Inspection on 05/09/07 for Selborne House

This inspection was carried out on 5th September 2007.

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

Selborne House 29/09/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Selborne House 34 Selborne Road Handsworth Wood Birmingham West Midlands B20 2DW Lead Inspector Sarah Bennett Key Unannounced Inspection 5th September 2007 09:40 Selborne House DS0000065913.V351195.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 Selborne House DS0000065913.V351195.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. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selborne House Address 34 Selborne Road Handsworth Wood Birmingham West Midlands B20 2DW 0121 515 3990 0121 5154340 selborne.house@selbornecare.co.uk 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) Selborne Care Limited Mrs Lynn Lacey Care Home 15 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (1) of places Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 15 service users under 65 with a learning disability. Registration Category 15 LD 29th September 2006 Date of last inspection Brief Description of the Service: Selbourne house was formally a nursing home recently converted, designed specifically to provide a choice of accommodation to the people living there, offering rooms with en-suite facilities with some bedrooms also offering kitchenette and dining room facilities. The accommodation comprises 15 bedrooms in total divided into a 7 and 8 bed unit. There are several communal areas that can be used as rooms for the people living there and/or staff areas for the purposes of private meetings and for staff training and interviews. The care home is split into two areas called Ascot and Beverly; each unit has two lounges, a dining area and a separate office and medication room. The accommodation has a large patio area and a substantial garden. The home is located in the residential area of Handsworth Wood, and is close to main transport links. Shopping and leisure facilities are available in Handsworth Wood and Birmingham would be accessible. The fees charged were not stated in the statement of purpose of the home. Inspection reports are available in the home. The manager said that copies could be provided on request. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over one day; the home did not know the inspector was going to visit. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Three people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home were spoken to. Due to some people’s learning disability and communication needs it was not always possible to get their views on the home. The Commission first registered the home in February 2006 and this was the home’s second inspection. Since the last inspection there have been a number of people move into the home. There were fourteen people living there. What the service does well: The people living there are supported to go out often and to the places they want to go to. Night staff who start work at 8pm support people to go out in the evenings. Each person who lives there has a care plan that they help to write. Staff are looking at ways of making it easier for the people who live there to do this and one person has done their care plan on the computer. Staff support the people living there to be as independent as possible in their own home, encouraging and supporting them to do the cleaning, cooking and their washing. One person living there said,“ I am very happy with all the support I get.” Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 6 The people living there said they can keep in touch with their family and friends, staff support them to do this where needed. Staff have the training they need so they know how to support the people living there to meet their needs and achieve their goals. One person said, “I like all the staff.” The home is clean and well decorated so it is a nice place to live. Staff ask the people who live there what they want to do, where they want to go, what they want to eat and drink and how they want to spend their time. 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 Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Selborne House DS0000065913.V351195.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 Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users generally have the information they need to make a choice as to whether or not they want to live at the home. Before people move in their needs are assessed so they know that their needs can be met there and they can visit the home so they know what it is like to live there. EVIDENCE: The statement of purpose of the home had been updated recently and now includes all the relevant and required information with the exception of the fees that are charged for people to live at the home. This ensures that any prospective service users have all the information they need to make a choice of whether or not they want to live there. Each person has a copy of the service users guide to the home in their bedroom. Eleven people had started living at the home since the last inspection. Records sampled of the people who live there included a detailed assessment that had been completed of the individuals needs before they moved in. This assessed whether their needs could be met at the home and whether or not they would have an opportunity to achieve their goals there. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 10 Records sampled of the people living there showed that they visited the home before they moved in and also had an opportunity to stay overnight to see what it was like to live there. After they moved in their social worker had visited them and the person was invited to meetings to talk about whether they wanted to continue living there. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans detail how staff need to support the people living there to meet their needs. People are given choices in their day-to day lives and are supported to make decisions. Generally the people living there are supported to take risks within a risk assessment framework. All risks to individuals need assessing to ensure their safety and well being. EVIDENCE: Three records of the people who live there were looked at. These included an individual care plan that detailed how staff are to support the individual to meet their needs and achieve their goals. They included how staff are to support the person with their daily living skills, during the night, their activities, occupation, personal care, behaviour, social skills, mobility, communication, and health needs. Care plans were written using ‘Widgit’ symbols making them easier for people to understand. Care plans were Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 12 detailed, evaluated monthly and updated where the person’s needs had changed. Care plans had been signed by the person and their key workers to show that they worked together on developing them and agreed to them. The manager said that a group of staff went to a learning disability conference where they saw a computer program for developing ‘Life Plans’. This involves the person, as it is a program that can be used by someone with a learning disability. There is only one computer in the home but people can use the one in the office and the manager has asked for another one. They also have a digital camera that people can use which helps to involve them in their care plans. One person had completed their ‘Life Plan’ using the computer program. It showed that the person was involved for example in creating an image of what they look like by using the program clicking on their hair length, colour and type, whether or not they wear glasses, their skin colour and type, their eye colour and their height and weight. It also included ‘Where I live.’ The person had stated “ I chose my bedroom when I moved in. I have personalised it with pictures of my family members.” ‘Who I live with’, ‘Helpers in my house’ ‘Help I need’, ‘Prized possessions’, ‘Choosing food’, ‘Your rules’, ‘Places I have lived’, ‘How I communicate’ and ‘Likes and dislikes.’ It was very good using pictures and an easy to use format ensuring that the person is involved in developing it. Minutes of a meeting with the people living there were seen. These were produced using ‘Widgit’ symbols making them easier to understand. At the meeting people talked about doing the washing up, going to church, going on holiday, decorating bedrooms, the lounge and foyer, meals and cooking. One person living there said they could choose the colour of their bedroom and of other rooms in the home. Staff were observed offering people choices throughout the day. For some people this was limited to what they wanted to eat and drink or where they wanted to spend their time due to their learning disability and communication needs. Staff said that when one person moved in they said they wanted a pet ferret. The person has a ferret and staff support them to look after it, another person has a budgie. Records sampled showed that one person has an advocate who attends any meetings with them with professionals and visits regularly. Records sampled included individual risk assessments. These stated how staff are to support the person to minimize the risks of them being scalded, having epileptic seizures when out in the community, using the laundry room, taking their medication, using a key to their bedroom, their finances, their health and dietary needs, using harmful substances, self-injury and self-harm and using electrical appliances and knives. One person’s records stated that they would sometimes drink the water from the fish tank. There was information in their daily records as to what staff needed to do to prevent the person doing this but there was not a risk assessment so it may not be clear for staff what to do. One person’s risk Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 13 screening tool stated that they have a history of arson but there was not a risk assessment for this or for another person who is at risk of harming themselves using needles and cotton. All risks to individuals need to be assessed so that the risks can be minimised as much as possible, ensuring their safety and well being. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the people living there experience a meaningful lifestyle. The people living there are encouraged to eat a healthy diet and said they enjoy their meals. EVIDENCE: The manager said that four of the people living there go to day services during the week. One person goes to college and they are also hoping to do some voluntary work. In the home they organise the post and do jobs that gives them a role helping them to feel valued. Another person has a voluntary job in a local shop. The manager said and records showed that each person has an opportunity to go out each day. Where they refuse to go out or are unwell this is recorded. Records showed that people go shopping, discos, pubs where there is ‘live’ music, for walks, to the cinema, out for meals, to day centres, bingo, Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 15 greyhound racing, bowling and to parks. Some records stated that people had gone out for a drive but it did not state where this was to. This should be recorded so it is clear that people are doing purposeful activities. Inside the home people help with the cleaning, watch TV, listen to music, tidy their bedrooms, help with their laundry, help to prepare their meals and drinks and lay the table for meals. One person enjoys colouring and drawing and spends a lot of their time doing this. Many of their pictures had been framed and displayed around the home. There is an activity room where people said they play snooker and darts. Each person had an activity planner, which was produced using ‘Widgit’ symbols making it easier to understand. These