residents to visit their family at home. The keyworker system is used to ensure relatives are appropriately communicated with about concerns and care needs. A well-qualified and experienced cook usually works three days a week. She is unfortunately off on special leave at this time. She has been working through a comprehensive food and kitchen management workbook under the guidance of the Environmental Health officer. She also holds an advanced food hygiene award. The staff have been preparing all the meals in her absence. Food is purchased locally, some of it with the residents help, and the meals are prepared fresh each day. Meals are eaten in a relaxed atmosphere and staff eat with the residents. Three areas of the house are used for dining so the groups are small and residents are better able to concentrate on their meals. Residents’ food preferences are known and their views sought as much as possible when the weekly menu is planned. A good variety of flavoursome meals and healthy meals are being provided. Taster sessions are held to find out if new foods will be enjoyed. Good efforts are made to meet one resident’s cultural food requirements. One resident regularly cooks and others help make drinks and snacks. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 13 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. Quality in the outcome area is excellent. This judgement has been made using available information and a visit to this service. The residents are having their personal care and health needs met in a sensitive and proactive manner. Medication is being safely stored and managed. EVIDENCE: Care records showed that residents are bathing or showering daily and their other personal care needs are being met. Appropriate gender care is being provided for the female resident. The residents all have single rooms and their privacy is respected. One resident is able to hold her bedroom key and locks her room when she goes out. Links with local health professionals are well established and all residents are registered with a GP and dentist. Annual health checks are being provided by the GP. Appointments are prioritised and the manager often attends these with the resident to keep informed. A resident with a very complex high risk health condition is sensitively supported and has two named staff supporting him during the waking day. Good work was carried out to support one resident to overcome his fears and accept a blood sample being taken. External links with health professionals are in place e.g. the consultant psychiatrist. As detailed above residents would benefit from increased professional input in regards to their behavioural and emotional health needs. The care plans include clear Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 14 details about the residents’ health needs and how these will be met. Health concern records are used to log any issues that arise. In case a resident is admitted to hospital information is ready in a quick reference format. The medication is being appropriately stored in two cabinets and the keys are kept secure. The manager ensures deliveries are checked in properly and the charts are set up correctly for the month ahead. Each resident has a medication profile indicating what medication they are on and why. Photos are in with the records to help avoid administration errors. The administration records showed that doses are being given as prescribed. A senior is always involved in the administration process and a double-checking and signing system is used to reduce the risk of errors. This risk would be further reduced if each resident’s boxed medication was stored in separate labelled containers within the carry case used rather than them all being mixed together. It is very positive that along with the medication administration training given by the supplying pharmacist staff are also working through accredited distancelearning training workbooks. Those who have finished level one are planning to go on and complete the more advanced level 2 workbooks. It is very positive that the manager is being proactive about discussing medication changes with the GP and the consultants involved. Changes to medication regimes have had positive outcomes for some residents. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 15 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. Quality in the outcome area is good. This judgement has been made using available information and a visit to this service. Complaints are welcomed and dealt with in a positive way. Suitable arrangements are in place to try to ensure residents are protected from abuse. EVIDENCE: A complaints procedure is in place. A version in a format more easily understood by the residents is on display. The manager has demonstrated that she responds positively to any concerns raised. A neighbour who complained in 2005 about car parking and noise levels has not expressed any concerns recently. Good communication links are now in place should she feel the need to raise a concern again. Recently a member of the public raised concerns with the Commission about staff using their mobile phones and not being attentive to the residents when supporting them out in the community. The manager took prompt action and introduced a policy of no mobile phones while on duty. Work mobile phones have been provided for emergency contact when on outings. A staff meeting was called to discuss the concerns and remind staff about good practice. The complainant was satisfied with the action taken. A relative of one resident has raised concerns about the level of training night staff have and how the staff are supervised when the manager is not on duty. These concerns have been discussed between the relative and the manager at a recent care review and when the manager takes the resident to visit his family each week. The manager thought they had been satisfactorily addressed. A record of the concerns and any action taken had not been kept and no factual information about staffing arrangements had been provided in Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 16 writing. The manager agreed to write to clarify arrangements and did this shortly after the inspection. This should be followed up again to see if