Inspection on 30/05/06 for Seeleys House

This inspection was carried out on 30th May 2006.

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

Seeleys House 06/01/09

Seeleys House 16/04/08

Seeleys House 12/04/07

Seeleys House 28/12/06

Seeleys House 22/03/06

Seeleys House 06/09/05

Seeleys House 31/03/05

Seeleys House 30/11/04

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 Seeleys House Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks HP9 1TF Lead Inspector Sue Smith Unannounced Inspection 30th May 2006 10.00 DS0000032334.V290053.R01.S.doc Version 5.1 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 DS0000032334.V290053.R01.S.doc Version 5.1 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. DS0000032334.V290053.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Seeleys House Address 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) Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks HP9 1TF 01494 670902 Buckinghamshire County Council Mrs Wendy S Rutland Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000032334.V290053.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2006 Brief Description of the Service: Seeleys House is registered to provide respite care at any one time for up to 12 people with learning disabilities. There is a rolling programme for respite care. The home is sited in a residential area of Beaconsfield and is owned by Buckinghamshire County Council. It is an adapted old school and provides single accommodation for service users with shared social space. Half of the building provides Day Care Services and is also owned by the Council. The fees charged are based on a unit cost per bed per night of £197.96 this is paid by Social Services. In addition to this fee the Service Uses each have a contribution to pay which is based on a financial assessment undertaken by the Counties Finance Department, this is based on the level of income support and disability allowance received by an individual (minus the personal allowance of £18.00 per week) this combined figure is then divided by seven giving a nightly contribution. This contribution is usually between £7.00 and £11.00 per night. Information to support potential Service Users and their families to make a decision for admission to the home is provided in the homes Statement of Purpose and the Service Users Guide. Both of these documents are provided to potential Service Users, with additional copies held in the home. DS0000032334.V290053.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 30th May 2006 by Sue Smith (Regulatory Inspector). The Manager was available throughout the inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information and documentation was used in the planning process to ensure hypothesis were formulated to support the inspector to explore issues of concern and verify practice and service provision. During the inspection a variety of documentation was assessed, which included Assessment forms, Careplans, Risk Assessments, Monitoring tools, Medication procedures, Rota’s, Recruitment files and Training and Supervision records. The Inspector for Case Tracking purposes identified three Service Users. The Inspector also accessed information held by the home of two other Service Users for assessment. As a result of this inspection seven requirements and two recommendations were made to support the home to further improve its practice. In addition the Inspector met with three Service Users at their local day centre to discuss their views of the service. In all cases there was positive feedback as to the suitability of Carers and the service provided. Issues to support the home to further improve its service highlighted in the returned Surveys and through discussion were fed back to the Manager. The Inspector would like to thank the Service Users for giving their time in completing this inspection and the Staff and Management for the warm welcome received. What the service does well: All potential Service Users are given information prior to admission as to what the service is able to offer them. This includes the Statement of Purpose and the Service Users Guide. DS0000032334.V290053.R01.S.doc Version 5.1 Page 6 All care is implemented in a manner that supports the Service Users to maintain their own levels of independence. Flexibility is evident when planning and implementing care, ensuring the Service Users have a say as to how and when support is implemented. The dignity and privacy of Service Users is maintained at all times whilst residing at Seeleys house. The implementation of a same sex philosophy of care implementation supports this. The home has adequate systems in place, which promote the equality and diversity of Service Users. Ensuring those of differing cultural or religious backgrounds are supported to maintain their beliefs and observances. The staff employed by Seeleys House receive ongoing training to support their professional practice and improve on their existing skills. The Manager is suitably experienced and skilled in her role, ensuring the home is managed in a manner that promotes the wellbeing of Service Users. Service Users reported she is approachable and they feel they can rely on her to solve any issues of concern they may have. Single room accommodation is provided for all Service Users, which are equipped with equipment and adaptations as necessary to support the Service User. The Home is cleaned to a high standard with infection control measures in place to support practice. Policies and Procedures are provided by the Organisation, which support the smooth running of the home and provide a point of reference for professional standards expected of staff. What has improved since the last inspection? Short term contracts have been offered to Agency staff who are familiar with Seeleys House to alleviate the staff shortages. DS0000032334.V290053.R01.S.doc Version 5.1 Page 7 Following the last inspection and the outcomes of the Quality Review Audit (undertaken by the Organisation) staff have reduced their overtime hours. What they could do better: The main issue of concern for