Inspection on 07/09/06 for Shapland Close

This inspection was carried out on 7th September 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shapland Close 06/10/09

Shapland Close 11/02/09

Shapland Close 15/01/08

Shapland Close 04/01/06

Shapland Close 06/09/05

Shapland Close 07/09/04

Shapland Close 29/04/04

Shapland Close 17/02/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Shapland Close Wilton Road Salisbury Wiltshire SP2 7EJ Lead Inspector Alison Duffy Key Inspection 7 September 2006 10:30 th Shapland Close DS0000028422.V291590.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 Shapland Close DS0000028422.V291590.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. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shapland Close Address Wilton Road Salisbury Wiltshire SP2 7EJ 01722 419777 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) SCOPE Mrs Elizabeth Jean Tooze Care Home 8 Category(ies) of Physical disability (8) registration, with number of places Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Shapland Close is a residential care home registered to care for eight adults with a physical disability. The home is situated on the outskirts of Salisbury, within close proximity to local amenities. The home is managed by SCOPE and the Registered Manager is Mrs Elizabeth Tooze. Shapland Close consists of two purpose-built bungalows with disabled access throughout. Each bungalow has four single bedrooms, a spacious lounge with dining area, an adjoining kitchen and specialised bathing facilities. A range of individualised, specialised equipment is also in place. All areas of the home are well maintained and decorated and furnished to a high standard. An additional bungalow contains the office and staff sleeping in room. Staffing levels are maintained at a minimum of five during the day. This enables two to be in each bungalow with an additional member of staff responding to individual need between the two. At night there is one waking night staff member in each bungalow. Another member of staff provides sleeping in provision. An on call management system is also in place. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on September 7th 2006 between the hours of 10.30am and 6.30pm. On arrival at the home Mr Rod Cook, Senior Support Worker, was on duty. Discussion took place with Mr Cook regarding current care provision and existing staffing arrangements. Mr Cook also assisted with the tour of both bungalows. Mrs Tooze, Registered Manager returned to the home following a meeting later in the morning. Mrs Tooze assisted with the remainder of the inspection and received feedback. The Inspector was able to meet with service users and members of staff on duty. Due to complex disabilities, service users were unable to give feedback about the service received. Various interactions between staff and service users were observed. These were positive and attentive. Varying documentation was viewed. This included care planning information, health and safety material and staffing documentation. Comment cards were forwarded to each service user’s primary relative and a number of health and social care professionals. Five comment cards were returned from relatives. Discussion also took place with one relative on the telephone. Two comment cards were received from care managers and two were received from GPs. One relative reported ‘ an excellent home with a most caring Manager. Our XX has complex needs but is treated as an individual with a superb key worker and deputy.’ Another confirmed ‘If and when XX or ourselves have a problem it is always attended to quickly. Also any medical problems with regard to XX are always seen to immediately.’ All relatives except one were satisfied with the care provided. One care manager stated ‘I can only comment on the quality of reviews held which are entirely satisfactory.’ Another stated ‘ The staff at Shapland Close have shown themselves to be professional and competent.’ A GP confirmed satisfaction with the overall care provided to service users within the home. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the service and taking into account the views raised on behalf of service users. What the service does well: A high level of personal care in relation to very complex need is given. Regular consultation and input from specialised health care professionals is received. Staff promote individuality and have given detailed consideration to varied activity. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 6 The environment is well maintained and decorated and furnished to a good standard. Private accommodation is personalised showing individuality. Established well-managed systems such as recruitment and the complaints procedure are in place, which demonstrate a commitment to service users and service provision. The home is well managed with a relaxed atmosphere and a service user focus. 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. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected 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 from evidence gathered both during and before the visit to this service. The admission process is detailed, organised and well managed thus minimising the possibility of unmet need. EVIDENCE: There have not been any new service users since the last inspection. It was not possible therefore to assess the admission procedure in practice. Detailed admission procedures however, devised by SCOPE, are available as required. Such procedures include an assessment at the service user’s existing residence. Discussion is held with the service user’s care manager, their relatives and any members of staff who may be currently caring for the service user. Various visits to Shapland Close would be arranged. Before any admission, assessments from care managers and any additional health care professionals would be received in writing. Any specialised equipment would also be in place before admission. Service users are informally assessed within the home on a regular basis. If they attend a day service, further structured reviews are held. An annual formal review is also undertaken. Within the assessment process, advice or intervention is regularly gained from specialised health care personnel. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Care planning is of good standard, yet short-term plans would ensure immediate care needs are met. Decision-making is fully promoted yet may be restricted for some, due to complexity of need. Service users’ safety is given priority, yet further safety would be assured through individuality within risk assessments. EVIDENCE: At the last inspection, not all care planning information reflected changes in condition or need. Mr Cook reported that as a result of this, the staff team have been completely reviewing all information. The care plans that were viewed contained clear, detailed guidelines of daily routines and assistance required. The use of individual equipment was identified and in some instances photographs demonstrated its use. Charts are in place to monitor bodily functions and a record of seizures is maintained. Mrs Tooze was advised however to ensure that staff clarify some terms such as ‘good recovery.’ Preferred likes and dislikes of service users were clearly stated and decisionmaking was addressed in relation to ability. The plans are readily accessible in Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 10 service users’ rooms. Service users’ next of kin have not as yet, signed the plans. Discussion with relatives, however, takes place on a regular basis. In addition to care planning information, daily observational sheets are completed. These were noted to be detailed and contained information such as unidentified scratches and marks. There were some matters however which did not appear to have clear follow up intervention. These included, for example, sore areas of skin, which required the application of cream. Mrs Tooze was therefore advised to develop a short-term care plan for these issues. All manual handling assessments have been updated with the input of specialist health care personnel. All risk assessments have also been fully reviewed. A large number of environmental assessments are in place. Individual assessments linked generally to health and activity, have also been devised. Within documentation however, a number of potential risks, associated to individuals were identified. These included slipping down into the bath water, choking and the effects of moving around on the floor. Mrs Tooze was therefore advised to further develop risk assessments in relation to individuality. Through discussion it was evident that risk taking is viewed in relation to opportunity and quality of life. Mr Cook expressed however that service users’ safety is also paramount. For example, one service user enjoys water-skiing, which presents varying risks. Due to the amount of enjoyment received, clear well-managed control measures have been devised in order to reduce possible risks. The practice is regularly reviewed. Mr Cook reported that it has been identified there may be a time when the risks become too high. The activity will then be stopped with alternatives found. Mr Cook reported that unfortunately this has already happened with horse riding due to restrictions with manual handling practice. Mr Cook reported that for existing service users, there are risks with many activities. These include having a seizure when out or visiting places, which are not conducive to the needs of wheelchair users. Mr Cook confirmed a balanced view is taken with risk taking. This encourages safety but also promotes quality of life. Through discussion with staff and viewing care-planning information, decisionmaking is clearly important. Mr Cook confirmed that some service users are able to express their wishes by nodding or pointing. Other service users may use specific movements, facial expressions or sounds to indicate their wishes and general wellbeing. Mr Cook confirmed that at times it is often a process of elimination which first targets basic care needs. Building relationships with service users is also essential. For example one service user may often make loud-pitched sounds. Staff have found that this may indicate that all is not well but alternatively, the sounds are often a form of expression. On a day-to-day basis, some service users require staff to make all decisions on their behalf. More difficult decisions would be discussed with parents or the service users’ care manager. Service users have regular input from a speech and language Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 11 therapist whereby communication strategies are reviewed. Service users also have access to communication groups within their day service. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 12 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 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are assisted to undertake meaningful activity and maintain important relationships. Meal provision is of a good standard and takes into account service users’ preferences, variety and healthy eating. EVIDENCE: Since the last inspection, the local college has reduced funding and therefore one service user’s placement has been withdrawn. This has caused distress yet Mrs Tooze has worked hard to find alternatives. Other than a few gaps, a full and varied programme is being finalised. Some service users continue to attend the local SCOPE day service on a Monday to Friday basis. Others attend on a sessional basis and spend the majority of time within the home. For these service users, Mrs Tooze has arranged full one-to-one staff support to assist with specific daily programmes. The programmes include activities, which staff know service users enjoy. These