Inspection on 17/04/07 for Smithies Moor

This inspection was carried out on 17th April 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

Smithies Moor 06/12/05

Smithies Moor 30/08/05

Smithies Moor 18/01/05

Smithies Moor 21/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Smithies Moor 46 Smithies Moor Lane Birstall Batley West Yorkshire WF17 9AN Lead Inspector Alison McCabe Key Unannounced Inspection 17th April 2007 11:25 Smithies Moor DS0000001096.V329325.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 Smithies Moor DS0000001096.V329325.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. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Smithies Moor Address 46 Smithies Moor Lane Birstall Batley West Yorkshire WF17 9AN 01924 474453 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) www.st-annes.org.uk St Anne`s Community Services Miss Judith Elizabeth Cooper Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user with learning disabilities aged over 65 years. 6th December 2005 Date of last inspection Brief Description of the Service: 46 Smithies Moor Lane is a care home registered to provide nursing care and accommodation for six adults with learning disabilities. The home is operated by St Annes Community Services, a charitable organisation. The property is a large detached bungalow which stands in its own grounds, overlooking countryside. There are parking facilities at the front of the home and attractive gardens to the rear. The home is located in a residential area on the outskirts of Birstall. Local shops, a post office and community facilities can be found within 1 mile of the home. The range of fees charged for this service is £375.94 - £407.94 per week. This does not include the nursing component which is paid directly by health. The pre-inspection questionnaire states that additional charges are made for the following: activities, hairdressing, toiletries/clothing, newspapers, holidays, meals and drinks out and transport. The service provider ensures that information about the service is available to prospective and current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection, a visit was made to Smithies Moor Lane by one inspector between the hours of 11.25 am and 4.30 pm. In addition to the visit, information used to inform the inspection includes notifications received from the home about any accidents, incidents or events that affect the wellbeing of residents, the pre-inspection questionnaire submitted to CSCI prior to the site visit and completed surveys from relatives and people living at the home, giving views about the quality of the service. All the people living at the home required support to complete the survey, and individuals’ named nurse, the home manager or close relative gave this. All indications on the completed surveys were positive with all expressing overall satisfaction with their care. Two surveys were returned from relatives and both indicated that they were happy with the service provided to their relative. Comments include: “….for her to call ‘Smithies’ home, makes me feel she is happy and settled there.”, “I can’t praise the staff enough.” Further comments are included in the main body of this report. As part of the site visit, the inspector had the opportunity to talk to the manager and staff on duty and some discussion with people living at the home took place. Time was spent observing care practice and interaction between staff and service users. All parts of the home were seen and a sample of records was examined. These include service user care plans, risk assessments, health action plans and daily records, monies, menus, staff training records, staff rotas, recruitment records. Medication and records relating to medication were examined. All requirements and recommendations made at the previous inspection have been addressed and none have been made as a result of this key inspection. Smithies Moor Lane is a well run home that has consistently maintained high standards of care. People living at the home appear to be happy and well cared for and staff are motivated and committed to providing a good service. The inspector would like to thank the service users and staff for their cooperation and hospitality during the site visit. What the service does well: Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 6 Before people move into the home, their needs are assessed. Individual care plans are in place describing how people’s needs should be met. Staff are good at supporting people to make choices, take reasonable risks and maintain as independent a life as possible. People living at the home enjoy active, fulfilling lifestyles both in the home and out in the community. People living at the home are treated with respect and dignity and get on well with the staff. The food is healthy, varied and balanced and individuals are encouraged to make choices about what they would like to eat. Staff are good at ensuring that individuals’ health needs are recorded and met appropriately. Medication is managed well at this home. Smithies Moor Lane is a well run home that has qualified, trained staff and no staff vacancies. Good procedures are in place to protect people from abuse and support people to make a complaint. The home is well maintained, comfortable and safe. Record keeping is excellent. What has improved since the last inspection? What they could do better: Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 7 Two staff have not received up to date movement and handling training, although this has been planned for June 2007. Quality assurance systems could be improved. Staff need refresher training in physical intervention. 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. The summary of this inspection report can be made available in other formats on request. Smithies Moor DS0000001096.V329325.