Seeleys House is still the shortage of staff; an action plan has been put in place to ensure suitable staff are always available until such time as a recruitment advertisement for Seeleys House is placed. The Inspector does require the Organisation to continue to explore how they are going to fully staff the home, with the individual programme of recruitment actioned. Careplans are in place, however these need to be changed to a more person centred approach with Service User and significant others involvement reflected. The existing Careplans need to be audited with a programme of archiving to ensure only relevant and up-to-date information is stored. Once this has been achieved and a more person centred plan is developed these could be used as the main personal file for the Service User. A Complaints/Concerns recording format needs to be provided to ensure the home has an accurate record should a complaint or concern be raised. Permanent kitchen staff need to be employed to alleviate the pressure on Care Staff to provide suitable meals. In the interim it is advised an Agency Cook is employed. The Manager needs to identify newer staff that have not received POVA training to support their professional development and maintain the safety of Service Users. The previously made requirement for the fitting of hold open devises to the two office doors is now ready to be actioned. The Inspector has asked that once this has taken place the management of the home informs the Commission in writing the completion date for this important work. DS0000032334.V290053.R01.S.doc Version 5.1 Page 8 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. DS0000032334.V290053.R01.S.doc Version 5.1 Page 9 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 DS0000032334.V290053.R01.S.doc Version 5.1 Page 10 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. Pre-admission assessments are undertaken for all potential Service Users to ensure the home is able to meet their needs. EVIDENCE: All pre-admission assessments are held on file and include social service Careplans and additional information from specialist therapists and family members. Assessments include such things as individual cultural needs and how the home will be required to meet these. All assessments are individual to the Service User and are used to make a decision as to whether the home is able to meet all of the identified needs during a respite stay at the home. DS0000032334.V290053.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected 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. Careplans are in place for all Service Users, however these need updating to ensure they are reflective of the current needs of Service Users and Person Centred. EVIDENCE: Each Service User has a Careplan folder, which contains information pertaining to their personal needs whilst in residence at Seeleys House; this includes upto-date risk assessments, which support the Service User to maintain their independence safely. It was found a lot of the information contained in these plans was out of date and didn’t need to remain in the file, as their presence was making finding the more up to date information hard for staff. The Inspector suggests the home begin archiving some of the more out of date information. In addition to the archiving of information, the home needs to ensure they start implementing a Careplan which is reflective of the PCP approach (Person Centred Plans), these are planned with the Service User and any significant DS0000032334.V290053.R01.S.doc Version 5.1 Page 12 others who may be able to provide in depth information which can be included in the Careplan. These can be presented in any format the Service User wishes as it is the intention that person centred plans are reflective of information understood by the Service User, these could for example be presented as a DVD, video, voice tape, or written and pictorial formats. The home can continue to maintain the original Careplan as a personal file, which will hold for example all the relevant correspondence, originals of assessments and social services Careplans. It is then up to the Service User and the staff member to translate this information into an understandable format. The Inspector believes this will be a process that will take at least twelve months to complete and will be dependent on the access Service Users have to Seeleys House in that twelve months. The Inspector is satisfied the Manager will begin the process with the frequent visitors to the Home and then complete Careplans for the remaining Service Users as soon as is reasonably practicable In the interim the home will need to begin archiving out of date and historical information. A requirement is made to this effect. DS0000032334.V290053.R01.S.doc Version 5.1 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 adequate this judgement has been made using available evidence including a visit to the service. Suitable activities are available to Service Users, however staff shortages have had an impact on the activities programme leaving Service Users with limited options when accessing the local community. Nutritious and tasty meals are provided to Service Users, however vacancies for designated kitchen staff need to be filled to ensure the needs of Service Users are fully met. EVIDENCE: The Home does provide Service Users with activities that are meaningful and fun, however the Service Users are presently limited in their access to the outside community due to the shortage of staff at the home. Service Users made comment that if they could change anything about the home it would be “get more staff as we cant go out because there’s not enough people” and “we cant get out to the pub”. Service Users commented that Seeleys House was “fun”. DS0000032334.V290053.R01.S.doc Version 5.1 Page 14 The Manager agrees the access to activities has not been brilliant but now the weather has improved they are doing lots more out doors, such as football and other sporting events. The Manager has commented that Service Users are getting out as and when they have a driver on and are they