Inspection on 21/11/06 for Smugglers Barn

This inspection was carried out on 21st November 2006.

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

Smugglers Barn 13/03/08

Smugglers Barn 22/02/06

Smugglers Barn 16/08/05

Smugglers Barn 06/01/05

Smugglers Barn 20/07/04

Smugglers Barn 13/01/03

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

CARE HOME ADULTS 18-65 Smugglers Barn Snow Hill Crawley Down West Sussex RH10 3EF Lead Inspector Mrs M McCourt Unannounced Inspection 21st November 2006 11:45 Smugglers Barn DS0000031912.V321196.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 Smugglers Barn DS0000031912.V321196.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. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Smugglers Barn Address Snow Hill Crawley Down West Sussex RH10 3EF 01342 719162 01883 742759 Areakes@aol.com 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) THF Care Estates Limited Mrs Anne Carol Reakes Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: Smugglers Barn is a Care Home registered to accommodate up to four people between the ages of 18 to 65 years, in the category of Learning Disability. The home provides personal care and support for people with Learning Difficulties, Autism, Aspergers Syndrome, emotional problems and challenging behaviour. The registered provider is Caring Homes Limited who have recently taken over ownership of the home. The responsible Individual is Miss Sylvia Lee and the registered manager in charge of the day-to-day running of the home is Mrs Anne Carol Reakes. The property is an attractive detached house in a rural setting, set in enclosed grounds on a site of approximately four acres. It is close to the village of Crawley Down and within easy travelling distance of Crawley and East Grinstead. A cat lives in the home, and within the grounds there is a stable block, yard and fields that house a variety of farm animals, including hens, goats and pigs. The animals and a vegetable garden are cared for on a daily basis by the staff and residents at Smugglers Barn. There is also a second care home in the grounds that houses five residents and is also under the management of Mrs Reakes, and known as Little Smugglers. They are two separate homes and are inspected separately by the Commission. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Tuesday 21st November 2006, lasting a total of eight hours. Pre-inspection planning took approximately two days. Preparation for the inspection included review of information, the request and examination of a Pre-Inspection Questionnaire, the reading of various policies and procedures, including; admissions/referral procedures, staffing rotas, menus, complaints policy and any complaints received by the Commission for Social Care Inspection. A full tour of the building took place and included the observation of health and safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Three staff members, the Registered Manager and the responsible individual; Sylvia Lee were spoken to at the time of inspection. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector also spoke with two Service Users accommodated at the home. Policies and procedures were examined during the site visit. What the service does well: Detailed assessments are carried out by both the home and the placing authority prior to admission. Care plans, needs assessments and risk assessments are clear and easy to follow. Written monthly reviews take place and are part of a structured layout that contributes to the six monthly reviews. In addition, advocacy workbooks are implemented for Service Users when they move into the home. Each Service User is assisted to go through the workbooks to enhance their understanding of advocacy and the benefits of using the additional support. The Inspector was of the opinion that the home has implemented some good examples of record keeping, with a particularly thorough reviewing process. With unlimited access to a working farm, day centre, regular college placements and the home’s own small holding of animals, Service users have sufficient opportunities to develop living skills. In addition there are various leisure activities available, including; table tennis, a pool table, karaoke machine, etc. Service Users tend to use these facilities in the evenings. The Inspector spoke with one Service User about his work on the farm, and he explained how he liked looking after the animals, especially the cat; Alfie. One of the Service Users has started travel training to enhance his independence Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 6 and this is progressing very well. Weekly activity planners demonstrate that Service Users are out nearly everyday, attending appointments, shopping and so on. Staff work within clear guidelines and risk management strategies in order to reduce the number of incidents of challenging behaviour. Through regular inspections and CSCI’s monitoring systems, the Inspector has observed significant behavioural improvements over the past eighteen months. On discussion with the Registered Manager the Inspector was told that by following strict behavioural guidelines, staff are able to identify triggers much earlier, helping to de-escalate potential situations. In addition, all staff have been employed as senior support workers due to the challenging nature of the work environment. There is a high level of staff support, including frequent supervision sessions, monthly, and sometimes fortnightly team meetings and regular training. The Registered Manager has also implemented an induction folder specific to Smugglers Barn staff, details of which can be found in the main body of this report. The Inspector was of the opinion that it was an excellent developmental tool for use with staff members. 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 Smugglers Barn DS0000031912.V321196.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. Smugglers Barn DS0000031912.V321196.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 Smugglers Barn DS0000031912.V321196.