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 Smithies Moor DS0000001096.V329325.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): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed before they move into the home so that staff are aware of individuals’ needs and aspirations. EVIDENCE: There have been no admissions to this home for several years. Individuals’ plans that were examined contained pre-admission assessments completed by the Care Manager. An admissions procedure is in place. The registered manager reported that, upon completion of the extension, a sixth person would be admitted to the home. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home have comprehensive care plans in place, are supported to take reasonable risks and make choices with the appropriate support, to enable individuals to lead as independent a lifestyle as possible. EVIDENCE: Care plans relating to two people using the service were examined. Both contained excellent detail about how individuals’ needs should be met. Evidence that person centred planning meetings have taken place was seen and individuals, their families or advocates are involved in the process. Records showed that care plans are reviewed on a regular basis and updated where necessary. Through observation of practice, and discussion with staff, it was evident that agreed care plans are implemented as intended. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 11 Staff were observed to offer choices to people living at the home about how they would like to spend their time, what to eat or drink and whether or not to allow the inspector to look around their bedrooms. Daily records included entries about what choices people had made. The manager and staff explained that photographs are used to enable some individuals to make choices about meals and activities, and examples of these were seen in an individuals’ records. A staff member described how support is offered to one individual to choose what they would like to eat or wear by physically showing them the options. None of the people living at the home control their own finances due to their level of learning disability, however clear systems are in place to monitor and record all financial transactions. Surveys completed by people living at the home suggest that people make choices about how they live their lives. Staff support individuals to take responsible risks, and records contained evidence that risks had been appropriately assessed and measured to reduce potential risks agreed. Staff were observed to implement the agreed measures to reduce risks. For example, an individual who requires supervision and support in the kitchen was supervised appropriately. On occasions the kitchen door is kept locked if staff are busy supporting individuals, leaving others unsupervised in the lounge. This is documented appropriately, and staff were observed to open the kitchen door again at the earliest opportunity. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at this home are supported to lead fulfilling and meaningful lifestyles where they participate in community based activities, maintain good contact with their families, enjoy a healthy and varied diet and have their rights as individuals respected. EVIDENCE: People living at this home enjoy active and fulfilling lifestyles. On the day of the site visit, individuals were involved in a range of in-house and community based activities, including going to the local pub, shopping and lunch out, reading magazines, table top activities and watching films. Financial records and daily records indicate that individuals go out almost daily and are involved in a range of ordinary living activities. One individual said, “I love living here”. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 13 People are supported to use local facilities such as the DVD rental shop, local library where an individual uses the computer for Internet access and to e-mail family members, and the local post office. All the people living at the home completed surveys with support and all indicated that they were supported to choose how to spend their time. Three added that if they asked to go out, staff would support them if they were available to do so, and one person said that staff did not take them to the pub every time they ask to go. There was evidence in the records that families and friends of people living at the home are in regular contact. For an individual with no family, the home uses advocacy services and there is regular contact with the appointed advocate. Evidence of this was seen in the records and staff confirmed this. A gathering of family, staff and people who live at the home had taken place the day prior to the site visit, to commemorate the birthday of an individual who had lived at the home but had passed away in the last year. The manager reported that staff support individuals to write to family members or do this on their behalf, and to send birthday/Christmas cards etc. Two relatives completed surveys as part of the key inspection and both indicated that they were always kept up to date with important issues affecting their relative. Staff were observed to respect individuals’ rights and responsibilities. Permission was asked before staff entered bedrooms and staff knocked on bedroom and bathroom doors before entering. Staff were observed to interact with individuals in a respectful manner and include people living at the home in conversation; staff did not interact exclusively with each other. There was guidance in individuals’ care plans about their responsibilities for housekeeping tasks, for example, how much support is required to do laundry and when staff would do this for an individual. The manager reported that residents’ meetings have recently been