are still managing to do things such as coffee shop, pub, shopping and visiting town, however they have been unable to continue accessing the Gateway club due to the shortage of drivers. They now have two relief staff that have passed the mini bus test so this should support Service Users to engage in more activities outside of the home. The Manager continues to monitor this area of the Careplan and has made improvements. The inspector will re-assess this standard at the next inspection, when the increase in staffing numbers and drivers should provide further support to the Manager to increase the activities and community access offered to Service Users. Service Users spoken with were complimentary of the meals offered at Seeleys House, with feedback such as “nice dinners” “like the roasts – pork” “lots of pudding” there were no complaints from Service Users in relation to meals. However there has been no employed kitchen staff at Seeleys House for over 2 year, necessitating care staff to undertake these duties. This has worked well in the short term but does need to be addressed, especially with the current low numbers of full time staff employed at the home. The employment of kitchen staff has been included in the proposed recruitment advertisement currently being formulated for Seeleys House. The Inspector has made a requirement that an Agency cook is employed at Seeleys House until such time as designated kitchen staff are employed. DS0000032334.V290053.R01.S.doc Version 5.1 Page 15 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 good this judgement has been made using available evidence including a visit to the service. The home ensures Service Users receive personal care in a manner that suits their individual needs, ensuring their privacy, dignity and independence is maintained throughout their stay at Seeleys House. Medication procedures at the home are thorough with suitably trained staff administering medication ensuring all Service Users are supported. EVIDENCE: On the day of inspection all of the Service Uses currently using the Service were out at their varies day centres, a decision was made that to gain the views of the Service Users we would visit one of the day centres to speak to Service Users who frequently use Seeleys House. Three Service Users agreed to meet with the inspector to talk about the care they receive at Seeleys House. All were complimentary and enjoyed their time at Seeleys, comments such as “it is fun at Seeleys” “lots of privacy” “always enough staff to have a bath”. One Service User commented she feels she can ask people to help, and that they are helpful towards people in wheelchairs. One service user commented they don’t usually notice when there is agency staff with another commenting “they sit there and don’t talk to me on their bums”. All of the DS0000032334.V290053.R01.S.doc Version 5.1 Page 16 Service Users felt the staff employed by Seeleys House helped them with their personal needs and were flexible in their approach. They also felt they were supported to maintain their levels of independence whilst at Seeleys House. However comments reflected earlier in this record raised concerns about the amount of activities taking place due to the staff shortages. Comment Cards received from Service Users and families were all complimentary when discussing the care provision at Seeleys with the only concern being the staff shortages necessitating the use of Agency staff that are not always familiar with the Service Users needs. The home maintains accurate medication administration records. The medication cupboard was found to be clean tidy and well organised. The systems in place support the Service Users to maintain a level of independence without placing others at risk. A new medication consent form has recently been sent to all Service Users and families, this has asked for more specific details such as allergies and known reactions. A copy of this is then sent to the G.P. MAR (medication administration records) sheets are written up when a person arrives from the updated medication list. The provided key has been used for all missed administrations and there were no gaps evident on the MAR sheets. There were no out of date medications held in the home with all medication stored appropriately. There is lots of information provided to support staff to safely undertake medication duties. Training was updated at the beginning of 2005; the Inspector has recommended the Manager ensure this is revisited with a further update session due to the constantly changing Service User group at the home. A reminder was given to make sure the date of opening was added to all medications held in bottles, as well as creams and ointments One issue of concern was raised with the Manager in relation to medication procedures. It was noted some filled prescriptions are arriving from the Pharmacy with the instruction “to be used as directed by the prescriber”. The inspector has advised the Manager write a letter to the G.P. requesting clearer instructions to ensure the Service Users and Staff are not left at risk of errors. This will be reflected as a recommendation. DS0000032334.V290053.R01.S.doc Version 5.1 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 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 poor this judgement has been made using available evidence including a visit to the service. The home ensures all complaints are actioned in line with the homes policies and procedures; however there is no complaint log in place leaving Service Users vulnerable. The home ensures staff are receiving POVA training, however not all staff have received this training leaving the service users vulnerable. EVIDENCE: There have been no actual formal complaints received since the last inspection with the two highlighted in the pre-inspection questionnaire seen as concerns that needed addressing to avoid a complaint. It was found on the day of inspection there is no system in the home to record complaints or concerns and the investigation information should a concern or complaint be raised. A requirement has been made to