Inspection on 14/06/05 for Saxonbury

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Saxonbury 30/05/07

Saxonbury 12/10/06

Saxonbury 16/11/05

Saxonbury 21/12/04

Saxonbury 08/07/04

Saxonbury 12/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Saxonbury Heathfield Road Freshwater Isle of Wight PO40 9SH Lead Inspector Janet Ktomi Unannounced 14th June 2005 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 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 Stationary 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. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Saxonbury Address Heathfield Road, Freshwater, Isle of Wight, PO40 9SH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01983 755228 01983 755228 Islecare 97 Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21/12/2004 Brief Description of the Service: Saxonbury is a residential home providing care and accommodation for up to six younger adults with Learning Disabilities, one of whom is now over sixtyfive years old. Saxonbury is a large detached two-storey property situated in a quiet residential area of Freshwater. All the homes bedrooms are single, one with en-suite facilities. The town centre with its shops and amenities is about three quarters of a mile from the home. There is off-road parking for several cars at the front of the building, from which there is level access into the home. An average sized garden is provided at the rear of the home. Saxonbury is owned by South Wight Housing Association and leased to Islecare 97 who are the homes proprietors. Islecare 97 have appointed a manager Mrs Helen Cotterill who, at the time of the unannounced inspection, is awaiting completion of the registration process with the Commission. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first unannounced inspection of this inspection year, core and additional standards were assessed. Core standards not assessed during this inspection will be assessed during the second unannounced inspection. The inspection was undertaken on a weekday afternoon and lasted four hours during which a full tour of the building was undertaken. Discussions were held with staff on duty and everyone living at the home was met during the inspection and those able gave the inspector their views about the service. Pre-inspection questionnaire, relatives and service user comment cards were returned to the Commission shortly before the inspection and information from these has also been used in the report. Service users stated that they enjoyed living at the home and liked the staff. Care and other records and documentation identified in the report were viewed. What the service does well: 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. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 7 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 standard(s) 1, 2, 3, 4 and 5. The admissions policy and procedure would ensure that existing service users and potential service users were compatible and that the home would be able to meet the needs of new service users. EVIDENCE: At the time of the unannounced inspection the home had one vacancy. There have not been any new admissions to the home for approximately five years. Discussions were held with the manager and staff in the home as to the procedure that would be employed should a referral be received about a potential new service user. The manager was clear about the service the home could provide and aware of the restrictions which would be placed on admissions to the one vacant room which must be accessed by a short flight of stairs. The manager was clear that she would not admit a person whose needs were very different from the existing service users as this could be detrimental to both existing and the new service user. The manager described the introduction procedure she would use for new admissions that would include day-time visits, staying for meals and overnight visits prior to admission. The manager stated that she would not accept any emergency admissions to the home. Discussions with care staff and the manager showed that they would consider the needs of existing service users when a decision to admit a new person to the home was made. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 8 The new manager has reviewed the home’s statement of purpose in June 2005. This was seen during the inspection and contains all the required information for both the statement of purpose and service users guide. Contracts are agreed between Islecare 97 and Social Services on the island who fund individual service user’s placements. Service users’ families are involved in placement planning and reviews. Due to cognitive limitations the service users would have difficulty in understanding and taking part in the contractual process. There have been no new admissions to the home therefore it was not possible to view any admission assessments and these standards will be reassessed if there have been any new admissions to the home when the second inspection this year is undertaken. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9 The care planning process identifies service users’ individual care needs and includes risk assessments where necessary and specific details as to how care needs will be met. Service users are offered opportunities to participate in the day-to-day running of the home. EVIDENCE: All service users have an individual care plan containing assessment information and detailing how their needs will be met. Two of the five service users care plans were read during the inspection. Each plan, which is regularly reviewed by the key-workers, identifies how the physical, emotional, health and social needs of the service user will be met. The inspector noted that individualised procedures/guidelines had been drawn up, involving external professionals when necessary to ensure care needs are appropriately met. The home operates a key-worker system and service users were aware of which staff were their key-workers. Daily recordings in respect of individual service users were found to be appropriate and regularly completed with care plans reviewed monthly. