Inspection on 25/07/06 for Saxby

This inspection was carried out on 25th July 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saxby 22/08/07

Saxby 19/12/05

Saxby 27/06/05

Saxby 11/01/05

Saxby 20/07/04

Saxby 14/01/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Saxby Upton Road Upton Aylesbury Bucks HP17 8UA Lead Inspector Mrs Maureen Richards Unannounced Inspection 25th July 2006 09:45 Saxby DS0000029711.V296678.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 Saxby DS0000029711.V296678.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. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxby Address Upton Road Upton Aylesbury Bucks HP17 8UA 01296 749969 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) Turnstone Support Limited Care Home 4 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Saxby is a small care home that is registered to provide care and accommodation to four service users with a learning and physical learning disability. The home is managed by Turnstone Support Housing Association. Saxby is situated in the village of Upton, which is a small village on the outskirts of Stone, but it is accessible to Aylesbury and Thame town centre and amenities. Access to amenities is via the homes own transport. The home is on a bus route to local villages and towns. Saxby is a single storey building, which has been refurbished and adapted to meet the needs of the service user group. All of the bedrooms are single. There is a car park at the front of the property and an enclosed rear garden. The current weekly fees are £1647.45 as indicated on the pre inspection questionnaire. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day. The key National Minimum Standards for younger adults were inspected and the progress in meeting requirements from previous inspections was evaluated. Comment cards were received from service users, relatives and professionals involved with the home. Three comment cards were received from service users. One of those was incomplete and indicated that the service user had walked away, the other two comment cards indicated that service users were happy with all aspects of their care. Three comment cards were received from relatives who were all happy with the quality of care being provided. One commented that “the staff are the very best, they are kind and very caring and I could not wish for any better”. Another relative commented that she is very happy with her relative’s progress, the staff are kind, caring and it is always a pleasure when I visit. Thank you all for caring so much. A comment card was received from the General Practitioner involved with the home who was happy with the care being provided. The inspection involved discussion with the manager, individual discussions with two staff, a tour of the communal areas of the home and one bedroom, examination of some of the required records, a discussion with one service user and observation of practices and staff interactions with service users. What the service does well: The home has specific and detailed service users plans in place to ensure that all of individuals needs are identified and met. Service user plans include up to date risk assessments to promote safety. Service users are supported and aids are provided to assist service users in making decisions and choices, which affect their lives. This is continuously being developed on and staff are motivated and committed to the development of this. A range of activities is made available to service users. Family involvement is encouraged and feedback from families as outlined above supports this. Service users rights and privacy are respected and promoted. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 6 Service users are actively involved in meal choices and a varied and balanced diet is provided. Systems are in place to ensure that service users healthcare and personal care needs are met and monitored and the staff at the home are proactive in responding to changes in individuals. Medication is well managed with a review of systems and procedures following drug errors to prevent reoccurrence and to ensure the safety of service users. The home has an effective complaints procedure, which has been developed in a user friendly format. The home is well maintained, clean, homely and bedrooms are individually personalised. Permanent staff have the required mandatory training and have access to specialist training. Staff are proactive in putting what they learnt from their training into practice within their work place. Staff at the home are motivated and committed to the continued development of providing a high quality of care for service users and this is evident from the continued development of service users involvement in all aspects of their lives. The organisation continues to develop paperwork in a user friendly format to further promote this. The home is well managed and monitored effectively by the organisation. What has improved since the last inspection? Assessment documentation for new service users is maintained at the home. The whistle blowing policy, supporting people who may challenge policy and the medication policy have been updated. The staff files for permanent staff have been developed in line with Schedule 2. A new manager has been appointed without delay to ensure continuity of a high quality of care within this service. A quality audit tool has been introduced and this is being developed. A fire drill has taken place but the frequency of fire drills do not appear to have been agreed. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 7 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. Saxby DS0000029711.V296678.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 Saxby DS0000029711.V296678.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 at least once during a 12 month period. 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 the service. Assessment documentation indicates that prospective service users are assessed prior to admission which ensures that their needs can be met and their compatibility with other service users is considered. EVIDENCE: The home has had no new admissions since the previous inspection. A requirement was made at the previous inspection that the manager must ensure that the assessment documentation for prospective service users is maintained at the home and the key information and known risks are made available to staff prior to the service user spending periods of leave at the home. The assessment documentation for the service user admitted to the home prior to the last inspection is now in place. This requirement must be complied with for any future admissions to the home. The home has a referral and assessment policy in place. Service users meeting minutes confirm that service users were made aware of visits and the admission of the service user prior to him moving in. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 10 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 this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service user plans are specific and detailed in plan of care, however the information within service users plans must be standardised and developed to promote continuity of care. Service users are supported to make decisions about their lives, which enables them to be involved in aspects of their care and life at the home. Risk assessments are in place, which promote the health, safety and welfare of service users. EVIDENCE: Three service users plans were viewed at this inspection. Each service user has two files, one a daily file and the other file which includes all information pertinent to each individual. Both files include a photograph of individuals. The files seen include a personal details information sheet, detailed information on Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 11 what the service users likes, things that are important to them and an indication on how the link worker at the home was chosen and why. The home has been in the process for some time of introducing essential lifestyle plans and these were in place in some of the files seen. However the files also contained care plans and support care plans, which the essential lifestyle plans were meant to replace. As a result service users files contained duplicated information in different formats and some of this information was overdue for review. A requirement was made at the previous inspection to address this, which has not been complied with within the required timescale. This must now be addressed as a priority. The essential lifestyle plans are detailed and informative in outlining how service users needs are to be met, in promoting service users involvement in decisions and in promoting independence. Some of the essential lifestyle plans included a review date, which was the same as the date of implementation and none of the essential lifestyle plans indicated that they had been discussed with service users. The home has one service user with epilepsy. This individual’s plan outlined the type of seizures and guidelines on the administration of medication to manage this. The information on the seizure types was unsigned to indicate author and the service user plan did not outline the action to be taken by staff in the event of the service user having a fit. This must be addressed. Service user plans indicate that service users are supported to make choices and decisions in all aspects of their lives and this continues to be developed. One service user plan outlines a range of objects of reference used to enable this individual to make choices and decisions, which has reduced frustrations for this individual as his needs are met and understood. Staff should be commended on the continued development and success of this. The home has advocacy involvement as required for individuals and to support service users at their reviews. The home has monthly service user meetings and minutes are maintained to support this. The minutes are written up in a user friendly format by the use of pictures. The minutes indicate that service users are supported to make decisions in relation to aspects of their daily lives. Service users plans outline the support required by individuals in managing their finances and Turnstone Support act as an appointee for some service users. The manager confirmed that service users finances were due to be audited by the organisation and a date was scheduled for this to take place. Service user plans included a range of risk assessments including moving and handling assessments. At the previous inspection it was advised that the risk assessment documentation was in the process of changing. To date the revised risk assessment documentation was only in place in one of the files seen. The risk assessments on file were up to date and showed evidence of being reviewed. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 12 The home has a missing person policy, which includes notification of a missing person to the Commission. A requirement was made at previous inspections for the confidentiality policy to be reviewed and updated. There was no revised copy of this policy at the home to indicate that this requirement has been complied with. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. A range of activities is made available to service users which promotes personal development. Family involvement and friendships are supported and encouraged to enable service users to develop and maintain family links and appropriate relationships. Individual rights are outlined in service user plans, which ensure service users rights are respected, and their privacy and involvement in decision making is promoted. A varied and balanced diet is provided which promotes the service users well being. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 14 EVIDENCE: One of the service users is involved in a work placement scheme and this individual is being supported to take up a college course later in the year. Some service users have specific activities with the Connect team who are based at Turnstone’s head office and see service users in the home, escort them out of the home for community activities or service users attend a session at the head office. Service user plans include an outline of individuals’ weekly activity programmes. Service users are supported to become part of and participate in community resources. Service user plans include a summary of monthly activities that have taken place, which include meals out, trips to Wendover Woods, day trip to Bournemouth, picnics and barbeques. Extra staff are provided for specific planned activities, including in the evenings and at weekends. The home has its own transport. Service users are on the electoral roll. Some service users have family involvement and service users plans indicate the level of involvement