ensure a complaints logging system is put in place. As the home is a respite centre catering for over 100 Service User, it has been suggested by Sarah Hague that a complaints form be formulated which will log all concerns and complaints with additional information added (dated and signed) in relation to investigations, actions taken, follow up correspondence and where the information has been stored. The Organisation will be keeping copies of all information in the Service Users individual file stored in the office; this will be separate to the Careplan. The Inspector agrees this will be the most productive system for the Service. The home follows the Buckinghamshire County Council Inter Agency Protection of Vulnerable Adults Policy (POVA), a large number of staff attended the provided two day training course, however as a number of these staff have DS0000032334.V290053.R01.S.doc Version 5.1 Page 18 now left the employment of Seeleys House this has decreased the number of staff who have a clear understanding of this policy. On speaking to staff they were clear as to what constitutes abuse and their professional responsibilities towards the Service User, however there was confusion when discussing the reporting systems of this policy, it is imperative the Manager identifies staff who have not undertaken POVA training and book them on a course as soon as is reasonably practicable. A requirement is made to this effect. DS0000032334.V290053.R01.S.doc Version 5.1 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 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 maintained to an acceptable standard, providing adequate adaptations and equipment to support Service Users. EVIDENCE: The home was found to be clean and tidy on the day of inspection; there is a need for some areas of the home to be redecorated due to the damage made by equipment such as hoists and wheelchairs. This is reflected in the continuous programme of redecoration of the home. The home provides sufficient adaptations and equipment to support Service Users all hoists, specialist baths, showers and wheelchairs were found to be in a good state of repair with regular servicing taking place. There were no offensive odours present throughout the home with a high quality of cleanliness noted. All staff are issued with antiseptic hand rub to support the infection control measures at the home. An inspection for Costing purposes was taking place on the day of inspection for the replacement of paving and steps to the front of the home, replacement DS0000032334.V290053.R01.S.doc Version 5.1 Page 20 of rotting fencing around the garden and levelling the patio leading to the front door. Once this has been approved works will start for their replacement. In addition the car park is due to be tarmaced and the Manager has requested funding to redecorate the lounge and dinging room. These works will greatly improve the indoor and outdoor facilities available to Service Users. DS0000032334.V290053.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is poor this judgement has been made using available evidence including a visit to the service. The Home is staffed by suitably trained and experienced staff, however there is still a long-term shortage of staffing numbers, which could leave the Service Users at risk. EVIDENCE: The Organisation has worked hard to improve the staffing ratios at Seeleys House. Sarah Hague (Senior Manager Learning Disability Team liaised with the Commission in response to the recommendation of the last report to not accept any further referrals until it was able to recruit further staff, the home has reached its negotiated target of staffing levels and are now in a position to continue taking referrals. An action plan has been put in place to ensure the existing staff team are not working excessive hours to cover the home, leaving them and Service Users at risk. A further five staff have recently been recruited, however there is a hold up with the chasing of references, the Organisation need to continue to address this shortfall in their recruitment process to ensure the home is able to fill its vacant posts as soon as possible. CRB checks have been applied for and once this process has been completed it is hoped these staff will join the existing team. DS0000032334.V290053.R01.S.doc Version 5.1 Page 22 Part of the action plan initiative in response to previous recommendations was to employ Agency staff on short term contracts to ensure the continuity of care is maintained. Further steps have been put into place to assess the dependency needs of all Service Uses when providing beds on any given day, ensuring the needs of all the Service Users can be met by the number and skills of the staff. The eminent retirement of a further two staff is being addressed within the action plan. The inspector is satisfied the Manager with the support from Sarah Hague is addressing the staff shortage problems for the home. A requirement is made for the Organisation to continue to explore how to staff the home through active recruitment for Seeleys House. Staff continue to receive necessary training with a training matrix in place to support the manager with the planning, however this does need to be updated to reflect the current staff team. A recommendation is made to this effect. Staff continue to receive 1:1 supervision sessions to support their professional practice. Staff spoken with at the time of inspection reported current staffing levels do make it hard, that it is nice to have the overtime but they do have to watch how many hours they are working. They feel they have managed to maintain a consistent approach to care and usually only get Agency that have been at the home previously. They reported that the Agency does try not to give two new members of staff at once. There were no reported burning issues within the staff team except for staff shortages. Service Users and Relative/friends feedback also made reference to the problems with staff shortages and the use of Agency Staff. Feedback was complimentary of the staff team and their commitment, several notes of thanks were