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 10 During the inspection it was noted that care staff consulted service users, providing them with opportunities to make choices about day-to-day events. Questions were formulated in a manner service users could understand and respond to. Within care plans there was evidence of multi-disciplinary decisionmaking where service users lacked the cognitive ability to make complex decisions. All the service users require support to manage their personal finances. The procedures for this were discussed and a random check will be undertaken on the next inspection. Staff encourage service users to take part in various aspects of the day to day running of the home according to their individual abilities. Service users are actively encouraged to assist with domestic tasks such as dusting, hoovering and shopping. Due to their cognitive abilities service users have limited input into the development of policies and procedures and management related issues. At present interviews for new members of care staff occur at the Islecare 97 headquarters in Shanklin, as such service users are not actively involved in the recruitment process. The manager stated that she hopes to change this and that care staff interviews will include service users in the future. Service users stated that they have service user meetings and that they are involved in day-to-day decisions concerning the home such as the menus and colour schemes for redecoration. Care plans contained risk assessments and clear guidelines for staff around daily activities. External professionals such as psychologists and community nurses, had been involved with care staff in the production of risk assessments which were designed to promote, not restrict, service users’ lives and choices. The home has a number of aids and items of equipment aimed to reduce risks for service users and, environmentally, the home has been made as safe as possible. The home has a policy for unexplained absences and photographs of service users, although this is not a concern with the current service users. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15 and 17. Service users enjoy a varied lifestyle with lots of opportunities for community and leisure activities. The home would support and maintain links with family members. Service users are involved in planning a varied nutritious diet. EVIDENCE: Each service user has an individual weekly programme of activities that includes a range of day services and leisure activities, intended to help develop and maintain life skills and provides opportunities for socialisation away from the home. Care plans and a list on the dining room wall contained details of individual weekly routines and of ad hoc social outings and activities organised by care staff. Discussions with care staff and service users confirmed that service users enjoyed these activities and had been involved in the development of their individual plans. Care staff, service users and care records confirmed that service users often enjoy ad hoc community activities as the weather and service users health permits. Service users stated they enjoy going out for meals, shopping, to the beach, swimming at a local pool, Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 12 for drives or to pubs for drinks. Service users are encouraged to participate in domestic activities as their cognitive and physical abilities allow. Due to physical, health and behaviour reasons it is not appropriate for service users to have a holiday away from the home this year. The home has therefore organised to rent a beach house at Totland and for service users to enjoy a week’s break at the beach returning to the home at night. Service users were aware of these arrangements and were looking forward to having the beach house. The home has a house-car capable of transporting service users who are wheelchair users. The lease for the car is divided equally between all the people who live at the home with an individually determined milage rate paid by each service user dependent on use. Due to physical, medical and cognitive limitations it is not appropriate for the people living at Saxonbury to have paid employment, service users do attend a variety of day centres part of the week. Staffing levels within the home are sufficient to enable service users to enjoy community activities during evenings or weekends. Care staff were observed interacting appropriately with service users during the inspection. All service users are registered to vote, however due to cognitive limitations not all of the people living at the home would be able to participate in the electoral process. During a tour of the home, the lounge and service users’ bedrooms were seen to contain a number of appropriate home entertainment options including televisions, music centres and sensory equipment. Service users stated that they enjoyed the food provided at the home and were involved in discussions about menu planning both on a daily basis and during service users’ group meetings. Several of the people living at the home have regular contact with family members. People living at the home attend day services either in the Freshwater area or in other parts of the island. This enables people to maintain friendships with people living in other areas and to meet and make new friends. The home does not have a separate room for receiving visitors however the lounge or dining room is generally available should there be a need to have a meeting in private other