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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Service Users individual aspirations and needs are assessed prior to admission. Statement of Purpose and Service Users Guide are available to Service Users and/or visitors at all times. The home ensures that there is a signed contract between the home and the Service User is in place, detailing breach of contract. EVIDENCE: A Statement of Purpose and Service Users Guide was sent to the inspector as part of the documents requested for the Pre-Inspection Questionnaire. They were also found on display at the home, on the notice board in the conservatory. The Service Users Guide is written using pictures and symbols. Both documents are in the process of being updated by the new company. Future plans include using CD Rom’s as a format for information. Previous inspection reports are kept in each Service Users’ personal file and in addition a copy is sent to parents/guardians for their information. All Service Users have a contract detailing fees, room to be occupied, insurance Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 10 requirements and breach of contract. Both of those sampled were signed by the Registered Manager and the Service User or a representative. Detailed assessments are carried out by the home. Information gathered is then used to implement comprehensive care plans. A sample of Service Users’ plans of care were looked at, and found to be signed by the Service User where possible, and if not, it had been recorded as to the reason why. Risk assessments had also been signed, or reasons why not, documented. Smugglers Barn DS0000031912.V321196.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 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home works hard to ensure Service Users know their assessed and changing needs and personal goals are reflected in their individual plans. Service Users are encouraged to make decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: Each Service User has two files in place; care plans, risk assessments and PCP’s in one. Contracts, medical appointments, incidents, medication profiles, behaviour charts and copies of the last inspection in the second. The care plan file consists of a skills assessment that underpins their individual care needs. It is a very thorough process and covers; clothing, personal hygiene, cooking/kitchen skills, community knowledge, communication, money, social behaviour, friendships, leisure activities, medical information and medication Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 12 abilities (can Service Users attend G.P. appointments unaccompanied, self medicate, etc). After collating all of this information, a Needs Assessment Profile is written up. The care plan is then made up of sections headed ‘Areas of Need’ and there are weekly monitoring sheets attached to each identified need. Staff record concerns and/or progress. Every ‘Area of Need’ document is signed by the keyworker and Service User, if able. If not or if they decline, then that is recorded too. From the weekly monitoring sheets a ‘Client Monthly Review’ progress report is written up by keyworkers, covering all of the ‘Area of Need’ subjects pertinent to the Service User. The monthly review is then signed by the keyworker and Service Users if able, then finally signed ‘off’ by the Registered Manager. The manager has a system of signing off the reviews in a different coloured pen to ensure her checks stand out. For the two files sampled, the reviews had been done consistently over the past twelve months. Once every six months the home will hold a full review of care using the information gathered from the monthly reviews. The Inspector was of the opinion that the home has implemented an excellent reviewing of care system that ensures keyworkers are always up-to-date with the changing needs of the Service Users. Risk assessments are carried out with individual Service Users. Once identified there is a clear process to be followed by staff, and a risk assessment form details the risk, which is then signed by the keyworker and Service User. Finally the document is countersigned by the Registered Manager. All risks are then monitored, reviewed and recorded individually. In addition, the Registered Manager has provided a ‘Risk Assessment & Guideline’ file for any agency staff that work at the home. This ensures that they do not have to ‘wade’ through lots of files before starting their shift. Again, a very good example of a recording system. Health care summary sheets are found in the Service Users’ 2nd file, and these detail outcomes from various health appointments. A ‘Medical Appointments’ form records visits to any health professional. There was correspondence from specialists; psychology, psychiatry, dental, speech and language and so on. Service Users’ meetings are held regularly, usually every month. Whilst generally very supportive and inclusive for Service Users, the Inspector suggested that evidence of actions from the meetings, following requests for walks, warm bath water, trampolining, etc be carried through to the next meeting to ensure continuity. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 13 Smugglers Barn DS0000031912.V321196.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): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users are supported to access a range of activities and are encouraged to attend regular evening events. In addition, the home is set on a smallholding, where a variety of animals are kept. Service Users are able to become involved in caring for them, and this brings much enjoyment. Service Users are offered a healthy diet and are encouraged to buy, cook and prepare meals as part of daily living skills. EVIDENCE: Two Service Users attend college part-time, studying subjects such as; computers, arts & crafts and cooking. Three Service Users attend Tandrige Hill Farm during the week and one does not attend either. He does however help to look after the animals kept at Smugglers, called the ‘day farm’. There is Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 15 also a classroom on site with access to arts & crafts equipment and computers, for all Service Users to use. In addition there are various leisure activities available, including; table tennis, a pool table, karaoke machine, etc. Service Users tend to use the facilities in the evenings. The Inspector spoke with one Service User about his work on the farm, and he explained how he liked looking after the animals, especially the cat; Alfie. The Service User then showed the Inspector some art work he had done that day in the classroom. Later in the afternoon he was due to have a reflexology treatment. One of the Service Users has started travel training to enhance his