for individuals. Visiting is flexible. Service users can see visitors in their bedrooms or in communal areas of the home. Three comment cards were received from relatives who indicated they were very happy with the care being provided. Service users are supported to maintain links with service users from other homes whom they previously lived with. Service user plans make reference to supporting individuals to develop their independence. Staff knock on service users bedrooms prior to entering and staff do not enter if the service user is not there. Service users plans outline how staff promote privacy in relation to accessing bedrooms. Service users have a key to the front door and their bedrooms. They are supported to use their key when leaving and entering the home. Service users are supported and encouraged to open the door to visitors. These practices were observed during the inspection. Service users plans outline the level of support required by individuals in opening and managing their post. Staff were observed engaging service users in all conversations and have developed a good understanding of service users communication needs. Service users can choose not to take part in an activity and on the day of the inspection one service user decided after a hospital appointment that he did not wish to go to his work placement. This decision was respected. Service users have unrestricted access to all areas of the home. Service users continue to be supported to become involved in housekeeping tasks and service users plans outline the level of support required by individuals in housekeeping tasks. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 15 Service users have three meals a day with drinks and snacks available as required. Service users are supported to choose what they want for each meal and pictures and objects of reference are used to facilitate those decisions. The main meal is planned daily and a range of meal options are available to promote this. The menus seen indicate that service users have a varied and balanced diet and alternatives are provided for individuals as required. Service users are provided with the appropriate eating aids as required and are assisted to eat their meals if required. The home can access dietician involvement for individuals if and when required. Some service user plans include eating and swallowing guidelines, which support this. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Systems are in place to ensure that service users personal care and healthcare needs are met and monitored which promotes their well being. Medication is well managed which promotes service users well being. EVIDENCE: Service user plans include moving and handling assessments, which outline how service users are to be moved and guided. Personal support is provided in private. Service users plans outline how service users are to be supported in meeting their personal care needs, including promoting service users choice of what clothes to wear. Times for getting up and going to bed are flexible and this was evident during the inspection and from the daily log records. The manager confirmed that service users are given a choice of staff on shift to support them with a specific activity or task. Service users have the technical aids and equipment provided as assessed as being required. Service users have access to a wide range of professionals from the Community Learning Disability team and general nursing input is accessed via the General Practitioner’s surgery. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 17 Service users have a nominated link worker at the home and one of the service users confirmed this. Service user plans clearly identify service users preferred routines, likes and dislikes. All of the service users are registered at a local General Practitioner’s surgery. Service users have access to a range of community based health facilities and records are maintained of all appointments and the outcome to support this. The service users are offered a well man annual health check through the surgery. Service users are supported to attend appointments and this was evident during the inspection. None of the current service user group are self medicating. Staff are responsible for administration of all medication. Two staff are involved in the medication administration with one staff member dispensing it and the second staff member checking it. All staff involved in medication administration are assessed and deemed competent to administer medication. Records are maintained to confirm those assessments. There is a list included with the medication to outline named staff who can administer medication and includes a sample signature of each staff member. The senior is responsible for ordering, receiving and disposal of medication with other staff being trained in this procedure. Records are maintained of all medication ordered, received and disposed of and a stock check record is maintained. The home has detailed guidelines on the use of all as required medication which are included with the medication administration records and in individual service users plans. The home does not use any homely remedies. The medication administration records showed no gaps in administration of medication. The home has had three medication errors since the last inspection and procedures have been reviewed and improved to address those. However the home failed to report the errors to the Commission under Regulation 37 and is reminded that they are required to do. A requirement was made at previous inspections for the medication policy to be reviewed and updated. A draft revised medication policy was available at the home on this inspection. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has an effective complaints procedure in place to enable service users to address issues. This should be reinforced to service users on a regular basis. Staff are clear of their role in reporting bad practice and training is provided to support this. However the adult protection policy is not in line with adult protection interagency procedures, which could potentially put service users at risk. EVIDENCE: The home has had no complaints since the previous inspection. The Commission was made aware of a complaint from the District Nurse in relation to the lack of supply of water in some areas of the home and the risks of cross infection. The manager has been actively pursing this in an attempt to address it. This should be logged as a concern within the complaints log maintained at the home. The home has a complaints procedure in place and a user friendly format of the complaints procedure. Service users records indicate that the complaints procedure was explained to them in January 2005 and a system should be put in place to do this on an annual basis. Staff confirmed that they are aware of how to support a service user with a complaint. The home has recently received two verbal compliments, these should be logged and fedback to staff. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 19 A requirement was made at previous inspections for the whistle blowing policy and the adult protection policy to be developed in line with interagency procedures. A revised copy of the whistle blowing policy was available but the adult protection policy has not been developed. The training records indicate that the majority of the staff have up to date adult protection training and this training has been booked for staff who require an update. Staff on duty were clear of their role in reporting bad practice and abuse. A requirement was made at previous inspections that the organisation must update the management of violence policy to include that any incident is reported to the Commission. A supporting people who may challenge policy was available in draft. This does make reference to notification of such incidents to the Commission. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is well maintained, clean and homely to benefit service users. Relevant polices must be updated to promote this. EVIDENCE: The home is well maintained with plans in place to decorate the sitting/dining room and kitchen and the carpet and three piece suite in the lounge is to be replaced. Service users will be supported to be involved in making choices of colours and textures. The garden is generally well maintained with a greenhouse and fruit and vegetables being grown. The garden has a seating area with a parasol and a separate seat in a shaded area of the garden. One of the bedrooms was viewed at this inspection. The bedroom was nicely decorated and personalised. Staff are responsible for the cleaning at the home and this was maintained to a high standard. Records and cleaning schedules are in place to support this. A requirement was made at a previous inspection for the infection control policy Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 21 to be reviewed and updated. A revised infection control policy was not available therefore this requirement has not been complied with. The home has had ongoing issues with the lack of supply of water at the home at intervals during each day. A district nurse has raised this as a concern in relation to cross infection. The manager has been proactive in trying to address this and during the inspection a contactor was on site discussing options to address the problem. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 22 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, 34 & 35 Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. Staff have the necessary training and skills to meet service users needs. The home has safe recruitment practices in place in relation to permanent staff. This must be improved and developed for agency and sessional workers to safeguard service users. The majority of staff have up to date mandatory training however confirmation of training for agency and sessional workers must be obtained to ensure that service users needs are met by appropriately trained staff. EVIDENCE: Staff are accessible to, approachable by and comfortable with service users. They are proactive in developing and promoting service users means of communication to promote their decisions and choices. The rota indicates that staff are reliable and in discussion with them they appear keen, motivated and committed to the aim and philosophy of the home. The organisation is proactive in providing specialist training and staff have recently attended communication skills training, diversity equality training, training in autism and epilepsy, dementia training is provided. The home has developed professional Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 23 relationships with the General Practitioner and other professionals involved with the home. A comment card was received from one professional who supports this. The home has five staff with an National Vocational Qualification (NVQ) and another staff member is registered on this course. Four staff files were viewed at this inspection. The files for the permanent staff at the home indicate that the schedule 2 information is being obtained and maintained on files. The organisation has some staff who work at the home on a sessional basis. The home has no confirmation of recruitment checks for those individuals. This is unacceptable and the manager is reminded that those individuals must not work at the home until she has obtained confirmation of the required checks for each individual. The home uses agency staff to cover some shifts. One agency confirms that the individual had two references, a criminal records disclosure check and disclosure number. The other agency faxes a copy of a criminal records bureau checks but there is no written information to confirm that references have been taken up. The Criminal Records Bureau copy for one agency worker had been tampered with to indicate the agency worker was female and not male. This is unacceptable practice by the agency that must not be accepted by the home. Staff files, in particular information on agency staff, should be reorganised. New staff, agency staff and sessional staff are inducted into the home and records are maintained to support this. Each staff member has an individual record of training undertaken and this indicates that most staff have the required up to date mandatory training. The senior oversees the training and she has identified staff who needs updates in specific mandatory training. The home has no confirmation of training for sessional workers and one of the agencies used do not indicate what mandatory training the individual agency staff members have. Saxby DS0000029711.V296678.