the relative needs any more information about how standards are being monitored and her son’s wellbeing safeguarded. Suitable policies are in place regarding abuse and staffs’ duty to report concerns to protect residents. Staff training in abuse and protection is being provided. Another in-house session has been planned for the following month. Since the last inspection a situation involving concerns about a member of staff’s attitude towards two residents was reported to the manager and referred under the vulnerable adult multi-agency procedure. The manager was advised to investigate this and manage it through the internal personnel procedures. The situation was appropriately handled and the worker was provided with additional training and more supervision to ensure a consistent and respectful approach was being provided. A review of the providers action plan developed following a vulnerable adult investigation that occurred in 2005 showed one point had not yet been addressed. Staff peer support groups were due to be set up to try and provide support for staff to confront any poor practice should it occur. The action plan was agreed in the multi-agency forum so the providers should review this and decide what action, if any, they are taking. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 17 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, 25, 26, 27, 28, 29, 30. Quality in the outcome area is good. This judgement has been made using available information and a visit to this service. The residents have a well maintained, safe, clean and attractive home. Their bedrooms are personalised and suitable adaptations have been made as necessary. EVIDENCE: The Home has large rooms that are attractively decorated and comfortably furnished. The garden is very small and is inadequate for the young and mobile group of residents. To balance this an allotment is used and some residents regularly go there to attend to the vegetables. The Home is being well maintained and a rolling programme of improvements is in place. Recently the downstairs shower-room has been attractively refurbished. There are plans to redecorate the communal rooms. The residents’ bedrooms have been personalised. A resident who prefers his room to be kept quite clear is being encouraged to accept new items. This is a slow process but his room looked better already. One resident showed the inspector his bedroom, which he seemed justly proud of. He has pictures of his family, many personal mementoes and hobby items including an exercise bike that he said he used regularly. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 18 There are a sufficient number of bathrooms and toilets to meet the residents’ needs. The environment has been adapted to meet any special needs e.g. an air conditioning has been fitted in one residents bedroom to help a medical condition, a raised toilet seat has been fitted to assist a resident who has some mobility difficulties. One resident’s low windows have been fitted with safety glass. The manager has taken advice when needed from the Fire Officer and suitable fire precautions are in place. The laundry is sited in the cellar, which is not ideal for staff carrying items up and down the stone steps, or for residents to be involved in doing their own washing. The facilities however, are in working order and are suitable for the needs of the Home. Arrangements are in place to manage infection control risks e.g. pump soap and paper towel dispensers, and staff are doing infection control training through distance learning workbooks. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 19 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, 35, 36. Quality in the outcome area is good. This judgement has been made using available information and a visit to this service. The residents are being supported by a competent and appropriately trained staff team in sufficient numbers. Staff are being effectively managed, supported and supervised. EVIDENCE: A high staffing level continues to be provided during the day with the usual number on duty being seven. The manager’s hours are usually over and above this. Staff reported that these levels are suitable for the high support and health needs of the residents. They confirmed these levels are being maintained and the rotas also evidenced this. Each worker is designated a particular resident to support on each shift so their role is clear. Despite there being three vacancies gaps in the rota have been covered by staff who know the residents. The cook has been off on special leave and the laundry assistant has transferred into a care position. Care staff are covering these duties until normal arrangements are resumed and the vacant post filled. The waking night staff assist with domestic tasks. Three staff have left since the last inspection but no new staff have started yet. Recruitment is in progress but these files are held at head office until the process is complete so were not available. The legal requirements were met the last time staff records were inspected in 2005. The overall level of previous Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 20 experience and expertise amongst the staff team is being improved. Staff currently being recruited have relevant background experience. Consideration is also being given to the cultural needs of residents and how these are reflected in the staff team. Induction arrangements are in place and new staff attend core training and work through the Learning Disability Award Framework. The manager is monitoring each staff member’s training needs. Provision includes safety training, first aid, medication, infection control and understanding challenging behaviour and autism. All staff have recently attended breakaway training to help meet one resident’s assessed needs. The level of specialist training has been increased over the last two years and the focus on this should continue in line with the service objectives of the service. The manager was made aware of a foundation programme for new staff on Autism awareness. Some staff have attended Total Communication training. The manager agreed to contact the local team and enquire about their recommendation made to CSCI about all staff including axially staff