independence and this is progressing very well. Weekly activity planners demonstrate that Service Users are out nearly everyday, attending appointments, shopping, etc, as part of daily living skills. Crawley and East Grinstead are the nearby towns that they visit frequently. One Service User also attends a local church occasionally. In the evenings, Service Users enjoy a range of leisure activities, including; Ready & Able (swimming) on Monday evenings, Bewbush Social club on Wednesdays, Gateway disco on Thursdays and the house shopping on Fridays. On Saturday and Sunday Service Users do what they choose in the day-time, and some go to visit relatives. In addition, Saturday evenings are DVD/video night. Approximately every four to six weeks Service Users go to Brighton and eat fish ‘n’ chips on the sea front, which is a particularly enjoyable trip out. Occasionally Service Users are taken up to London to either a museum, or to look at the Christmas lights, etc. Staff were observed interacting with Service Users, and the Inspector noted that at all times staff were respectful and understanding in their approach. Service Users’ meals are planned one week in advance, usually on Thursdays. As part of daily living, meals are then planned and prepared each day, with Service Users taking it in turns to help out and assist with cooking the meal on ‘their’ day. A log book is kept in the kitchen area to record meals eaten. A Service User spoken with said he really enjoys the meals provided by the home, especially pork chops, omelette and cheese salads. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 16 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are able to support Service Users’ physical and emotional needs, and personal support is offered in all aspects of daily life. Medication administration and storage is good. EVIDENCE: Service Users’ independence is reflected in their choice of clothes and flexible regimes were observed over the duration of the inspection visit. Staff understand the principles of keyworking and have been trained in person centred planning. As previously highlighted, health care is reviewed regularly, and good, clear, records are kept of all health and professional appointments. Assessments are Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 17 in place for specialist care, and any health concern is closely monitored, evidence of this was contained in daily log files. The Inspector has known the service for a number of years and has observed that some Service Users, who often display challenging behaviour, have had a significantly reduced number of incidents recently. On discussion with the Registered Manager the Inspector was told that by following strict behavioural guidelines, staff are able to identify triggers much earlier, helping to deescalate potential situations. Service Users have settled well into the placement. In addition, another Service User’s behaviour has improved, with far fewer incidents of extreme behaviour over the past three years now. Medication is stored in a locked metal cabinet, located within a lockable office. The home uses the Boots MDS system and all medication was stored securely. MAR sheets were looked at and found to be accurate and up-to-date. The Registered Manager has written homely remedies on to MAR sheets, although the Inspector noted a minor issue, regarding Paracetamol and Lemsip, that was discussed with the Registered Manager at the time. The home has implemented a ‘witnessed’ form to record confirmation that the correct medicine has been given and that the Service User has actually taken it. Furthermore, a checking system is in place. On a daily basis stock is checked against quantity recorded and the number of tablets are written on to the MAR sheet at the beginning of the four-week cycle. The inspector ‘tested’ the system with the Registered Manager by cross-referencing, and this confirmed that the systems in place work. Smugglers Barn DS0000031912.V321196.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are protected from abuse, neglect and unnecessary self-harm EVIDENCE: The Commission has not received any complaints in respect of this service. The complaints policy and procedure were both available and are up-to-date. A complaints file contains written responses to each complaint and there have been no new complaints received since the previous inspection. The Service Users’ complaints procedure is provided in pictorial format and is displayed in the sun lounge. Advocacy workbooks are implemented for Service Users when they move into the home. Each Service User is assisted to go through the workbooks to enhance their understanding of advocacy and the benefits of using the additional support. Details of local advocacy groups are accessible to all in the sun lounge. Records examined during the inspection demonstrated that staff had received training in recognising signs of abuse and further discussions confirmed that they were fully aware of how to report any concerns. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 19 A copy of West Sussex County Council Adult Protection procedures was visible in the staff office. Smugglers Barn DS0000031912.V321196.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, 25, 26, 27, 28 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users live in a homely, comfortable and safe environment and enjoy the unique, therapeutic benefits of living and caring for a range of animals. EVIDENCE: Smugglers Barn is a large detached house with accommodation provided over two floors. It is surrounded by its own gardens and in addition has a large area designated to car parking. Communal space is plentiful, consisting of lounge, kitchen/diner, office, conservatory that is also used as an activity room. The property is sitting on four acres of grounds and farm buildings. These house several types of animals, including; pigs, goats, hens, ducks, geese and a house cat. The Registered Manager told the Inspector that two retired horses would be arriving next week. The environmental tour found the home to be clean, bright and comfortable. The Inspector looked at a sample of bedrooms, and these were personalised to Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 21 suit individual taste. personal files. An inventory of Service Users’ furniture was seen on Staff are trained in COSHH and infection control, although there is little or no soiled laundry. Smugglers Barn DS0000031912.V321196.