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. The home is being effectively managed and monitored to benefit service users. Some improvements are required to health and safety practices and recording to benefit and ensure the welfare and safety of service users. EVIDENCE: The manager has been in post since May 2006. She has applied to the Commission to be the registered manager of this service. She confirmed she has obtained her National Vocational Qualification level 4 in management and intends to enrol on the level 4 in care. Staff confirmed that the change in manager has been a positive one and that the manager is approachable, supportive and proactive in addressing issues. Requirements from previous inspections have not been complied with in relation to updating policies. This is the organisations responsibility and not the Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 25 manager. The manager is committed to complying with the outstanding requirement in relation to the development of service users plans. The organisation carry out monthly visits of the home and records of the visits are maintained to confirm this. The organisation has commenced a quality audit process. The home has obtained feedback from service users, relatives and observed staff practices and from this action plans have been developed. Staff questionnaires are being developed to support this. The manager was unsure if feedback had been obtained from professionals or how this was intended to be achieved. All of the quality audit feedback to date was filed in different areas on the computer. This information and feedback should be compiled in one document and made more accessible to the home. The majority of staff have up to date mandatory training. This must be confirmed for agency and sessional workers as outlined under standard 35. The organisation provides fire training on a three yearly basis and the manager should facilitate annual updates to support this. The home has accident and incident records in place. It was noted that accidents and incidents which affect the well being of service users are not being reported to the Commission as required under Regulation 37. This must be addressed and staff must be informed of their responsibility to do this. The home carries out monthly health and safety checks and one of the service users is supported in assisting with this. Staff check and record water temperatures and a control of legionella guidance is in place. Staff check and record fridge, freezers and food temperatures. There were gaps in the recording of food temperatures. Food stored in the fridge was not labelled to indicate when opened and some food stored in the freezer was not sealed properly. This must be addressed. The home has staff task risk assessments in place, which were recently reviewed. One staff member does most of the redecorating with the involvement of a service user. A risk assessment must be put in place to address this. The home has COSHH data sheets in place and a manual handling of loads assessment, which was due for review. The home has up to date records of gas service and portable appliance testing. The home did not have a copy of fixed electricity service and this will be due five years from the initial date of opening. The home has records in place to confirm that the fire equipment has been serviced and an up to date fire risk assessment is in place. Records are maintained to confirm that the fire alarm, emergency lighting and the fire bells are checked weekly and that the dorguards are being maintained. The last fire drill took place in January 2006. A requirement was made at the previous inspection that a fire drill must be carried out and a system put in place to ensure that regular drills take place in line with the organisations procedures. The requirement for a fire drill to be carried out has been complied with but Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 26 there is no clear guidance or protocol on the frequency of fire drills. This must be addressed. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 3 X 2 X 3 X X 2 X Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The manager must ensure that all of the service users plans are updated with the essential lifestyle plans, kept under review, signed and indicate discussion with service users. (Previous timescale of 31/01/06 not met) Service user plans must include clear guidelines on the management of medical conditions. The adult protection policy must be developed in line with interagency procedures. (Previous timescale of the 31/03/05, 31/08/05 and 31/03/06 not met) The manager must ensure that confirmation of recruitment checks is provided for all sessional and agency staff working at the home, prior to them working a shift at the home. The manager must ensure that she obtains confirmation of mandatory training for individual sessional and agency staff supplied to the home. DS0000029711.V296678.R01.S.doc Timescale for action 30/09/06 2 YA6 3. YA23 15 30/09/06 13 31/10/06 4 YA34 19 31/08/06 5 YA35 18 31/08/06 Saxby Version 5.2 Page 29 6. YA40 Appendix 2 7 YA42 37 8 YA42 23 The confidentiality policy and the 31/10/06 policy on infection control must be reviewed and updated. (Previous timescale of the 30/04/05, 31/08/05 and 31/03/06 not met) The manager must ensure that 31/08/06 all events in the home that affect the well being of service users are reported to the Commission. The frequency of fire drills must 31/08/06 be agreed and regular fire drills must take place in line with the organisations procedures. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard YA6 YA22 YA22 YA39 YA42 YA42 YA42 Good Practice Recommendations Service user plans should be reorganised, standardised and old and out of date information archived. The complaint from the district nurse should be logged in the complaints file and records of compliments should be maintained. A system should be put in place to explain the complaints procedure to service users on a more regular basis and at least annually. All of the quality audit feedback should be complied in one document and made more accessible to the home. The manager should facilitate annual updates in fire training and fire procedures. Food temperature records should be consistently maintained and food in fridge and freezers must be stored and labelled appropriately. A task risk assessment in relation to staff decorating should be put in place. Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Saxby DS0000029711.V296678.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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