introduced and have been successful. Two have taken place so far and minutes of the meetings are kept. The deputy manager has taken responsibility for arranging and chairing these meetings. A completed relatives’ surveys included a comment “They treat all the residents with respect. My relative is given choices and so feels part of everyday life, although she can’t communicate verbally they know what she prefers”. One completed survey stated that people are always supported to live the life they choose, and one said this usually happens. People living at the home take it in turns to choose what is on the menu, and clear records are kept that evidence this. A record of what each person has eaten each day is kept, and these showed that a varied and balanced diet is offered. Fresh fruit and vegetables are always available, and a record is kept of how much fruit and vegetables each person has a day to help ensure that the recommended five portions are given. The manager and staff reported that most meals are cooked from scratch using fresh ingredients. An individual living at the home said that she enjoyed the food provided. Wherever possible, staff support individuals to participate in meal preparation and Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 14 shopping, and this was observed during the visit. Photographs of different meals are used to support people to make choices about what they would like. Staff offered drinks and snacks to people throughout the day. An individual at the home has been offered good support to stick to a healthy eating diet, and staff were observed to encourage her with this and support her to make healthy choices. Excellent information about how individuals should be supported with meals was seen in the care plans and staff were observed to support people in the agreed way. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individuals’ health and personal care needs are met at this home. EVIDENCE: All staff were observed to offer personal support in a respectful and discreet manner. Staff were very careful to respect individuals’ privacy and dignity, maximising individuals’ independence wherever possible. Individuals were observed being supported to make choices about when/where they would like to eat/drink and movement and handling practice was good. People living at the home looked well cared for and each had their individual style of clothing and haircut. A relative commented in a survey “…her appearance is modern and they take care of her hair, make-up, jewellery etc. These are things often overlooked when people are in care and sometimes it’s the little things that matter.” Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 16 The manager and staff reported that staff shop for one person who finds clothes shopping distressing. Staff were observed to encourage the individual to have a look at the newly bought clothes to decide whether or not they liked them. A flexible approach is used in the service to meet individuals’ needs. Excellent personal support plans are available setting out in detail how individuals prefer to be supported with their personal care. Attention to detail in this area is excellent. A range of equipment and aids is available to maximise individuals’ independence. The manager reported that, since the last inspection, new weighing scales that can be used with a hoist have been purchased and are shared between three St Anne’s services. People living at the home benefit from a stable staff team and each person has a named nurse and keyworker. Both relatives that completed a survey indicated that the care home gives the support that is expected and agreed and that the service meets the different needs of the people living there. Records examined showed that individuals are supported to have regular health screening and access a range of health services. Health action plans are in place in addition to the ‘OK Health Check’, which is completed annually. Clear, detailed information was available in the records about individuals’ healthcare needs. At the time of the site visit, an individual’s named nurse was in the process of trawling old medical records to add further detail to the medical history. There was clear information in the records of how individuals’ health had improved, deteriorated etc over the years and of treatment and action taken. The Commission for Social Care Inspection (CSCI) has received a number of notifications regarding hospital admissions and the deteriorating health of one of the people living at the home who has since passed away. The records demonstrate that close monitoring of the individual’s health took place and that problems were identified and dealt with promptly by staff. Medicine management at the home is good. Medication was checked against records in respect of two of the people living at the home. All medication checked balanced with the records kept. Good systems are in place for auditing medication, and the medication is stored securely and is well organised. Excellent detail about under what circumstances ‘as required’ (prn) medication should be given was in the records. The CSCI have received one notification about a medication error since the last inspection. However, upon closer examination, it was found that it had been a pharmacy error that staff had picked up rather than staff at the home making an error. There was evidence in the records that medication reviews take place and that monitoring of changes in individuals’ wellbeing takes place. Through discussion with staff and examination of records, it is evident that there is an awareness of the changing needs of the people living at the home as they get older. Many of the staff have attended training in dementia care, and two staff are in the process of completing a masters degree in quality of life issues for people with learning disabilities. Staff have dealt with the death Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 17 of one of the people living at the home with sensitivity and respect. All the people living at the home were given the opportunity to attend the funeral, and the person who shared a room with the deceased was supported to swap rooms at his request. The inspector was invited to watch a DVD, showing photographs of the person who had died, throughout his life. The other people living at the home have also had the opportunity to see the DVD and a copy has been given to the family. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at this home are protected from harm and abuse, and a clear complaints procedure is in place. EVIDENCE: The pre-inspection questionnaire indicates that no complaints have been received at the home during the last twelve months. The manager confirmed this. A satisfactory complaints procedure is in a place and a copy was seen in individuals’ files. All relatives and people living at the home indicated on the completed surveys that they knew how to make a complaint. A satisfactory adult protection procedure, including whistle blowing, is in place in addition to the Kirklees Vulnerable Adult procedures. The manager reported that physical intervention has not been used for some time, and that physical intervention plans have been removed as staff have not received up to date training in this area. If physical intervention is still required for any individual living at the home, appropriate training is required to ensure the safety of the service user and staff involved. Through discussion with staff and examination of records, it was apparent that the use of de-escalation and distraction techniques is successful. The manager and staff demonstrate an understanding of individuals’ behaviour and a staff member confirmed that physical intervention would be used as a last resort and avoided wherever possible. Notifications received by CSCI from Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 19 the home since the last inspection have included four incidents where a service user has been hit, pushed or scratched by another service user. The manager had a good understanding of why these incidents had occurred and had taken the appropriate steps to protect all the people living at the home from any further incidents and notify the appropriate people. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at Smithies Moor Lane benefit from a clean and comfortable environment that is soon to be extended to offer more space and single bedrooms. EVIDENCE: Since the last inspection, planning permission has been approved to extend the building. The building will be extended so that all bedrooms are single occupancy, there will be an additional toilet, a separate laundry room and a new quiet lounge. The registered manager explained that a start date has not yet been arranged, however agreed that she would contact the CSCI to discuss arrangements for people living at the home when the building work commences. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 21 A tour of the premises was conducted and all parts of the home were seen. The home was clean and comfortable and free from unpleasant odours. Four people living at the home indicated on a survey that the home is always clean and fresh, and one said ‘usually’ .The pre-inspection questionnaire states that, since the last inspection visit, the kitchen has been re-decorated. Some redecoration is required in two of the bedrooms, however the manager explained that this would be done along with the building work. Suitable equipment and adaptations are in place in order to meet the needs of the people living at the home. The laundry provides a commercial washing machine with sluice facility and tumble drier. The laundry area is clean and hygienic. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from being supported by sufficient, well qualified, trained and supervised staff that have had all the necessary checks before working with people so that they are kept safe. EVIDENCE: Staff were observed to have positive relationships with people living at the home and all indicated in the completed surveys that the staff treat them well. Those spoken to had a good understanding of the needs of individuals and appeared to be motivated and committed to providing a good service. Feedback from relatives’ surveys includes one relative who thinks that the care staff usually have the right skills and experience to look after people properly, and one who thinks that care staff always have the right skills and experience. The pre-inspection questionnaire indicates that, of seven care staff, four have achieved NVQ level two or above. All new staff complete the Learning Disability Award Framework (LDAF) induction and foundation training. The manager reported that the three care staff who have not yet achieved NVQ Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 23 level two or above are either working towards the LDAF or have started the NVQ training. The pre-inspection questionnaire shows that no staff have left the home since the last inspection, and many of the staff have worked at the home for a significant period of time. Some staff have been re-deployed to Smithies Moor Lane from another of St Anne’s homes. The manager said that the home was fully staffed and that there is a minimum of two staff on duty at all times, including one qualified nurse and one support worker. Staff explained that this is increased, depending on what activities or appointments people have planned, where one to one support is provided. Rotas submitted with the preinspection questionnaire confirm this. The home provides one waking night staff and one sleep in night staff and there is always a