written in the comments section in relation to the level of support received by the staff team. DS0000032334.V290053.R01.S.doc Version 5.1 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 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. Quality in this outcome area is adequate this judgement has been made using available evidence including a visit to the service. A suitably skilled and experienced Manager is in charge of the home, ensuring the needs of Service Users are met. A clear quality audit system is in place, which supports the ongoing development of the home, ensuring the quality of service is maintained for Service Users. Systems to protect the Health, Safety and Welfare of Service Users are in place. EVIDENCE: The Manager is suitably qualified and experienced in her role. Staff spoken with at the time of inspection reported they were happy with the management structure and felt things would become a lot easier (less pressure) once they have a full staff team. There were no complaints with the conduct of the DS0000032334.V290053.R01.S.doc Version 5.1 Page 24 Manager and all staff and Service Users found her approachable, friendly and supportive. Discussion with the Manager on how the home ensured equality and diversity within the service was positive which such things as information at the referral stage made available to potential Service Users and cultural needs are listed in the pre-admission assessment and subsequent Careplan. Information is made available to staff for reading on such things as cultural dietary requirements (supported by the use of a Halal butcher) religious observation and so on. Support is offered to Service Users to observe and maintain their religious practices and a same gender care philosophy in place. The home has an Equal Opportunities Policy in place with no restrictions based on colour, religion or sexuality. Buckinghamshire County Council runs the home, they provide the home with an annual business plan, this includes a service plan and team plan. This outlines areas that are identified for monitoring and how improvements will be made. The plan discusses pilots for such things as inter-client group protocols, provides work plan targets, who leads these, when, any other limits and comments. From the business and service plan the Manager then writes the team plan. For example staffing, key working, needs of clients and how to respond, occupancy, transitions – young people coming through. An internal audit report was received March 06; nothing of major concern was highlighted with the overall rating as good. The Manager was asked to look at whether staff were breaching the working time regulation. This was addressed with a reduction of overtime hours for the remaining staff team and the implementation of short-term contracts for Agency staff. Health and Safety systems are in place, which support staff and protect Service Users. The previous requirements made on the Organisation in response to the last Fire Authority report to fit recommended devises to the two office doors is now being actioned, a decision has been made to fit devices that will be activated by the fire alarm system. A quote has been received and work is due to begin. The Inspector has made a requirement for notice of when work will be completed to be sent directly to the Commission. There were no items of C.O.S.H.H. found around the home with all such items locked away securely when not in use. Health and Safety monitoring systems were found to be dated and signed. DS0000032334.V290053.R01.S.doc Version 5.1 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 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 2 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 3 34 2 35 3 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 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X DS0000032334.V290053.R01.S.doc Version 5.1 Page 26 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 Timescale for action 06/06/07 2 YA6 15 3 YA17 16 (2) A requirement is made for the home to work in the next 12 months towards providing Service Users with Careplans, which are reflective of a more person centred approach and are formulated with the Service User. The home will need to begin 06/09/06 archiving out of date and historical information from the Careplan ensuring all information is current and up-to-date. A requirement is made that an 30/05/06 Agency cook is employed at Seeleys House until such time as designated kitchen staff are employed. A requirement has been made to ensure a complaints logging system is put in place. It is a requirement that the Manager identifies staff who have not undertaken POVA training and book them on a course as soon as is reasonably practicable. A requirement is made for the Organisation to continue to DS0000032334.V290053.R01.S.doc 4 5 YA22 YA23 22 Schedule 4 & 11. 13 (6) 06/08/06 06/08/06 6 YA34 18 (1) a 30/09/06 Version 5.1 Page 27 explore how to staff the home through active recruitment for Seeleys House. 7 YA42 13 (4) Acoustic hold open devices must 06/10/05 be fitted to the two front offices as described in the April 2005 Fire Authority report and additional correspondence from the Fire Authority giving permission for the fitting of such devices. This work must take place within 28 days of this inspection. PREVIOUSLY MADE REQUIREMENT NOT COMPLETED. The Manager must notify the commission of the completion date for the fitting of the hold open devices to the two front office doors. 06/08/06 8 YA42 13 (4) 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 20 35 Good Practice Recommendations The inspector has advised the Manager write a letter to the G.P. requesting clearer instructions to ensure the Service Users and Staff are not left at risk of errors. The training matrix used by the Home needs to be updated to reflect the current staff team. DS0000032334.V290053.R01.S.doc Version 5.1 Page 28 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 DS0000032334.V290053.R01.S.doc Version 5.1 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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