included a range of activities inside and outside the home as well as taking part in household chores helping people to develop their independence skills. Activity planners showed that night staff that start work at 8pm go out with people in the evenings. A vehicle is provided by the company for staff to drive to enable people to access the community. People also use public transport, some people went by bus with staff to a Chinese buffet for lunch. Each person has a bus pass. The manager said that when people go out in the evenings they use taxis, as this is safer. One person’s records showed that they are registered with the ‘Ring and Ride’ transport service. One person’s goal is to learn to drive. The manager said that the person had started driving lessons and they are doing really well. They have the information for the theory test on CD-rom making it easier for them to access and staff support them with this. The manager said that most of the people living there go to church and go to different ones depending on their choice. One person goes to the temple with their relative. People said and records showed that they are supported to keep in touch with their family and friends. Each person has a telephone in their bedroom so they can make and receive calls in private. Some people visit their family or their family visits them. One person had gone out for the afternoon with their friends. One person had been on holiday to Blackpool. The manager said that one group of people are going with staff to Devon at the end of September and another group had not yet decided where they wanted to go but were looking at hiring a cottage. The menu folder included a range of pictures for breakfast, lunch, dinner and desserts to help people to choose what they want to eat. Each person had a menu planner that was produced using ‘Widgit’ symbols. Food records showed that people ate a variety of food but not everyone had a healthy diet including the recommended five portions of fruit and vegetables each day. Minutes of Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 16 review meetings showed that one person had stated that they did not want to eat salad. When talking to this person they said that they knew where the fruit was and they could have it whenever they wanted but they did not really like it. The manager said that one person who lives there is a good role model for healthy food and it is hoped that other people may follow this. One person has Halal meat and this is cooked and prepared separately to respect their religious beliefs. One person said they liked Caribbean food and that it is always available and often they cook it with support from staff when necessary. Another person said, “We do our own menu, a van delivers the food, I do a list and get what food I want. I can have a drink when I want one”. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the personal care and health needs of the people living there are met so ensuring their well being. The management of the medication protects the people living there so that they receive their prescribed medication at the right time. EVIDENCE: Care plans sampled detailed how staff need to support each person with their personal care. Some people had been out to day centres, when they came back staff supported them and asked about their day. One person said,” I have help from staff to shower but staff leave me to dress myself as I don’t need help. I go and get my hair done, staff come with me. I can get up and go to bed when I want to.” Each person had a moving and handling assessment that stated how staff are to support them with their mobility whilst ensuring their safety and that of the staff assisting them. People were well dressed and this was appropriate to their age, gender, their cultural background and the activities they were doing. One person said, “ I go Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 18 out shopping with staff to buy clothes, yesterday I bought a necklace.” Care plans sampled detailed how staff are to support individuals to ensure their health needs are met. Each person had a Health Action Plan. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to use. Records showed that where appropriate health professionals are involved in the care of individuals. People have regular health check ups including going to the dentist, chiropodist and having their eyes tested. Each person had been weighed monthly and a record of this was kept. Where people had gained weight, which could be detrimental to their health it was recorded what support staff needed to offer to help the person to lose weight. This included exercise and encouraging the person to eat a healthy diet. Medication is stored in a locked cabinet in the unit that the person lives in. Lloyds Pharmacy supply the medication using the Monitored Dosage System (MDS). This makes it easier for staff to know what medication each person has and at what time. Records showed that people had their medication reviewed regularly to ensure that the medication is still effective in meeting their health need. Each person had been assessed as to whether or not they could administer their own medication so encouraging people to maintain their skills if they are able to. Where people were prescribed as required (PRN) medication individual protocols were in place stating when, why, how much and how often the medication should be given to the person. These were reviewed monthly and updated where there were any changes. A separate cabinet is available in each unit for Controlled Drug’s (CD’s) as required. There were no CD’s prescribed or stored. Some medication cannot be stored in the MDS blister packs as this affects the medications effectiveness. This was stored in a separate medication cupboard and checked to make sure it was being given as prescribed. Records sampled showed that medication had been given to individuals as prescribed. The manager said that four members of staff are currently doing a medication course at a local college and other staff are doing the Lloyds Pharmacy course. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the views of the people living there are listened to and acted on. Arrangements are generally sufficient to ensure that the people living there are protected from abuse, neglect and self-harm. EVIDENCE: There had been no complaints received by the home or the Commission in the last twelve months. The home has a complaints procedure that includes the relevant information so that people would know what to do if they were unhappy with the service they are receiving. The procedure uses ‘Widgit’ symbols making it easier to understand and it is displayed around the home. One person said, “ I can talk to staff if I’m not happy, there is always somebody to talk to.” Some people who live there display behaviour that can challenge. Records sampled included individual detailed behaviour support plans that stated how staff are to support the person to minimize these behaviours and the impact they may have on them or the other people living there. They included diversion techniques and only using restraint or medication as a last resort. The individual and their key workers had signed the plan to show that they agreed to it. Some incidents had been recorded in people’s daily records where their well being or that of others had been affected. However, these had not been reported to the Commission as required under Regulation 37. These should be reported so that the Commission can determine whether or not Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 20 these incidents have been dealt with appropriately to safeguard the people living there. Records sampled included an individual property list that had been completed on their admission to the home and updated since. Some entries had not been dated so it was not clear when they had been updated. These should be dated so that if some of their property should go missing they would know when it was bought and what belongs to them. One person living there said their money is kept safely in the home and they go to the bank to collect it with staff. They said they ask staff whenever they want their money and always get a receipt when they buy something. The manager said that most people are their own appointees, two people have relatives as their appointee and a few people have Birmingham City Council as their appointee. Each person had a finance risk assessment that stated how the risks to the person of being financially abused are minimized. Records sampled showed that one person had in the past made allegations of abuse against male staff. Their risk assessment stated that only female staff are to assist them with their personal care to help reduce these risks. All staff had received training in adult protection and the prevention of abuse so they know how to keep the people living there safe. Staff had also received training in managing challenging behaviour and supporting people who can display behaviours that challenge. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, clean and safe environment that meets their individual needs. EVIDENCE: The home is spilt into two units, Beverley and Ascot. There are eight people who live in Beverley and seven people who live in Ascot. Six of the eight bedrooms in Beverley have their own kitchen. These are referred to as ‘apartments’ as people have a bedroom, kitchen and shower/WC. This offers people a chance to develop their independence skills. Two of the people living there have expressed a wish to move on to more independent living and are being supported to do so. All bedrooms have en suite facilities. There is also a main kitchen in Beverley Unit that is mainly used by the two people who do not have their own kitchen but others also use it when they want to. On the ground floor there is also a lounge, laundry room and the office. There is an activity room where people said they could play snooker and darts. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 22 The home was previously a nursing home and had a lift. This has been decommissioned and was locked so that people are not able to enter it, which could be a risk to their safety. There is a housekeeper who cleans the communal rooms. Staff support the people living there to cleaning their bedrooms/apartments. These were personalized and where people were able to they had their own key. Each person has a phone facility in their room so that they can have privacy for calls. The home was generally well decorated and furnished. There were some marks and stains on the walls in the landing and the stairs. The manager said it is being redecorated in stages to minimise disruption to the people living there. In Ascot there is a kitchen on the ground floor. Staff said that most of the people living there are not able to cook but are encouraged to wash up and make drinks. One person can use the kitchen unsupervised. There are also three bedrooms on the ground floor as well as a laundry room, lounge and conservatory that leads to the garden. On the first floor there is a lounge that is used as a ‘quiet’ room and also for meetings. The manager said that the people living there do not use this room very often so they are planning to make it into a snoozelen room making it more useful to the people living there. The home was clean and there were no offensive odours making it a pleasant environment for the people living there. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing, their support and development are sufficient ensuring that staff have the skills and knowledge to meet the needs of the people living there. The recruitment practices are robust so protecting the people who live there. EVIDENCE: The AQAA stated that 81 of staff have National Vocational Qualification (NVQ) level 2 or above in Care or are working towards achieving this. This exceeds this standard that at least 50 of staff have this ensuring that they have the skills and knowledge to work with the people living there. The manager said there are no staff vacancies. Originally all staff worked in both of the units but since more people have moved in there is now a core team in each unit depending on staff skills and qualities in working with the people who live there. There are nurses on duty 24 hours a day in Ascot Unit. The home was originally set up as a nursing service but none of the people living there have an identified nursing need. During the day there is also a Team Leader on duty. Team Leaders have NVQ level 3 in Care and one of them Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 24 is currently doing NVQ level 4. The nursing staff work a combination of day and night shifts. The manager works mainly Monday to Friday but her hours are flexible, at night, late evenings and occasional weekends. Three records of staff that work there were looked at. These included the required recruitment records including evidence that a satisfactory Criminal Records Bureau (CRB) check had been done ensuring that suitable people are employed to work with the people living there. Training records showed that staff received training in medication, food and nutrition, management of violence and aggression, physical intervention, fire safety, moving and handling, health and safety, first aid, food hygiene, abuse, culture and diversity, mental health and care planning. Records showed and staff said that when staff first start working at the home they complete an induction, some of which is on DVD’s so they can work through it over the first few months of their employment and it is not all rushed in the first few days. Staff supervision records were held on the computer on the individual supervisor’s memory stick so these could not be accessed. Staff said that they receive regular supervision and support. The manager said that she does group supervisions with nurses and Team leaders. Two staff are currently doing supervision and mentoring courses. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 29, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that the people living there benefit from a well run home. The people living there can be confident that their views underpin the self-monitoring, review and development by the home. Arrangements are in place to ensure that the health, safety and welfare of the people living there are promoted and protected. EVIDENCE: The registered manager has several years experience in managing care services for people who have a learning disability and is a Registered Learning Disability Nurse. The findings of this inspection show that as more people have moved in during the last year the home has continued to be well managed benefiting the people who live there. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 26 There is a quality assurance system in place. At the annual audit in May this year the home achieved 81 and the report stated that they were maintaining a good standard. The audit included assessing staffing, training, catering, housekeeping, laundry, care, the external environment, drugs, security and safety, social needs and care plans. The manager had completed an action plan following the audit so addressing any areas where there were shortfalls. The Operations Director said that the audit tool is currently under review. Staff complete monthly care plan and medication audits. Staff had audited the records and documents in July this year and had identified the action to be taken where there were deficits. Staff had also audited the care plans in July. Medication audits had been completed weekly. The Operations Director said he has started developing questionnaires/ satisfaction surveys in a tick box format to make them more accessible for the people living here. Fire records showed that staff test the fire equipment regularly to make sure it is working. An engineer regularly services the fire equipment to make sure it is well maintained and in good working order. Fire drills had been held monthly so that staff and the people living there would know what to do if there was a fire. The windows have restrainers on them so that the home is secure and so that people do not fall out of them. These are checked weekly to make sure they are not broken, which could put people at risk. Staff check the water temperatures regularly to make sure they are not too cold or hot which could put people at risk of being scalded. Records showed that during August this year all the portable electrical appliances were tested to make sure they are safe to use. The AQAA stated that an engineer completed the annual test of the gas equipment in November 2006 to ensure it is safe to use. Selborne House DS0000065913.V351195.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 2 2 3 3 X 4 3 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 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA1 YA9 YA14 YA23 YA23 Good Practice Recommendations The fees charged to the people who live there should be stated in the statement of purpose to help them decide whether or not they want to live there. All risks to individuals should be assessed to ensure that staff know how to minimise these ensuring the safety and well being of the person. Records of when people go out for ‘drives’ should state where these are to so as to ensure they are purposeful activities. Any event that affects the well being of the people living there should be reported to the Commission to ensure that people are being protected from abuse. When people’s property lists are updated these should be dated so that it is clear when people have bought new things and when they last had things if they should go missing. Selborne House DS0000065913.V351195.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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