include shopping, trips to the park and the library, hand massages and manicures. When at their day service, service users have access to various groups and specialised health care intervention Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 13 such as physiotherapy, occupational therapy and speech and language therapy. Staff encourage involvement with the local community through the use of local facilities. The home has its own transport to facilitate journeys as required. Public transport is also used as appropriate. All activities are linked to individual need and interest and may include swimming or a trip to the pub. Family contact is promoted. Relatives are encouraged to visit at any time and may use service user’s private accommodation in order to receive privacy as required. Some service users go to their parental home on a regular basis. Mrs Tooze confirmed that the parental role is very important and therefore communication is an important factor. As stated earlier in this report, service users are encouraged to make decisions in relation to their ability. The home is very service user focused with an emphasis on service users’ wellbeing. Preferred routines, likes and dislikes are clearly identified within care planning information. Practises such as enabling service users to choose their own clothing, if they are able, is promoted. Privacy is maintained through established practices of undertaking personal care in private accommodation or specialised bathrooms. Service users are addressed as they prefer and this is recorded within care planning information. Key dates are also recorded so that staff can assist service users with remembering family birthdays and Mother’s Day, for example. Due to complex needs, any mail would be passed to service users’ next of kin or representative. There have been small changes made to the menus since the last inspection. Some meals have been withdrawn following feedback from some relatives. Mr Cook confirmed that the menus are very much devised through experience of knowing service users preferences. The menus demonstrate variety with the main meals consisting of dishes such as lasagne, shepherds pie and tuna pasta bake. Service users are offered an alternative if they do not appear to be getting on very well with what has been prepared. A choice of pudding is always given. Mr Cook confirmed that staff continue to have the responsibility of meal provision. Meals are flexible in time and service users receive full assistance from staff at all mealtimes. Meal requirements such as cutting up food and specific utensils are stated within care planning information. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Health and personal care are well managed with regular input from specialised services. Clear, organised medication systems minimise the risk of error. EVIDENCE: Service users continue to require full assistance from staff in all aspects of daily living. Such assistance is documented within care planning information. Within one plan, guidelines were available in relation to a service user getting up from the floor. It was noted, that later in the inspection, this practice was appropriately followed. All service users have a range of individualised specialised equipment. This is monitored and serviced regularly and staff receive full instruction regarding its usage. Prompts such as diagrams regarding the use of a sling for a hoist are also in place. Service users are unable to express how they wish their care to be delivered. In such instances staff rely on their experience to recognise gestures, facial expressions, general contentment and individual communication systems. Mr Cook confirmed that many staff have worked at the home for a long period of time and therefore know service users well. The home operates a key worker system. This was reported to work well. A high level of one-to–one work is undertaken, especially with those service users who spend more time in the home rather Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 15 than at day services. Detailed varied programmes have been devised which demonstrate that considerable thought has been given to productive, valued activity that service users will enjoy and gain benefit from. Service users are unable to manage their health care needs and therefore rely on staff to recognise any signs of ill health. Within discussion with staff and viewing daily records, it was evident that matters are identified at an early stage. The reasons for incidents are also investigated and control measures are applied. Service users have access to general and specialised health care on a regular basis. Service users are generally registered with a local GP although one service user continues to have a GP in the vicinity of his parental home. Temporary registration in Salisbury is therefore undertaken. Service users who are registered with the local GP have six-monthly health reviews. Checks are also undertaken regarding previous family illnesses, which may affect service users’ wellbeing in the future. Referrals for specific requirements such as wheelchair services are made as required and out patient appointments are attended with staff or family assistance. Services such as physiotherapy and speech and language therapy are an integral part of service users’ health care provision. All medication is stored appropriately in a locked wall cupboard in the kitchen of each bungalow. A monitored dosage system is used to administer medication to service users. All medication is delivered on a monthly basis. Documentation demonstrated that all medication is checked on receipt. Within the drug round, two members of staff sign to identify that the medication has been administered. The medication administration sheets were satisfactorily maintained. SCOPE have clear medication policies and procedures. Due to complex health conditions, service users are unable to manage their medication or give consent. One medication has a separate care plan. The documentation shows a date of 2003 yet the medication remains current. Mrs Tooze reported that arrangements are currently in place to up date the information with specialised health care personnel. Guidelines are in place for those service users receiving their medication by specialised means. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a clear, well-managed complaint procedure that encourages complaints to be successfully resolved at an early stage. The risk of abuse to service users is minimised through the home’s adult protection systems. EVIDENCE: The home has a detailed complaints procedure devised by SCOPE. Due to complexity of need however, service users’ involvement with the formal complaint procedure is limited. All service users are therefore reliant on others to recognise any forms of discontentment. Mr Cooke confirmed that parents or representatives are essential advocates. Such contact was expressed as invaluable and a way to resolve issues at an early stage. Mrs Tooze reported that she aims to regularly discuss care provision with relatives. Six monthly parents meetings are also held. Comment cards received from relatives confirmed that they are aware of the complaints procedure. Mrs Tooze reported that there have not been any formal complaints since the last inspection. The home has detailed adult protection policies available to staff for reference. Specific staff have the designated responsibility of adult protection. They also attend regular refresher courses. Adult protection training forms part of SCOPE’s training plan and the majority of staff have undertaken this. Staff appear attentive and record any bruising or marks on service users. In one instance Mrs Tooze was advised to ensure staff give factual information rather than stating, for example, large bruise. Mrs Tooze reported that body maps are generally used in order to visualise the extent of the bruising. Discussion also Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 17 took place of the need to inform service user’s care managers of any unidentified bruising of a significant or suspicious nature. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 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 the following standard(s): 24, 25, 26, 26, 28 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The environment is well maintained, cleaned to a good standard and conducive to service users’ needs. Service users also benefit from private accommodation, which is decorated to a good standard, equipped to meet individual need and demonstrates individuality. EVIDENCE: Shapland Close consists of two purpose built bungalows, which are located in a quiet position away from the main road, on the outskirts of Salisbury. All amenities are within close proximity. Both bungalows have full disabled access throughout. All service users have a single room, which is decorated and furnished to a high standard. All rooms have specialised equipment including an overhead hoist, an individualised bed and armchair and commode as required. Despite such equipment, the rooms are homely and personalised to a high degree. Each bungalow has it own facilities although the laundry is shared. Within each bungalow there is a spacious lounge and dining area that is homely and Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 19 comfortably furnished. Both kitchens are well equipped and on the day of the inspection both areas were ordered, clean and tidy. All areas of the home were also clean and odour free. Laundry facilities are located within an outside building, which is not ideal as staff are required to go outside for such. The situation is well managed however and current facilities were reported to meet existing need. All equipment is domestic in style, which was a considered choice by being more cost effective despite its high usage. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels are maintained in line with the previous Registration Authority and supports one-to-one work with service users. Service users are protected through an efficient, well-managed recruitment procedure. Training has been slightly neglected due to uncontrollable circumstances, yet greater focus is now assured. EVIDENCE: Staffing levels continue to be maintained at five or six staff on duty during the waking day with a minimum of two in each bungalow. At night each bungalow has one waking night staff and an additional member provides sleeping in provision. There is also an on call management system. Mr Cook reported that the home has continued with some staffing shortages due to vacancies, maternity leave and long-term sickness. Mrs Tooze confirmed that the home has two vacancies of 31 and 39 hours. Although this appears significant Mrs Tooze reported that staff have been excellent and have covered many additional shifts. Agency staff are also used to cover some shifts. In such instances the same agency staff are requested in order to ensure consistency. Within discussion it was evident that consideration is given to staff in order to enable them to function well. For example, one member of staff was on the staffing roster to start at 7am and then was due to undertake one-to-one work Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 21 with a service user. In order to enable the staff member to be ‘fresh’, Mrs Tooze removed the 7am start from the member of staff. The member of staff therefore started work later and was able to dedicate all her time to the individual service user. An additional member of staff was asked to provide cover for the 7am shift. There been no new staff since the last inspection and therefore recruitment documentation was not viewed on this visit. Mrs Tooze confirmed that there have been no changes to SCOPE’s recruitment policies and procedures. These are detailed