than the service user’s bedroom. One service user confirmed that he has visitors at the home. Service users informed the inspector that they are involved in menu planning decisions and that they liked the food provided at the home. Individual choices are made available to service users, with food being cooked within the home by care staff, who were aware of individual preferences and dietary needs. Where service users have limited cognitive ability to express choices they are shown several options and will indicate a preference. Specialist advice from speech therapist has been sought to ensure food is offered at an appropriate texture, using suitable aids and support given by care staff maximises Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 13 independence. Service users generally eat within the dining room although snacks and drinks are taken in the lounge or bedrooms. Service users are encouraged to help with activities such as laying and clearing the table and with baking cakes and other safe kitchen tasks. Care staff have all undertaken food hygiene courses. All records required in relation to meals are maintained by the home. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. Service users healthcare needs are fully assessed and met with the assistance of external health professionals where appropriate. Staff provide personal support to all service users and ensure that dignity and privacy are maintained at all times. All medication is appropriately stored however the home must ensure that all medication administration records are fully completed. EVIDENCE: The home operates a key worker system that provides for individual support and monitoring of service users’ daily needs. Care plans detailed the type of support individual service users’ require to ensure their personal care requirements are fully met. There was evidence from conversations with staff, and care records showed, that individual service users have access to specialist support and advice as and when required. Service users spoken with confirmed that they are able to choose their own clothing, hairstyles and appearance. Service users also confirmed that staff respect their privacy and knock on bedroom doors before entering. All service users are registered with local GPs and support is provided from care staff to make and attend appointments. The pre-inspection questionnaire information and accident book confirmed that one person living at the home has attended the accident department for an injury sustained at day services, and all have regular dentist, optician and chiropody appointments. Within care Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 15 plans are details as to how specific health needs such as epilepsy will be managed. Care records recorded that specialists such as psychologists and community learning disability nurses are accessed as and when required. At the time of the unannounced inspection all medication was found to be stored appropriately. The medication administration records were viewed and it was noted that medication had not been signed as given in two service users’ individual records. The home uses a pre-dispensed system and a check of the medication showed that the tablets were no longer present and in all likelihood had been given but not signed for. None of the service users living at the home are able to self medicate, therefore all medication is administered by care staff who have received additional training and been deemed competent. All care staff have completed the City and Guilds medication administration course. Guidelines as to the administration of as required medication (such as paracetamol) were noted within care plans. No controlled medications are held within the home. The medication storage cupboard has been moved from the kitchen and is located in a quieter area of the home. Improved lighting has now been provided in this area. The manager and care staff need to ensure the medications administration records are signed and a procedure for checking should be implemented. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 16 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 standard(s) 2 and 23. The home has a complaints policy in symbol format with service users’ opinions sought and respected by staff. The manager and care staff are aware of adult protection issues and follow the locally agreed procedure in the event of adult protection concerns. EVIDENCE: Islecare 97 has a complaints policy which is made available to service users or their representatives in the service users guide. There is also information as to how to complain available around the home. The complaints policy should ensure that all complaints are appropriately investigated within twenty-eight days. The home maintains a complaints book, this was viewed and no complaints have been received during the past year. Staff were aware of what procedure they should follow should a service user or their representative make a complaint. Service users at the home were observed making comments and sugestions to care staff and it is the inspectors opinion that those able would feel capable of making a complaint if they wished to do so and that the manager or care staff would listen to their complaint and take the appropriate action. The home has a copy of the Isle of Wight Adult Protection Policy together with the Islecare 97 adult protection and whistle blowing policies. The manager confirmed that all staff receive training in respect of adult protection as part of the Islecare 97 induction programme. Staff spoken with during the inspection were all aware of the adult protection policy and procedures and clear about their responsibilities to report issues of concern without delay. All service user bedrooms contain a secure lockable facility where valuables or money may be Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 17 stored. The employment procedures followed by Islecare 97 should ensure that unsuitable people are not employed at the home and include POVA and Criminal Record Bureau checks. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 18 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. The premises are well maintained and suitable for the existing service users providing all single bedrooms and appropriate bathing, WC, and communal space. EVIDENCE: Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 19 In general terms the structure and layout of the home is suitable for the needs of the current service users in that it is safe, well maintained and meets service users’ needs in a comfortable and homely way. The lounge is a good size and has been redecorated and has new furniture. The kitchen, again of a good size, has been recently refurbished. There is level access into the home and ramped access to the rear garden from both the lounge and dining room. Damp areas noted during the previous inspection have been rectified. The rear garden appeared safe and is fully enclosed with seating, a patio, vegetable garden and lawn area. All bedrooms within the home are for single occupancy, one having en-suite facilities. Five of the bedrooms are a good size, whilst one is smaller. All bedrooms are centrally heated and naturally ventilated. They were seen to contain appropriate furniture, adequate lighting and storage space. All rooms were seen to be well decorated and individually personalised. All bedrooms have a wash basin. The home has two assisted bathrooms, one containing both parker bath and shower, and a third bathroom upstairs. The bathrooms also contain a WC. One bedroom has en-suite facilities. The number and facilities within the bathrooms are appropriate to the current service user group. All bathrooms have lockable doors and staff were noted to knock on bathroom doors prior to entering. The home has redecorated the lounge with people living at the home having selected the colour scheme. The home has additional communal space within the dining room and the gardens that are located to the front and rear of the property. All communal areas are accessible to all service users with ramps leading to the gardens. The home’s office, which doubles as the staff sleep-in room, is available for professional meetings but is not accessible to people with restricted mobility. However as the home is small and many service users are out at activities during the day the home’s lounge or dining room could be used for larger meetings. During the inspection people who live at the home were seen using communal rooms and moving about independently within the home. Some of the people living at the home have restricted mobility. Their bedrooms and communal facilities are located on the ground floor affording them full access of all these areas of the home. The manager stated, and care records confirmed, that referrals are individually made for specialist equipment. As previously stated the home has two assisted bathrooms situated on the ground floor. Appropriate moving and handling risk assessments have been completed with aids and equipment available. The home’s routine maintenance is carried out by handy men employed by Islecare. Care staff undertake all domestic tasks within the home, sometimes supported by service users where appropriate. On the day of the unannounced Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 20 inspection the home was found to be clean, tidy and free from offensive odours. Laundry facilities are located within a locked utility room. The manager confirmed that the washing machines were capable of washing to a high temperature. Care staff confirmed they have undertaken infection control training. The home has a no smoking policy. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 35. The home employs appropriate numbers of care staff to meet the needs of service users. A comprehensive recruitment, induction and training programme should ensure that unsuitable people do not work in the home and staff have the necessary skills required to meet service users’ needs. EVIDENCE: The manager and staff confirmed that they have all received job descriptions provided by the company Islecare 97 and were aware of their roles as key workers and care staff. Many of the staff have been employed at the home for a number of years and have a good understanding of the service users’ needs. Both male and female staff of various ages are employed at the home. Staff spoken with understood when and how to seek advice and support via the Islecare on-call system. During the inspection care staff were observed interacting appropriately with the service users. Comment Cards returned by relatives of people who live at the home confirmed that care staff are caring and competent, with service users stating that the staff are helpful and nice. As previously stated the home has a consistent staff group with many of them having been employed at the Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 22 home for a number of years. Care plans detailed how specialist support and advice is obtained from Community learning disability nurses, psychologists and care managers. The pre-inspection questionnaire completed by the manager confirmed that all staff have completed core and specialist training to understand and meet the needs of the people living at the home and that three of the nine care staff employed at the home have NVQ level 2 in care. All staff working within the home have completed the Learning Disability Award Framework at introductory and foundation level. Care staff have also all achieved the City and Guilds in medication administration. The manager and care staff confirmed the information in the pre-inspection questionaire that they