Inspection on 27/06/07 for Sambourne Road (58)

This inspection was carried out on 27th June 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sambourne Road (58) 13/01/06

Sambourne Road (58) 17/08/05

Sambourne Road (58) 05/02/05

Sambourne Road (58) 06/09/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Sambourne Road (58) 58 Sambourne Road Warminster Wiltshire BA12 8LE Lead Inspector Tim Goadby Key Unannounced Inspection 27th June 2007 09:55 Sambourne Road (58) DS0000028356.V336712.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 Sambourne Road (58) DS0000028356.V336712.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. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sambourne Road (58) Address 58 Sambourne Road Warminster Wiltshire BA12 8LE 01985 217147 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) H5044@mencap.org www.mencap.org.uk Royal Mencap Society Janet Candow Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated at any one time is 6 Only the one, named, female service user with a learning disability referred to in the application dated 9 March 2004 may be aged 65 years and over Not more than 1 male service user in the age range 18 - 64 years with a physical disability may be accommodated at any time 13th January 2006 Date of last inspection Brief Description of the Service: 58 Sambourne Road provides care and accommodation for up to six adults with a learning disability. The home is also registered to care for one person with physical disability. The service is operated by Mencap, a national voluntary organisation in the learning disability field. The property is a detached house in a residential area, within walking distance of Warminster’s amenities. There are also good public transport links. The building dates originally from Victorian times, and has been extended at one side. All service users have single bedrooms, one of which is downstairs. Each bedroom has a hand basin, but there are no other en-suite facilities. There is a shower on the ground floor, and a bathroom upstairs. There is also another separate toilet, off the half landing on the staircase. Fees charged for care and accommodation vary widely, reflecting that some service users have lived in the home for several years, and that others have additional funding for extra care hours. The current range is from £343 to £1133 per week. Service users pay a weekly rent contribution from their benefit income. This is around £64 for most of the current group, rising to £99 for one service user in receipt of pension credit. The service has a Statement of Purpose and Service User Guide, which are key documents setting out information about the home and its facilities and services. A version of the Guide has also been produced on DVD, with the participation of the current service user group. Prospective service users and their representatives are also made aware of CSCI inspection reports. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection concluded in June 2007. The process included a review of regulatory contact since the last inspection in January 2006. The main event during that period was the registration of a new manager, Mrs Janet Candow. The service supplied a new Statement of Purpose in April 2007, and completed an Annual Quality Assurance Assessment (the AQAA) for this inspection. Survey forms were completed by five service users, each of whom was supported to do this by an independent person. Four relatives of service users also completed forms, as did one staff member. An unannounced visit took place to the home between 9.55 am and 3.15 pm on the 27th June 2007. This fieldwork involved sampling of records, with case tracking of two service users; discussion with service users, staff and the registered manager; and a tour of the premises. What the service does well: 58 Sambourne Road supports service users who have many strengths and abilities. The service builds on these to promote choice, independence and development for them. Service users are supported to take control of their own lives in all areas, including employment, education, relationships and leisure activities. Care plans and risk assessments provide a clear and detailed framework, within which service users are enabled and empowered. Service users contribute fully to decisions about their own lives. They also have opportunities to contribute to all areas of the conduct of the home and to participate as full members of their local community. Service users are supported to meet their health care needs effectively, as part of their overall well-being and quality of life. There is a focus on health promotion, with service users being encouraged to adopt a healthy lifestyle in areas such as diet and exercise. Each individual is enabled to have regular health checks. When any health issues develop, they are supported to seek appropriate medical advice and assistance. The arrangements for raising complaints are suitable to the needs and understanding of service users. Information is presented in accessible formats and is readily available. Service users are able to raise concerns, and can be confident that these will be responded to appropriately. Service users are supported by staff who receive relevant training, which equips them with the knowledge and skills to deliver a good quality service. A wide range of topics are covered by all staff, from induction onwards. This includes gaining nationally recognised qualifications in social care work. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 6 Service users can be confident that their views underpin service quality and development. Systems for quality assurance include a strong focus on getting all service users to have regular input. This is done in various ways. Annual surveys and monthly house meetings enable service users to comment on various aspects of the home. Service users also participate in ongoing audits and checks. The service development plan has key targets based on extending person-centred care to all areas of what the home provides. Service users are supported to maintain their own safety, both at home and elsewhere. They are fully engaged in checking health and safety, and in receiving information and training about key areas. Service users have participated in producing material such as DVDs and leaflets to help promote understanding of health and safety topics. What has improved since the last inspection? What they could do better: Some service users are allocated specific additional hours of care as part of their overall funding package. Where this is the case, these hours should be clearly shown within the staff rota. This helps to show that all service users are receiving the service to which they are entitled. Where risk assessments change in response to developing circumstances, care should be taken that current information is always easily identifiable. This removes any risk that outdated documents might be referred to in error, and helps to ensure that service users always receive the appropriate support. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 7 Medication records need to be maintained accurately, to demonstrate effective practice and uphold the safety of service users. One error within one service user’s records was noted at this inspection. The manager indicated that she would take action to address it. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed. EVIDENCE: Sambourne Road had one vacant place for around 18 months, until a new service user moved in at the beginning of June 2007, shortly before this inspection. Records for this individual were checked at the visit. Documents show a thorough assessment process before making a decision about whether the home could meet the person’s needs. This included accessing assessment and life history information from the service user’s previous home and from other professionals who have worked with them. The service user and their family were fully involved in the process. They were given various information about the service, including access to a copy of the previous CSCI inspection report. The service user also made some trial visits to Sambourne Road, including staying for a weekend. This enabled the existing service user group to have Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 10 input into the decision about admission, as well as helping the new person to make an informed choice. The purpose of the admission, to work on the individual’s independence and skills development, is clearly set out. Reviews are due to be held after three months and then at regular intervals after that. The new service user was present during the inspection visit. They were seen to be interacting with other service users and staff in a relaxed fashion, and appeared to have settled in well. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users contribute fully to devising their individual plans, which reflect their strengths, needs, preferences and goals. Service users can make choices and decisions in their daily lives, and about the conduct of the home. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. EVIDENCE: Two sets of service users’ records were sampled at this inspection. These were clear, comprehensive and up to date. Service users have significant input into documents about their own care and support. Records are discussed with Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 12 them, and they sign to indicate this. Most are written in the first person, based on the person’s own words. This process is developing, in line with the application of ‘person centred planning’. Service users have their own folders, filled with information about important aspects of their lives, and illustrated with relevant photos. Each service user is fully involved and engaged in producing their plan, which is a meaningful way of getting them to identify their own goals. Some information is also produced for service users in audio and visual formats. For instance, minutes from house meetings are read on to a cassette tape by one of the service users, so that others can listen to these. All staff have attended person-centred approach training. The home is aiming to develop its application of the technique by extending it to areas such as contracts, terms and conditions of residence, risk assessments and involvement in all aspects of the running of the home. Information for service users is presented in accessible formats. Lots of pictures and photos are in use both in records and on display around the home. They help to remind service users of their various allocated tasks. Each service user has an allocated staff keyworker who works closely with them. They produce monthly reports on each person. These are summaries, compiled from other records, and from talking to the individual. These monthly updates provide good evidence of regular review. Fuller reviews are also held at suitable intervals. Other relevant people contribute to these, such as relatives, and any professionals involved with an individual’s care. For service users at Sambourne Road, decision making is an integral part of their lives. The approach underpinning all that the home does is to promote opportunities to exercise independence. This is set out in a mission statement called ‘Our House, Our Choices’, which stresses each service users’ right to make choices in all aspects of their daily lives. This is within a framework of taking a full part in all the necessary jobs in the household, and attending any other settings that form part of the weekly