Inspection on 21/11/06 for Sarsen House

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Sarsen House 01/02/06

Sarsen House 14/09/05

Sarsen House 16/03/05

Sarsen House 12/07/04

Sarsen House 26/02/04

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 Sarsen House West Overton Marlborough Wiltshire SN8 4ER Lead Inspector Tim Goadby Key Unannounced Inspection 21st November 2006 09:25 Sarsen House DS0000028644.V319067.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 Sarsen House DS0000028644.V319067.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. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sarsen House Address West Overton Marlborough Wiltshire SN8 4ER 01672 861139 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) Tullyboy Homes Mrs Catherine Howie Susan Margaret Perry Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Sarsen House provides personal care and accommodation for six people with a learning disability. The service is owned by Tullyboy Homes, a private sector organisation. They run another similar home in Wiltshire. Both owners have close involvement in all aspects of service delivery. Another senior staff member also helps to manage the two homes. The home is in the village of West Overton. This is approximately three miles from the town of Marlborough, which offers a range of amenities. The service first opened in 1995. Most of the service user group have lived at Sarsen House from that time. They also knew each other for many years beforehand. The property is a two storey house. A ground floor extension has been added since it became a care home. All service users have single bedrooms. Two of these have en-suite facilities. Others have access to bathroom and toilet facilities nearby. There is a range of communal space. The home also has a large garden. Fees charged for care and accommodation range between around £945 and £1155 per week, based on the assessed needs of individual service users. Information about the service is available within the home at all times. All of the material produced by Tullyboy Homes itself can also be provided in pictorial format. Copies of CSCI inspection reports are also available in the home. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed in November 2006. The evidence gathered included pre-inspection information supplied by the service; six survey forms completed by service users, with support where necessary; and three survey forms completed by staff of the home. An unannounced visit to Sarsen House was carried out, lasting approximately five and a half hours. During this visit all service users were present, for at least some of the time. The inspector also met with the registered owners and managers, and with other staff on duty. This fieldwork section of the inspection included the following: observation of care practices; sampling of records, with case tracking; sampling a meal; discussions with service users, staff and management; and a tour of the premises. Feedback was given throughout the inspection. What the service does well: Service users can be confident that the home meets their needs and aspirations. The group appear settled and comfortable in their surroundings. Most of them have lived at Sarsen House for a number of years. The home has also coped well over some periods of substantial and difficult change. This has included a couple of admissions, the death of one service user, periods of serious ill health for others, and the management of complex behavioural needs. Staff have had to learn many new skills, as the nature of care they are providing has altered. They have also worked through the emotional effects of loss and bereavement, and the likelihood of further similar experiences. Service users have their abilities, needs and goals reflected in their individual plans. Sarsen House has a comprehensive care plan format. This provides a range of relevant information for each service user. Needs are identified and the actions to be taken in response are clearly described. There is also a focus on service users’ strengths and preferences. Plans are kept under regular review, responding well to significant changes in individual service users’ needs. Care plans help to show how the home is meeting a lot of standards. The home consistently maintains high standards in the delivery of health care. Where service users have significant needs, steps are taken to get them the most appropriate treatment. When necessary, additional care and support have been put in place, working with all relevant health care professionals. Service users benefit from the focus on promoting and maintaining the best health possible, enhancing their quality of life. The organisation has good management systems. The owners have close daily involvement with all aspects of the service, applying their own expertise in relevant areas. There are two registered managers within Tullyboy Homes, Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 6 both with care and management qualifications. Another carer is also taking on additional responsibilities, and is working towards a more senior role. Service users benefit from a well run home. 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. The summary of this inspection report can be made available in other formats on request. Sarsen House DS0000028644.V319067.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 Sarsen House DS0000028644.V319067.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area was not assessed. Standards relating to admissions to the home were not applicable at this inspection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions to the home since the previous inspection. It is therefore not possible to rate practice under the relevant standards. The organisation has suitable procedures, which have been applied appropriately when needed. The key standard was met on the last occasion on which it was assessed. Sarsen House DS0000028644.V319067.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. 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 have their abilities, needs and goals reflected in their individual plans. Service users can make choices and decisions in their daily lives. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. EVIDENCE: Two sets of service user records were sampled in detail during this key inspection. These related to service users with particular needs relating to healthcare and behaviour. The records were seen to be up to date, with evidence of recent review. This included reflecting changes for service users Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 10 whose needs are developing continuously. The input of all other relevant professionals is clearly shown. The home is working well with local health and social care services to ensure regular access to advice and support from a range of specialists. Care plans include a section on goals for each service user. These set out the actions being taken towards these targets. They provide a framework for review. This takes place at regular intervals. Where changes have been made, the previous information is also left visible. This shows how things have developed. The home promotes service users’ rights to make their own choices and decisions, wherever possible. A Users’ Charter sets out their entitlements. Experimentation and exploration are encouraged. The input of the home’s staff team, and other relevant parties, is to ensure that responsible decisions are reached by a process of assessment. Guidelines for the approach taken to particular needs are drawn up with help from other professionals. A particular restrictive practice is operated with one service user. Care standards legislation allow the possibility of such an approach, if it is the only practicable means of securing the individual’s welfare. There has been extensive review and consultation around this issue. The service user’s care record contains appropriate information about the use of the technique. Decision making has been shared with other agencies, to enhance the protection of the vulnerable individual. The practice is being kept under regular review. Information has been updated within relevant records since the previous inspection. Current documentation is clearly and coherently presented. Guidelines have been amended to reflect accurately the current use of the practice. Concerns are being addressed appropriately with all the other professionals involved, and the service user’s own representatives. There is a clear future plan in place for how to respond to the needs of this service user. Sarsen House DS0000028644.V319067.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. 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 offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 12 Service users attend various educational and occupational activities during the week. Staff from the home may support some of these sessions. Some service users are not able to attend every time, depending upon how their health varies. Sessions are kept open for them with this understanding. Service users also receive support on an ‘outreach’ basis. This enables them to have opportunities at home, or in the community. Sessions which take place at Sarsen House provide a chance to join in for those service users who are too unwell to go elsewhere. When service users have gaps from either of these options, the home’s own staff offer one to one support. Access to these opportunities has become less reliable over recent months, with cancellations reported to be more frequent. As a result, Sarsen House is looking into the possibility of alternative options. Recent attendance at a new music session organised by another care home has proved popular with service users. Weekly activity programmes for each service user also show what they are offered at home or elsewhere, when they do not have planned sessions at other facilities. There is a strong focus on ensuring that service users participate in their local community. The group have become well known within the village itself. Some friendships have been established with local people. Several service users attend the village church. Other regular outings include shopping and trips to the local pub. All service users have access to a wide range of activities both at home and outside. At home, people have entertainment equipment in their own rooms, as well as in communal areas. There is also a range of games, puzzles, and books available. Outside the home, users attend some local clubs specifically for people with learning disability. They also access a full range of integrated activities. Usually service users will go out either individually or in pairs, accompanied by staff. It is clear that this is seen as an important aspect of service delivery. All service users receive the opportunity of an annual holiday, escorted by staff. These are done in small groups. Some service users may only go for short breaks, if they find it difficult to cope with longer periods of absence from familiar surroundings. Holiday destinations have included trips overseas. One service user had just returned from a weekend away. There are no restrictions on visiting times. Service users can see visitors in their own room, the small sitting room, or in the garden. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 13 Sarsen House supports all its residents in maintaining contact with friends and family. As well as visits, this may be done by letters and phone calls. Relatives are seen as a valuable resource. They can provide knowledge about the needs and life history of individual service users. Interaction between service users and staff is positive and relaxed. Service users are able to choose how they spend their time when at home. Staff are knowledgeable about individuals, and sensitive in respecting their wishes. The home operates a no smoking policy. There is generally unrestricted freedom of movement for service users. They are expected to respect the privacy of each other’s bedrooms. Some areas are kept locked for particular health and safety reasons. External access is also made secure. All meals are prepared by staff of the home, who receive training in food safety. Menus are based on the known likes and dislikes of service users. Input and advice has also been obtained from a dietician regarding the particular needs of some individuals. Special dietary supplements are used if required. The home has had success both in encouraging weight gain for service users in poor health, and in promoting weight loss for service users who could benefit from this. Some service users use adapted cutlery and crockery. An occupational therapist has advised on the most suitable items for the relevant residents. Most of the household usually dine together, with staff giving support as necessary. One service user’s preference to eat separately is respected. On the day of this inspection visit lunch was a choice of three flavours of soup, served with French bread. Fresh fruit was available for dessert. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 14 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 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 are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: All the service users at Sarsen House have assistance with personal care. This is tailored individually, depending on their abilities, and any safety concerns. For instance, some may require observation when bathing, due to their health needs. Attention is given to ensuring that residents maintain a positive image at all times. Personal care needs of some service users have been influenced by their health and mobility problems in recent months. The home has worked closely with Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 15 occupational and physiotherapists to ensure appropriate support is given. This has included regular assessment and review by these professionals. They have advised and trained staff on support techniques to use. They have also identified relevant equipment, and given instruction in its proper use. Health needs continue to develop for the service users at Sarsen House. These may be linked to natural ageing processes, or to the particular conditions that some service users have. There is ongoing monitoring and review of care. As well as responding to situations as they arise, the home plans ahead for likely future changes. This includes ensuring that staff receive training on any relevant topics. Each service user has regular review by a specialist consultant, with consideration of all aspects of their physical and mental health. As particular service users have become seriously unwell, additional support has been accessed from all relevant health professionals. Getting input from a range of appropriate sources has been beneficial to both service users, and to the staff team at Sarsen House, by providing skilled assistance, and reassurance that all possible steps are being taken. At this inspection, the folder for a service user who has had particularly complex health needs shows clear evidence of the wide range of input they have received. This has involved all relevant professionals in carrying out suitable assessments, and this process is continuing in response to the ongoing changes in the service user’s needs. None of the present service user group are self-medicating. So staff are involved in storage, administration and recording of any prescribed drugs. They receive training after they have been in post for six months. Training also includes instruction from a community nurse in the specific technique for administration of a drug to help manage epilepsy. Arrangements for the management of medication are appropriate. There is secure storage. Administration is carried out in line with relevant guidance. One service user may be prescribed a new medicine to be given ‘as required’. Although the particular drug is not classified by law as requiring additional controls, it is recommended that some extra measures are applied in its management. Advice on these recommendations has been provided to the home since the previous inspection, and was discussed again during this visit. Records relating to administration of medication were generally maintained appropriately. A couple of good practice recommendations were identified. One service user was no longer being given a particular drug. Nonadministration was being recorded, but not the reasons for this. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 16 Another service user is prescribed an ‘as required’ drug, to be given once at night if necessary. Records for this were slightly confusing, as they initially appeared to show the drug being given twice on some nights. Further investigation made clear that this had not happened. Rather, the drug was given beyond midnight, and then again before the following midnight, but only once before the service user retired on each occasion. Ways of avoiding this recording difficulty were discussed during the inspection. The home indicated it would probably set an agreed time at which the drug may be given, so that the issue of it being administered twice within the same 24 hour day would then not arise. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the service’s policies and procedures for complaints and protection. EVIDENCE: A complaints procedure is in place. There is a version with symbols and photographs, intended to be more comprehensible for service users. The service has received one complaint since the previous inspection. Appropriate actions have been taken in response to the issues raised. The complainants have been kept informed of these. Sarsen House operates in accordance with local multi-agency arrangements for adult protection. A copy of the relevant procedure is kept in the home. A whistle blowing policy is also in place. The home has appropriate staff conduct and disciplinary procedures. The service has referred some incidents involving service users to the local adult protection process. Suitable strategies have been put in place to respond to issues arising between particular service users. Potential disturbed behaviour from service users is addressed clearly in their Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 18 care plans. There are appropriate guidelines for staff on how to manage any such situation. Staff receive training on abuse and adult protection within their core induction standards. Tullyboy has also arranged further training in the topic for staff of both its homes, due to take place in early 2007. Sarsen House staff will be the first group to receive this, as it is felt to be particularly relevant to some of the recent issues involving service users. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 19 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, 29 & 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 clean, comfortable and safe environment, which is suitable to meet their needs. EVIDENCE: All parts of the home were seen during this inspection. Sarsen House is an attractive property, set in its own garden, in a pleasant village location. Accommodation for service users is provided on two floors. This includes a ground floor extension that was added by Tullyboy Homes. The home presents as well decorated and maintained. Periodic audits of the building are carried out. These identify any tasks to be addressed. Recent improvements have included a complete rewiring of the property and the installation of new oil tanks. There is also an ongoing Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 20 programme of redecoration. Most major work is carried out when service users are away on holiday, to minimise disruption to them. Each service user has their own bedroom. Four of these are on the ground floor. All rooms are decorated and furnished to reflect the taste of their occupant. Two of the bedrooms have en-suite facilities. The others have bathroom and toilet facilities nearby. Areas of communal space are all on the ground floor. There is a large lounge, and a separate dining room. The kitchen also has a seating area, which is often used by one of the home’s residents. Externally there is an enclosed garden. Appropriate equipment has been obtained to help meet the needs of service users with impaired health and mobility, such as a specialist bed. This has been done with support and advice from the relevant professionals, who have also given instruction in appropriate usage. Records are kept of cleaning schedules, and audited as part of the overall quality assurance process. Care staff carry out all cleaning and household tasks. Many of these are carried out during the week, leaving weekends more free to undertake activities with service users. Also at weekends a couple of young people work a few hours solely on cleaning duties. Laundry facilities are situated in the garage, away from those parts of the accommodation regularly accessed by service users. These have been improved since the previous inspection, with renewal of the wall and floor coverings. This means that these areas can be kept hygienically clean, minimising any infection risks. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. 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 the home’s recruitment policy and practices. EVIDENCE: As a service registered under previous care home legislation, Sarsen House must maintain minimum staffing levels in line with those in place as of 31st March 2002. Staffing requirements are being kept under review, as the needs of service users develop. Recently numbers for daytime shifts have been a minimum of three carers. Managerial staff are usually also present during daytime hours, and form part of the numbers providing care. Nights are covered by a waking staff member, due to the increased support needs of some service users. Three people are employed to work night duty. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 22 Over recent months, one service user has received funding to enable an additional carer to be supplied each day, to give the extra support needed by this individual. These hours have usually been covered by the use of agency workers. Around the time of the inspection visit the service user’s circumstances were changing, and it was likely that the additional funding arrangement would end in the near future. The home was fully staffed at the time of this inspection. When necessary, cover is maintained by a pool of relief staff. There is a checklist for all stages of recruitment, selection, and joining the organisation. This is closely linked to the home’s quality assurance system. Two records for recently appointed staff were viewed. These showed that all required checks are carried out, at the appropriate times. New starters do not commence working until satisfactory clearances have been obtained. Service users have informal involvement in the recruitment and selection of staff, as candidates visit the home. All new starters are subject to an initial probationary period of six months. This may be extended, if it is felt that an employee has not yet demonstrated the necessary competence or conduct. Additional supervision arrangements are then put in place. New staff are overseen by a senior carer during their initial induction and orientation. After a couple of months, once they have settled in, they begin working on a nationally recognised set of induction standards – the Learning Disability Award Framework (LDAF). One of Sarsen House’s managers acts as an assessor for this, including for employees working in other homes. This helps Tullyboy to earn credits to put its own candidates through the training. The home’s training programme includes any external courses which may be relevant to the needs of the user group. This includes distance learning packages on some topics. Some learning also takes place in-house. Talks are occasionally given by some of the professionals with whom the home has contact. Training planned for the coming months includes information about dementia, which is relevant to the developing needs of some of the home’s service users. Individual training records are maintained for all employees. These include information about any qualifications people may have gained in previous employment. The organisation also has a strong commitment to training in National Vocational Qualifications (NVQs). There have been some recent difficulties in Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 23 finding a suitable provider of this. Some staff have had to switch, meaning delays for them in making progress towards their awards. However, the majority of the staff team have achieved a qualification, placing the service above the minimum 50 target for care staff with an NVQ. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered managers are 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: Tullyboy Homes has two registered managers. Both work in both of the homes Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 25 operated by the organisation. They are each qualified to the required levels in both care and management. In addition, one has a professional background in learning disability nursing. Although not practising in this setting, she has maintained her registration through regularly updating her knowledge. The managers attend a range of courses and conferences and are looking for further learning opportunities to continue to extend their own professional development. Tullyboy Homes is also a member of social care organisations which include other care providers, bringing opportunities to share best practice ideas. Usually these two senior staff will alternate the weeks when they focus on Sarsen House. The other week will be spent in the organisation’s other care home. However, they are available for advice and support when required. The access to two well qualified managerial staff is of advantage to the service. One carer within the organisation is now studying towards the NVQ Level 4 award, and taking on additional responsibilities. The intention is that this staff member will also be able to offer managerial support to both services. An extensive quality assurance system has been devised and implemented by the organisation. It is built around the home’s Statement of Purpose, and tailored specifically to the service. The system enables a comprehensive audit of all areas of performance. Frequencies of review are set at varying intervals: monthly, quarterly, or annually. Staff are allocated different areas to check. Annual review is tied in with the service’s end of financial year. This enables findings to be incorporated into the next year’s business plan. It is also shown who is responsible for checking on various areas. Views of service users have been accessed via a questionnaire. This was repeated most recently in July 2006. Staff support service users in this exercise, and make an accurate record of their responses. There is evidence of regular checks and maintenance on key equipment and systems. Staff receive training in a range of health and safety topics, including food safety and manual handling. Bed sides are being used with one service user. The documentation in place for this includes evidence of risk assessment by appropriate professionals, which has been kept under review. However, at the time of this inspection the most recent change in practice had not been reflected by a note in the service user’s records. A further review was just about to take place. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 3 X Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Refer to Standard YA20 YA42 Good Practice Recommendations Care should be taken to ensure clarity in all records relating to the administration of medication to service users. Risk assessment records should be kept up to date whenever there is any change in practice between two set review points. Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 28 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 Sarsen House DS0000028644.V319067.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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