have all undertaken the appropriate mandatory training and update courses which include, first aid, health and safety, food hygiene, fire awareness, manual handling and also Person Centered Care training. The home currently has five service users, most with high care needs. Service users and care staff stated that they felt there were appropriate numbers of staff on duty to meet the service users’ needs. Duty rotas and staff confirmed that on weekday mornings the home aims to have three members of staff on duty with two through the evening and one sleep-in at night. Where possible the home has three staff members on duty throughout the weekend. The manager works a day-time shift each weekday. On call arrangements are provided by the manager and senior care staff who are available at night should the female service user require personal care when a male staff member is on sleep-in duty, although this is not often required. As stated the home has a low rate of staff turnover and staff try to provide additional cover for holidays and sickness to avoid the need for agency staff. The home has a low rate of sickness as stated by care staff. Islecare has a bank system and the same bank staff would be used wherever possible. In addition to care work care staff also undertake a range of cleaning, cooking and transport to day service duties. The home has regular staff meetings with minutes of the most recent being displayed for staff to read on the office wall. The manager confirmed that the staffing levels would be reviewed depending on the needs of any new service users admitted to the home. The manager described the recruitment procedure that was in use for a new member of the team. The manager stated that she would be interviewing the person the day following the unannounced inspection. Care staff interviews currently take place at the main Islecare 97 offices in Shanklin. The manager stated that she would in future aim to increase the involvement of service users in the recruitment process by holding interviews at the home. Prospective care staff are invited to visit the home during the recruitment process and meet with service users at this time. The records in respect of the new staff member and any others recruited this year will be viewed at the next unannounced inspection. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41, and 42. The management arrangements within the home ensure that service users’ needs continue to be met and creates a homely atmosphere in which service users feel valued and are well cared for. EVIDENCE: Since the previous inspection a new manager has been appointed to the home by the proprietors, Islecare 97. The new manager was previously a registered manager of a similar home for people with learning disabilities belonging to the same proprietors. The manager is now undertaking the registration process and this will be completed as soon as the enhanced level CRB is received. Care staff confirmed that senior Islecare 97 managers regularly visit the home with Regulation 26 visits by a representative of the proprietors being recieved at the Commission on a monthly basis. The home is small therefore the manager has contact with all service users each day she is in the home. Due to Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 24 cognitive disabilities service users surveys would be impractical. Service users informed the inspector that they are consulted on issues such as choice of menu, activities and the home’s decoration. The manager confirmed, and minutes were seen, of service users’ meetings that the manager chairs on a monthly basis and as required. The proprioters ensure that an annual audit of the home is undertaken by a suitably qualified person who works for the company but is based elsewhere in the country. The home employs the corporate Islecare `97 Ltd policies and procedures that cover a comprehensive range of topics and comply with current legislation. Policies are subject to regular reviews. All staff are provided with information about new policies and required to read these and sign to confirm they have done so. Policies and procedures are held within the office and available for all staff. The local policy in relation to adult protection is held within the home. Care staff confirmed they were aware that the policies existed and where to find them should the need arise. During the inspection a range of records including accident book, medication administration records, staff meetings, care plans, fire detection equipment check book, menus and duty rotas were viewed. With the exception of the medication administration records were found to be appropriately maintained and stored as per the requirements of the Data Protection Act 1998. The majority of these are stored within a locked cabinet in a locked office, with staff files stored separately. It is required that all medication administered within the home is signed for by the person administering the medication and that the manager introduce a checking system. The appropriate insurance certificates were seen. Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Saxonbury Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 2 3 x Version 1.30 H55H05_S12531_Saxonbury_V218326_140605.doc Page 26 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 17 (1) (a) Schedule 3 (3)(1) Requirement The home must ensure that medication administration records are fully completed. Timescale for action Immediat 14-6-05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 27 Commission for Social Care Inspection Mill Court Furrlongs Newport, Isle of Wight PO30 2AA 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 Saxonbury H55H05_S12531_Saxonbury_V218326_140605.doc Version 1.30 Page 28 - 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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