attending the one day course. Current training in relation to the administration of emergency medication for epilepsy should be reviewed against recent guidance issued by the Joint Epilepsy Council. Staff continue to be encouraged to gain NVQ qualifications in care. Seven are in the process of gaining this and another ten are due to enrol. If staff retention can be achieved then the 50 minimum ratio of qualified staff should be achieved in the next year. Both staff spoken with reported that team morale is good and the staff team are working consistently. Staff meetings are held regularly and the minutes are shared to keep staff who were not there fully informed on relevant decisions. Each shift is planned and led by a shift leader. The handover session observed was carried out in a professional manner and the focus was on how the residents’ needs were going to be met during the next shift period. Staff are being provided with regular supervision sessions. Where issues of competency have been identified appropriate action has been taken e.g. capability processes started or extra training and closer supervision introduced. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 21 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, 38, 39, 40, 41, 42. Quality in the outcome area is good. This judgement has been made using available information and a visit to this service. The residents are benefiting from a well run home. Procedures and record keeping systems are in place to safeguard their best interests. Their health and safety is being promoted. A formal quality assurance system is not yet in place to ensure high standards are consistently achieved in all areas without intervention from CSCI. EVIDENCE: The manager is suitably qualified and attends appropriate training courses as they become available to continue her own personal development. She continues to work to develop the service and improve the quality of life for the residents. The staff spoken with reported that they found her to be a good leader who is supportive and approachable. The deputy has left but a new one is due to start soon. The service is being monitoring from the providers and line manager during monthly visits. This has proved effective in identifying areas of good practice Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 22 and shortfalls. A recent visit noted that fire test records and drills had not been kept up to date. The manager had taken appropriate action to rectify this. At the last inspection it was reported that a formal quality assurance system had been decided upon but this has not yet been implemented. This has been a legal requirement since April 2002 and the providers now need to make introducing this a priority. A sample of records were seen as detailed throughout the report. Record keeping systems have been improved e.g. care plans. A sample of residents’ monies was inspected. Records were up to date and showed the personal allowance is being spent on appropriate items such as clothes and toiletries. A system is in place where the balance in each resident’s tin is checked at each shift changeover. The provider and manger have reviewed what residents are expected to pay for and staff now have clearer guidance about this. Members of the senior management team hold appointee-ship for some residents. Records relating to these arrangements were not seen on this occasion but safeguards were described e.g. two signatures are needed for bank withdrawals. It is very positive that one resident is being supported to manage her own money. Opportunities should be considered for other residents to get involved even if the tin is stored in their bedroom not the office. Health and Safety management systems are in place e.g. checks on hot water before bathing. The manager provided evidence that routine servicing and safety checks are up to date e.g. an electrical wiring certificate was issued in April 2006 and the fire alarm serviced in January 2006. Checks are being monitored during the provider’s monthly visit. The manager has further developed the risk assessments relating to residents’ care and environmental hazards. Both staff spoken with reported that safety issues are well managed. Basic safety training is provided during the induction programme and videos are used to provide refresher sessions. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 23 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 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 2 36 x 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 3 12 4 13 3 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 3 2 3 3 3 x Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO. 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 YA39 Regulation 24 Requirement Introduce a formal quality assurance system in line with regulation 24 and standard 39. Timescale for action 30/09/06 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 Complete the current work to develop accurate care plans and risk assessments. Develop clear intervention strategies for any of the residents’ behaviours that could result in staff physically restraining them. These should include all pre-restraint steps including the use of ‘as needed’ medication and then set a clear framework for the type of restraint permitted, by whom and for how long. Ensure any strategies take account of the potential impact on the resident’s quality of life. Store boxed medication in separate named storage containers. Keep clear records of any concerns raised and what action is taken to address these. DS0000018672.V296042.R01.S.doc Version 5.2 Page 25 2. 3. YA20 YA22 Safeharbour 4 YA23 5. YA33 YA19 Follow up the written response to the concerns raised by one relative. The providers should review the action plan they developed following the vulnerable adult investigation in 2005 and decide if staff peer support groups are going to be set up. Consider the benefits of commissioning periodic input from a behavioural therapist as part of the specialist service provided. Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Safeharbour DS0000018672.V296042.R01.S.doc Version 5.2 Page 27 - 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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