qualified nurse on duty. The manager reported that agency staff are very rarely used at the home, and bank staff or regular staff from the home cover any shortfalls due to sickness or annual leave. This is very positive as it allows for consistent care to be delivered to people living at the home by staff who understand their needs. The manager explained that there are staff meetings monthly and, where necessary, additional meetings for the nursing staff. Staff spoken to confirmed this and records of these meetings are kept. Staff recruitment records are held centrally, and the Provider Relationship Manager (PRM) from CSCI inspects a sample of these periodically. A new system has been introduced to the home recording the dates that preemployment checks have been received in respect of each member of staff and confirming that all the necessary documentation has been completed. Records of two staff members were seen and indicated that all the required checks had been completed. A staff training record was submitted with the pre-inspection questionnaire. This shows that all staff have attended various relevant training events since the last inspection. Two staff members had not attended movement and handling updates, however the manager reported that this was booked for June 2007. All staff require training in physical intervention and the manager has requested this. Training attended includes movement and handling, health and safety, food hygiene, fire training, adult protection, dementia, epilepsy awareness, palliative care, Msc quality of life-learning disabilities, first line management. The manager confirmed that staff training needs are discussed in one to one supervision and appraisals with staff. There was evidence in the records that new staff attend structured induction and foundation training. It is positive that St Anne’s is supporting the manager and one of the qualified staff to undertake a masters degree in ‘Quality of life – learning disabilities’. The manager reported that this had been of benefit to the service. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 24 The manager reported, and records confirmed, that staff received one to one supervision at least six times a year. The manager and deputy manager conduct supervision with staff. Where it has been identified as necessary, additional supervision and support meetings are held. This was confirmed by a staff member and records of supervision dates. A staff member reported finding supervision helpful and supportive. Smithies Moor DS0000001096.V329325.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): 37,38,39,41,42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Smithies Moor Lane is a well managed home that has good safety standards and a high standard of record keeping, however although some quality monitoring takes place, a more formal approach to this would improve the service in this area. EVIDENCE: The registered manager is a qualified nurse having an RNMH qualification and also has an NVQ level 4 in management and NVQ assessor’s and internal verifier’s award. Records show that she attends regular training and, as previously mentioned, is currently undertaking an MSC in Quality of Life – learning disabilities. Staff and a service user reported having a positive relationship with the manager. One staff member said “this is the best Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 26 managed home I have worked in”. The manager demonstrates a clear sense of direction and acts as a positive role model for the team. Staff describe the manager as approachable and supportive and one commented that there is “a recognition of people’s skills and abilities”. A requirement was made at the last inspection that results from quality monitoring need to be made available to people using the service or other interested parties, for example relatives or advocates. The manager said that results are now being made available, however the annual questionnaires were not sent out last year. The manager said that surveys would be sent out at the end of May, and reported that as part of her Msc, she would be developing surveys aimed at people using the service. The home has an annual development plan and, it was as a result of this, that service user meetings were introduced. In order to ensure that the home continues to offers a good quality service, it may be beneficial to utilise a more formal audit tool, however in the meantime, consistent monitoring of quality must take place. Record keeping at this home is excellent. Records examined were detailed, up to date, well organised and clear. It is positive that the high standards identified at the last inspection have been maintained. The pre-inspection questionnaire indicates that maintenance of equipment and health and safety checks have been conducted at the required intervals. Records show that staff have received relevant training in this area with the exception of two staff that have not yet attended movement and handling training. (One of these staff is new and one has transferred from another St Anne’s home and are due to attend this training in June 2007). Records relating to health and safety that were examined were in good order and demonstrate that the necessary action is taken to keep service users and staff safe. Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 3 35 3 36 3 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 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 3 3 3 X 4 3 X Smithies Moor DS0000001096.V329325.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. Refer to Standard Good Practice Recommendations Smithies Moor DS0000001096.V329325.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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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