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 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users are supported and protected by a competent and qualified staff team, enabling the home to meet individual assessed needs. The home’s recruitment policy and practices ensure that documents required for the protection of Service Users are available and in place. EVIDENCE: The staff team is made up of nine permanent senior support workers. All staff have been employed as senior support workers due to the challenging nature of the work environment. It came about because the home’s own policy states that only a senior support worker can be left alone with any one of the Service Users, and as this is often the case, the home believed it better to minimise risk by recruiting people with a higher degree of knowledge and understanding of the client group. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 23 The rota shows that there are three staff on all shifts (am and pm), with a sleep-in and a waking night on night shifts. Service Users do have a moderate to severe level of disability, with a range of challenging behaviour, which is why all staff work at senior level. Staff meetings are held on a regular basis, monthly or more regularly if required and staff spoken with told the Inspector that the Registered Manager will hold additional meetings, should there be issues that need addressing urgently. Staff said that they discuss person centred planning, complaints, care plans, opinions, menu planning and so on. The Inspector looked at a sample of minutes and found them to be regular and up-to-date. The Inspector looked at a sample of staff files and found that recruitment information was available, accurate and stored securely. A training and development matrix is used by the Registered Manager to plan future training with team members as part of her targets set at her annual appraisal. Personal files also list training allocated to individuals with dates of when completed. The Registered Manager has implemented an induction folder specific to Smugglers Barn staff. It includes; expectations, a checklist of documents required, contracts, job description, work ethics, what and when to report a regulation 37 incident and is combined with a comprehensive workbook that staff work through during their employment. The Inspector was of the opinion that it was an excellent developmental tool for use with staff members. Supervision is carried out regularly, at least six each year, with the manager striving to ensure staff receive a 1 to 1 session every six weeks at least, or sooner if need be. Performance reviews are then carried out annually. Grievances and/or disciplinary actions are carried out in a thorough and well documented manner, with incidents investigated and outcomes recorded. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 24 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 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home benefits from a well run home with a clear management structure and approach. The home endeavours to seek the views of Service Users, staff and outside parties in order to review and monitor service delivery. The health, safety and welfare of Service Users and staff are promoted and protected. EVIDENCE: The Registered Manager is Mrs Anne Reakes and she has managed the service for four years now. She has obtained City & Guilds in care and her RMA. Mrs Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 25 Reakes told the Inspector that she attends mandatory training when required which is discussed through the Reg 26 visits and at her own appraisal. Mrs Reakes is the Registered Manager for the new service built next door (Little Smugglers). In order to manage effectively she is supported by a deputy manager in each home. As previously highlighted, all employed support staff are recruited to a senior level to ensure Service Users needs are met. Staff spoken with said that the Registered Manager is a good manager who is ‘hands on’. The Inspector was also told that staff are encouraged to work through issues on their own initiative, but if necessary she will mediate to resolve problems when required. Another staff member told the Inspector that the manager does a brilliant job. The home has a quality assurance policy. Each year the director sends out an anonymous survey to professionals, such as; G.P.’s, dentists, social workers, etc. Service Users receive a questionnaire every six months that seeks information about their happiness with the home and the care provided. The surveys are provided in symbol format and the Inspector looked at a sample selection of these. An analysis from the results of the residents questionnaire is sent out to the home for information. In addition, staff are surveyed in the same way, with the information being put into an analysis format and sent back to the home. This is carried out once a year. Mandatory training is provided for all staff and a training matrix was seen by the Inspector. Health & Safety at work is included in staff induction. All staff were trained in fire safety on 11th October 2006. There is a record of regular fire drills and weekly alarm checks are realistically carried out monthly. The home has a contract with CHUBB, who last visited on 19th October 2006 to check equipment. There were data sheets for COSHH. Water temperatures were recorded in a file. The maintenance of electrical appliances is checked monthly by either the Registered Manager or a designated person, and any issues are then discussed at the regulation 26 visit. PAT tests were done in September 2006 for which the home is awaiting certificates to come from head office. CSCI reports are given to each Service Users, then stored on their individual files. Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 26 Smugglers Barn DS0000031912.V321196.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 3 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 4 25 3 26 3 27 3 28 4 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 4 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 4 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 4 3 x 4 3 x Smugglers Barn DS0000031912.V321196.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 Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Smugglers Barn DS0000031912.V321196.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!