routine. Most service users manage their own money with some support from staff. For instance, they may be reminded when they have bills to pay, or be helped to budget and save for things such as holidays. Pictures are used to help with this process, by enabling a service user to attach a meaningful consequence to the amount of money they need to save. One service user uses a personal tape recorder to keep verbal records of their ongoing balances. Service users also have a range of risk assessments. These are regularly reviewed. Evaluations are carried out in response to any changes in circumstances, or significant events. The approach taken balances benefits Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 13 and harms, and is used positively to promote opportunities for service users. If controls have to be put in place, the reasons for these are documented and they are kept under review. Programmes are developed with the individual to build their skills, so that the controls can be relaxed when appropriate. The home’s newest service user’s records demonstrate this approach. They set out that higher levels of support are being provided initially, as the service user adjusts to their new home, and the process of assessment and skills training continues. They also show that there are longer term plans to enable the person to develop more abilities and independence, as a main goal of their move to Sambourne Road. Some risk assessment information could be reviewed so that it is easier to locate the most up-to-date guidance. Where there has been a recent change in practice in some examples, the relevant information is noted down. But it is not always cross-referenced effectively, so some outdated documentation could be referred to in error. The manager acknowledged the need to address any such discrepancies. She explained that Mencap are in the process of introducing a new risk assessment format, so that all such documents will be reviewed in the near future in any case. Some service users also attend groups outside the home which give them the opportunity to discuss issues such as keeping safe in the community. They are able to bring back any ideas which are useful to share with other service users. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. Service users are supported to plan and prepare appropriate meals. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users are supported to develop their independence and to reach their maximum potential. The current group are able in many areas. Support from staff therefore takes the form of advice and encouragement. Service users are enabled to have control in many aspects of their daily lives. For instance, using clear and detailed risk assessments to support individual judgements, some are able to be in the house without staff supervision for set periods of time. In connection with this, they have been able to demonstrate sets of key skills that uphold their safety. One of the rules of residence at Sambourne Road is that smoking is only permitted in a designated part of the garden. Any service user wishing to smoke is made aware of this, and that to smoke anywhere else is a breach of their tenancy agreement. Service users who smoke are also given advice about safety aspects, via the fire service; and information about the impact on health, along with the opportunity to access help to quit smoking, if they wish. Each service user contributes to the overall daily running of the home. They regularly answer the door to visitors, answer the phone and make drinks for people. They are also allocated responsibility for household chores. Individual agreements are negotiated with service users about acceptable minimum standards for issues such as the cleanliness of their rooms. Service users undertake various activities outside the home. These include some day service resources specifically for people with learning disability. Service users also attend sessions at local colleges, and some have either voluntary or paid employment. The home is aiming to develop the involvement of service users in choosing and planning activities. At home, service users can choose how to spend their leisure time. Each has their own bedroom. There is also a quiet room upstairs, which is used by people for hobbies such as sewing and personal computing. This room also has a telephone which service users can use for making private calls. Service users also regularly access amenities in the local community. They are enabled to do so independently, in line with risk assessments. Some can also travel further afield, making use of public transport. They also have the opportunity to go on holiday. Some make the necessary arrangements themselves, with staff support. The destinations and activities which service users choose reflect their own interests and preferences. As well as holidays organised from within Sambourne Road, some service users also go away with friends or family. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 16 Daily routines are flexible within the usual structure of activities which take place at certain times, such as work or college. One service user who has difficulty establishing a suitable sleep pattern has been provided with a more planned programme of day and evening activities, to help with this. Service users are able to maintain key relationships. They all have some family contact and are supported to visit their relatives. They also have other significant friendships, such as former residents, colleagues from work or college and members of churches they attend. This means that some individuals have very active social lives. Information about important relationships forms a key part of person centred plans. Feedback from relatives confirmed that they maintain regular contact with service users. This includes phone calls, visits to the home and service users going to visit families, or for days out or holidays with them. Each service user has their own room, which is their private personal space. They have keys to these rooms and lockable space within them. Staff will not enter without permission. Agreements are in place about emergency situations that might override this. Service users have unrestricted access to all communal areas, and keys for the front door, in line with risk assessments. Service users have full involvement in the planning and preparation of meals. Each individual is given an amount of housekeeping money at the beginning of each week. They retain responsibility for this over that period, and return any receipts and change at the end. Service users then have an allocated day when they prepare the main meal. Menus are planned through discussion and a knowledge of likes and dislikes. Alternatives are always available, if people prefer not to have the main option. Staff may give some input, to ensure that issues such as budgeting are considered. Each service user is encouraged to buy fresh ingredients as much as possible, to avoid an over reliance on processed foods and ready meals. Sambourne Road (58) DS0000028356.V336712.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): 18, 19 & 20 Quality in this outcome area is good overall, although quality in the area of healthcare is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to address their personal and health care needs effectively. Service users control their own medication where possible, within appropriate procedures that ensure their protection. EVIDENCE: Service users at Sambourne Road require minimal assistance with personal care. Relevant information is included in their individual plans, and reflects each person’s own wishes in this area. Risk assessments also support judgements about safe levels of independence. Staff provide any support, reminders and encouragement, as required. Each service user has a Health Action Plan. This addresses a range of issues, including vision and hearing, communication, continence, nutrition and Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 18 medication. Records are kept of any contacts that service users have with medical professionals. The home also monitors key indicators such as weight. Sampled records showed the steps being taken in response to concerns about the physical health of one service user. The individual was supported to see their GP, and a referral to a consultant was being made as a result. An occupational and a physiotherapist visited Sambourne Road to assess the individual’s safety using the stairs. Service users who are taking medication usually retain control of this. Most medication received into the home is recorded and stored centrally. Service users then receive a week’s supply, checked and dispensed into a dosette box. One service user is on a different system, where their medication is supplied by the pharmacy already presented in a week’s package. This is also checked before being supplied to them. Service users are risk assessed for their capacity to be responsible for their own medication. Those who do retain their own medicines have suitable lockable storage in their rooms. Staff also monitor them and give reminders if necessary. Checks are made during the week to see that the service user is on track with their prescribed doses. If problems arise, situations are reviewed. Records relating to medication were seen to be generally well maintained. An error was noticed, where the running total of stock in house for one medicine had not been completed accurately on one occasion. The manager was to investigate this anomaly following the inspection. Staff receive training about medication, which has recently been updated for the whole team. This includes learning about in-house systems, as well as an external course covering wider aspects of medication practice. Information is available in the home about medicines which are being taken by service users. Sambourne Road (58) DS0000028356.V336712.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): 22 & 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: Mencap’s organisational complaints arrangements include information for service users on how to raise concerns. This is available in various formats. It includes details on useful external contacts, including the CSCI. The information is easily accessible in the home, and service users are reminded about the arrangements regularly. Service users are positively encouraged to raise any concerns they may have. Complaints records show that they feel able to do so. The concerns tend to be issues arising between different service users. Records for such complaints show that these are taken seriously and responded to appropriately. One relative of a service user mentioned in their survey form that they had some minor concerns, but that they were going to raise these with the manager. By the time of the inspection visit this discussion had taken place, and some actions had been put in place as a result. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 20 Policies are also in place regarding abuse and safeguarding vulnerable adults. These include information about the multi-agency procedure within Wiltshire. All staff receive training on these topics as a key element of their induction, and have update sessions at least once every three years. In addition to this, the staff team were due to visit their local Police vulnerable adults unit. There is also a policy relating to how staff can raise any concerns about practice, which is usually known as ‘whistle blowing’. This is to be discussed within team meetings to promote staff awareness of it. If service users have particular issues relating to behaviour they are supported to develop suitable approaches for managing these. This includes input from relevant professionals such as a behavioural nurse specialist. One example of an approach was seen, where the service user has been helped to use pictorial representations of their moods to help them communicate what they were feeling and to reflect on how they handled the situation. This is helping the individual to identify positive outcomes and future solutions. Guidelines are also in place to help service users who have had disagreements. These help them understand each other’s perspectives and respect each other’s boundaries. Staff support is based around risk assessments which cover safety issues and also uphold the rights of the service users concerned. Sambourne Road (58) DS0000028356.V336712.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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: 58 Sambourne Road is a spacious detached property, within a residential area of Warminster. It is conveniently situated for local amenities, and also for public transport links to other centres. Service users are able to access a wide range of facilities independently. The property is owned and maintained by a housing association. It is decorated and furnished to provide a comfortable and homely feel. Some recent improvements have been carried out, such as replacing some carpets with laminate flooring. More work is planned. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 22 All service users have single bedrooms, one of which is downstairs. Each bedroom has a hand basin, but there are no other en-suite facilities. There is a shower downstairs, and a bathroom upstairs. An additional toilet is situated off the half landing from the staircase. The main communal space is a lounge with dining area on the ground floor. A spare room upstairs is a ‘quiet room’, used by service users for hobbies and activities. Downstairs, there is also a kitchen, a utility room, and the staff office, which is also used by the person sleeping in at night. The home has areas of garden at both front and rear. Additional fencing has been provided to offer increased privacy. Work has been put into improving the appearance of the front garden over the past year or so, with the involvement of service users. A service user with a downstairs bedroom also has an area outside their room which they have filled with pots and hanging baskets. The individual is clearly very proud of this area and enjoyed showing it during the inspection visit. The home was clean and hygienic in all areas seen during this unannounced visit. Service users participate fully in keeping it this way. Rotas allocate various cleaning tasks amongst the group. Training in infection control is planned for all staff shortly. Sambourne Road (58) DS0000028356.V336712.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): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. EVIDENCE: The home employs three full and four part-time staff. There have been no changes in the staff team over the past year. Mencap also has a pool of relief staff who can be used to cover any shifts when necessary. Some service users are funded for specific additional hours of care, so that they can have one-to-one input to help support some of their needs. This arrangement was in place for two service users at the time of this visit, but only one of these had the allocated hours clearly shown on the rota. It would be good practice to ensure that the funded hours for both service users can be clearly identified within overall staff cover. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 24 Numbers on duty reflect the needs of the service user group. There are usually two staff plus the manager on duty during weekdays. Two staff remain on duty into the evening, up until around 10 pm if that is needed to support service user activities. There are also two staff on duty during the daytime at weekends. Overnight cover is provided by one staff member sleeping on site. They can respond to any service user needs which may occur. One comment from the relative of a male service user remarked that it was a shame that the home does not have any male staff. In response, the manager explained that Sambourne Road can have access to some male cover via relief staff. They are aware of the importance of some male service users having such contact, and have planned for this in areas such as who is to support service users when they go away on holiday. The same relative also commented positively on the approach of the home’s staff, writing that they are “exceptionally sensitive to the residents’ feelings” and also that “They are always helpful”. Staff recruitment records were checked, including one for a recently appointed relief worker. These showed that all required recruitment checks are completed, and that new staff do not begin work until they have received the required minimum clearance. Mencap’s recruitment procedures include systems to promote equal opportunities for all prospective employees. Diversity monitoring forms are completed by applicants, to give the organisation a picture of the range of people who are attracted to working for them. Service users at Sambourne Road participate in recruitment by meeting job applicants when they make informal visits to the home. Service users also take part in the induction of new staff. Induction and foundation training is linked to national standards for the social care workforce, and provides a pathway into National Vocational Qualifications (NVQs). New staff are ‘mentored’ by the home manager, or another senior support worker. Induction covers in-house topics, alongside Mencap’s organisational