and require a systematic robust process before employment. All candidates must complete a detailed application form, be formally interviewed and have satisfactory checks in place before they are offered a post. Candidates are also sent a range of information as standard practice. Such information includes a job description and terms and conditions of employment. Equal opportunities are also monitored throughout the process. Mrs Tooze reported that due to staffing shortages and the fact that she has provided some management time to other care homes within SCOPE, training has been slightly neglected. At present eight members of staff have NVQ 2 and three have NVQ 3. Mr Cook is also an NVQ Assessor. Since the last inspection communication training has taken place. Staff have also watched training videos as a refresher regarding adult protection, first aid and food hygiene. Mrs Tooze reported that priority would now be given to assessing shortfalls and arranging dates as appropriate. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 22 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 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Shapland Close is effectively managed with a service user focus. An established formal quality action group is used as a forum to develop service provision. Established health and safety systems are in place to reduce potential risks to service users. However, mechanical devices to hold open fire doors would ensure further safety. EVIDENCE: Through discussion it was evident that Mrs Tooze has high standards of expected care provision. Mrs Tooze has a genuine concern of the wellbeing of service users and manages the home with such focus. Mrs Tooze has many years experience of working with adults with complex physical disabilities. She also has NVQ 4 in Management and the Registered Manager’s Award. Due to management vacancies within the organisation, Mrs Tooze has recently provided management cover to other care homes in the area. This has reduced her time at Shapland Close and therefore she admits, aspects such as staff Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 23 training have been slightly neglected. Mrs Tooze reported that management vacancies have now been covered so priority will be re-established. Mrs Tooze reported that the home’s quality action group continues to meet and is a successful forum. The group consists of a parent, a representative from the Community Team for People with Learning Disabilities, a member of staff and Mrs Tooze. The group meet on a six monthly basis and discuss various objectives. A parents meeting is held before the group in order to enable involvement and further views. Minutes of the group are taken and distributed to all interested parties. The quality action group is an established forum. SCOPE do not however have a formalised quality assurance system within the organisation. Various systems are in place to address health and safety. Health and safety forms a mandatory part of the home’s training programme and regular audits take place. A member of staff takes specific responsibility for the subject and regular refresher/updates are provided. Mr Cook is also a manual handler trainer so spontaneous training can be undertaken. Detailed manual handling assessments and various generic risk assessments have been developed. As stated earlier in this report, further attention should now been given to risks associated with service users’ complex needs and individuality. The fire book demonstrated satisfactory testing of the fire alarm systems. All staff had received fire instruction at a staff meeting yet three had not signed the fire log book. A number of fire drills had taken place as required. Mrs Tooze was advised to ensure that staff record the time of the drill. Documentation demonstrated contracts are in place regarding systems and fire extinguishers. On a tour of the accommodation it was noted that a service user’s door was propped open with a wedge. Mr Cooke explained that the door needed to be open to give the service user free access to the room. Through discussion with Mrs Tooze it was agreed that a mechanical device agreed with the fire officer was required. Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 24 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 12(1)(a) Requirement The Registered Person must ensure that all aspects of required care provision are identified within care planning information. This could include the development of a short-term care plan. The Registered Person must ensure that fire doors are not propped open unless with a mechanical device that is linked to the fire alarm system. Timescale for action 31/10/06 2 YA42 13(4)(c) 07/09/06 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 Refer to Standard YA6 YA9 YA23 Good Practice Recommendations The Registered Person should ensure that clarity is given to terms such as ‘good recovery.’ The Registered Person should ensure that any risks associated with service users’ complexity of need is fully addressed within the risk assessment process. The Registered Person should ensure that care managers DS0000028422.V291590.R01.S.doc Version 5.1 Page 26 Shapland Close 4 5 YA35 YA42 are informed of any significant bruising. The Registered Person should ensure that training provision is reviewed in order to identify any shortfalls. The Registered Person should ensure that all staff sign and date the fire log book in order to demonstrate their receipt of fire instruction. This was identified at the last inspection. The Registered Person should ensure that the time and a small account of each file drill are maintained. This was identified at the last inspection 6 YA42 Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Shapland Close DS0000028422.V291590.R01.S.doc Version 5.1 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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