approach. New staff are appointed on a six month probationary period, and not confirmed in post until induction and foundation is completed. The home has a training plan dating from January 2007. Training covers all mandatory topics, such as first aid, food hygiene, and health and safety. Mencap training for all staff also incorporates sessions on the values of care, equality and diversity, communication, and the protection of vulnerable people. Beyond this, training is provided on any topics relevant to the needs of the home’s service users. Sessions planned for later this year include infection control, autism and Makaton, which is a specialist communication system using Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 25 signs and symbols. Staff can also access courses which may be helpful to their job role, such as developing their computing skills. Each staff member has individual training records. These show what sessions they have attended and when refreshers are due. They also include copies of any certificates gained. All except one of the current staff team have obtained a National Vocational Qualification (NVQ) in care, at Level 2 or higher. The one staff member currently without an NVQ is due to begin studying for the Level 3 award. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Service users’ health and safety are protected by the systems in place. EVIDENCE: The registered manager for Sambourne Road is Mrs Janet Candow. She has extensive management experience within Mencap, having acted as manager Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 27 for a number of their Wiltshire services. Having previously worked at Sambourne Road, she returned as manager when the previous postholder was seconded to another role. Her appointment was then confirmed as long term, and she completed the process of registration as manager in January 2007. Mrs Candow has completed the Registered Managers Award and NVQ Level 4. One relative noted some unhappiness about the way the previous manager had left, with what this respondent felt was a lack of notice. However, the relative also stated that they are “very happy” with the way the home is being run under Mrs Candow’s management. Quality assurance measures include systems for obtaining feedback from service users, their relatives, staff of the home and other stakeholders. Surveys are carried out annually, inviting responses on a range of topics. These findings are then collated to identify any themes for action. There is also a range of regular audits of the various aspects of service delivery. Records are kept in-house to demonstrate that these are carried out. A senior Mencap manager carries out monthly visits to report on the conduct of the home, as required under care homes legislation. Development plans identify goals under a range of headings. This includes objectives based on service users’ desired outcomes. Current development plans have a strong focus on promoting greater input of service users to all aspects of the running of the home. For instance, involving them in audits of the home; developing their participation in their own care planning and record keeping; and increasing their input to management tasks such as the administration of petty cash, and the drawing up of staff rotas. A staff member who completed a survey form wrote that “this house is run in a friendly supportive manner and new ideas are always discussed and developed, involving all service users and staff team”. The completed AQAA also demonstrates that the service has a suitable quality assurance system in place. There are various systems to uphold health and safety. A range of general risk assessments are in place for safe working practice topics. There is a documented monthly workplace safety audit. Any issues highlighted are addressed as appropriate. Records show that necessary services and repairs are carried out by relevant external contractors. There are also regular checks conducted and recorded in house, on issues such as water temperatures. Some service users help to carry out these checks, which promotes their own awareness of health and safety topics. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 28 Records show that all required tests and staff instruction for fire safety are carried out and up to date. If faults are identified, these are reported and resolved. Fire drills and evacuation practices are usually carried out once a month. This is to ensure that all service users are fully aware of how to respond in an emergency situation, and supports risk judgements about their ability to be at home without staff supervision for short periods. Health and safety topics are covered in staff training. The home also works with service users to promote their awareness of such issues. Service users have produced a DVD on safety in the home, and keeping yourself safe. They have participated in drawing up individualised policies on ‘Going missing’. Service users have also participated in the making of a leaflet about fire safety. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 4 X X 4 X Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 30 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard YA2 YA9 YA20 Good Practice Recommendations Hours which are funded for one-to-one work with specific service users should be clearly identifiable on the rota. All risk assessments should be updated to make clear which is the most recent information. Care should be taken to ensure that an accurate audit trail is maintained in medication records. Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Sambourne Road (58) DS0000028356.V336712.R01.S.doc Version 5.2 Page 32 - 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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