Inspection on 28/02/07 for St Chads House

This inspection was carried out on 28th February 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Chads House 22/02/06

St Chads House 08/03/05

St Chads House 08/09/04

St Chads House 17/12/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 St Chads House Withies Lane Midsomer Norton Bath Bath & N E Somerset BA3 2JE Lead Inspector David Smith Key Unannounced Inspection 28th February and 15th March 2007 11:00 St Chads House DS0000008189.V332398.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 St Chads House DS0000008189.V332398.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. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Chads House Address Withies Lane Midsomer Norton Bath Bath & N E Somerset BA3 2JE 01761 413173 01761 419204 stchads@orchardvaletrust.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) THE ORCHARD VALE TRUST Mr Paul John Maggs Care Home 4 Category(ies) of Learning disability (4) registration, with number of places St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 4 persons aged 18 - 64 years of age requiring personal care only 22nd February 2006 Date of last inspection Brief Description of the Service: St.Chads house is owned and operated by Orchard Vale Trust, a Registered Charity. The home was opened in 1995 to provide care and support to four adults who have a Learning Disability and Challenging Behaviour. It is located in the town of Midsomer Norton and has easy access to local shops and facilities. Bath is approximately nine miles away. St.Chads is a spacious detached house set in its own grounds. There are four single rooms, each with en-suite facilities, two communal lounges, kitchen and dining area and a sensory room. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a Key Inspection of this service. The home was visited by myself, and one colleague who supported the inspection process on the first day. We gathered information during this visit through discussions with residents, the Manager, his line manager, the Trust’s Chief executive, Seniors and Support Workers. Interaction and communication between staff and residents was also observed during the course of our visit. Care plans and associated records were examined together with Risk Assessments, accident/incident reports, medication, staffing and health and safety records. We were also provided with a tour of the home. Other sources of evidence have been used as part of the Key Inspection process. These include the home’s action plan in response to the last CSCI inspection. The Commission also provided the home with a range of ‘Comment Cards’ for stakeholders to complete prior to this visit. Seven were competed and returned. The home uses the term ‘resident’ to describe the people who live in the home. This term has therefore been used throughout this report. What the service does well: Each relative and health care professional who responded by comment card said they were satisfied with the overall care provided by the home. The ethos of the service is clearly defined and remains focused on positive outcomes for each resident. Professional expertise is sought when necessary in order to ensure a specialist approach of support is promoted for each resident. There remains an extremely low turnover of staff. This helps to ensure consistency in supporting each resident and maintaining a cohesive staff team. St Chads offers very attractive accommodation. This provides residents with a homely environment, which is maintained to a very high standard. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 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 St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the information they require to enable them to choose where to live. EVIDENCE: The home has a brochure, which is used as both the statement of purpose and service users guide. This provides details of the service and support the home is able to provide. This would be supplemented by a comprehensive assessment process, which is operated by the home, should a vacancy arise. There have been no new admissions to the home for a number of years. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are in place that identify resident’s assessed needs and personal goals. The review process must be improved. Residents make decisions about their lives and are given assistance as and when needed. They are consulted on, and participate in, all aspects of life in the home. The Risk Assessment process supports each resident to take risks. These are reviewed and updated regularly. Each resident is assured that information about them remains confidential and is stored securely. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 10 EVIDENCE: One care plan was examined in detail during this visit. This care plan was both sophisticated and detailed. It contained clear guidance on the areas of support the resident requires and how this should be provided. The daily records complement this process by ensuring there is a constant process of evaluation and review of the support being provided and the outcomes for the resident focused upon. One Resident has had a recent multi-agency review. However, the other three people who live in the home have not had a formal multi-agency review meeting for some time, although there has been informal contact with the relevant Funding Authorities or Social Workers. Both the Manager and his line Manager discussed the reasons for the lapse in regular formal review meetings at length. This situation appears to have arisen due to time which should have been allocated to preparing and hosting reviews being re-allocated towards staff training, particularly Learning Disability Award Framework (known as LDAF). We were shown that extremely comprehensive review documents are in the process of being completed and during the second day of my visit, I was advised that the Funding Authorities had been contacted to arrange dates for formal review meetings to be held. It is important that these reviews are re-established to ensure that all professionals involved with each person’s care and support are included in the care planning and review processes. They may also play an important part in highlighting the very positive outcomes for each resident and their continued personal development since moving to the home. It was evident through both discussions with residents and staff and observation of their communication/interaction that each resident is supported to make decisions. They are actively involved in all aspects of home life such as cooking, cleaning, and gardening as well as deciding what activities outside of the home they would like to take part in. Care and support was being provided within a risk assessment framework. Healthy risk taking continues to be encouraged and supported, as evidenced within the wide range of opportunities and activities all four residents have been able to enjoy. Each of the person centred risk assessments I examined were detailed and have been regularly reviewed. Each person’s care records are stored appropriately and confidentiality is respected. At no time during either day of my visits were any records left St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 11 unattended by staff. Each time records were completed they were returned immediately to their normal place of storage. St Chads House DS0000008189.V332398.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): 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. Residents are supported in their personal development. The residents currently accommodated clearly demonstrate the home’s success in this area. Residents are encouraged and supported to take part in appropriate leisure activities, including the use of many community-based resources. Involvement of resident’s families is encouraged and remains central to the philosophy of the home. Each resident’s rights and responsibilities are explained and promoted within the home. A healthy and balanced diet is promoted within the home. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 13 EVIDENCE: Residents are supported to reach their full potential in relation to their personal development. A great deal of importance is placed on residents being able to participate in all aspects of home life and supported to enjoy a range of leisure activities, outings to places of interest, and to choose and attend holidays. The records I examined showed that residents use community facilities each day. This includes going swimming, for bike rides, walks, shopping trips, tenpin bowling, skittles, lunches and meals out. I also noted that there had been trips to the Bristol Hippodrome Theatre and a charity golf day at a local club, where residents and staff formed a team to compete. Two residents are currently on holiday in Florida, supported by members of the staff team. The residents who live in the home have all demonstrated significant progress in their personal development. It is evident that the positive outcomes for each resident remain the focus of the care planning processes and support of the staff team. By remaining focused on these, the home demonstrates its commitment to a person centred approach. Each member of staff I spoke with spoke very highly of the varied opportunities offered to each resident and how the staffing levels during the day allowed trips out of the home to be planned on both a group or individual basis. Families have been fully involved in the home’s assessment and care planning process. Orchard Vale Trust was originally a family led organisation and the involvement and support of each person’s family remains central to the philosophy of the home. All four residents have contact with members of their families and there are no restrictions on visiting times and relatives are free to visit whenever they wish. Clear records are maintained relating to any contact with families. One person told me that they see their parents regularly. They either visit them at St.Chads or they stay with their parents occasionally at weekends. Each relative who responded by comment card said they are welcome to visit at any time and they could see their relative in private if they wished to do so. Each also said they were satisfied with the overall care provided by the home. One relative said “the home and staff are top rate”. Two families said they were always consulted about their relative’s care, however two others said they did not always feel consulted. It would appear that the home does work hard to ensure relatives are kept informed and that St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 14 any concerns raised or views expressed by families are taken seriously and dealt with professionally and empathetically. It was evident that each resident is aware of their rights and also their responsibilities in residing at St.Chads. For example, in one care plan I examined there was a clear set of daily rules and routines which this resident had agreed to accept responsibility for. The home currently uses a five-week ‘rolling’ menu, which has been devised by residents supported by the staff team. The menu plan shows that a wide variety of food is offered to residents and a healthy and balanced diet is promoted. Residents are encouraged to help prepare and cook meals. They eat their meals in the dining area with members of staff. St Chads House DS0000008189.V332398.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans clearly explain the support each resident requires in relation to their personal and health care. Experienced staff have a good knowledge of each resident and how to provide appropriate levels of support. The home’s policies and procedures in relation to medication administration promotes the welfare and safety of each resident. EVIDENCE: Each resident is registered with a local GP and dentist. Other health care professionals support the home when required. Records examined show that one resident is currently supported by a Clinical Psychologist provided through the Somerset Community Learning Disability Team, based at Fiveways in Yeovil. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 16 In addition to external resources, there remains a high level of clinical expertise within the organisation to ensure that the care planning meets the needs of each resident. The continuity the home has managed to maintain within the core staff team also assists in providing consistency and quality of support in this area. Health care professionals who responded by survey said the home communicates clearly and works in partnership with them. Any specialist advice they give is incorporated into care plans. Each confirmed they were satisfied with the overall care provided by the home. One said the home “offers an excellent person centred service” and another stated they were “impressed by the excellent care the residents are given”. Each member of staff spoken with had a good knowledge of each residents support needs and were clear on the support and guidance they should provide. The record keeping for residents is excellent and can be easily tracked. This process ensures that resident’s health care is monitored and the support provided is subject to review. The home uses the Lloyds Pharmacy monitored dosage system of medication administration. The medication is kept securely within the home and the senior member of staff on duty holds the key. The storage facilities were clean and tidy. Each resident has their own named storage containers for non-blister packed medication and dispensing pots. There are clear guidelines to follow in relation to medication taken when necessary (known a ‘PRN’ medication) and a robust check of all stock. Medication is dispensed and administered by staff, although one resident does dispense their own medication from the ‘blister pack’. Clear records are maintained within the home and the recording sheets I examined were all complete with no gaps evident. Staff are provided with in-house medication administration training. This however, will be updated as this forms part of the new ‘Red Crier’ training materials now used within the home. This is discussed in more detail later in this report. The home’s GP said that they felt each resident’s medication was appropriately managed by the home. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Residents are enabled to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Residents are protected from abuse, neglect and self-harm. Behavioural approaches are detailed. These ensure support for each resident is agreed upon and clearly defined. EVIDENCE: There is a formal complaints policy and whistle blowing procedure available in the home. This procedure sets out the various stages and levels that a complaint or concern may be dealt with, makes reference to other related policies and procedures, and refers to a complainant’s right to complain to the CSCI. The home has an in-house complaints and comments book. No complaints have been recorded since the last inspection visit. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 18 One resident I spoke with told me that they are very happy living at St.Chads but if they did have a problem or became unhappy about any issue they would speak to the staff. They felt sure staff would listen to them and help. Each health care professional who responded said they had never received a complaint about the home. Three relatives who responded by comment card said they were aware of the home’s complaints procedure, while one said they were not. One relative who responded by comment card said they had made a complaint, although the Manager explained to me that a formal complaint had never been made using the home’s policy. These concerns were discussed with this relative on a more informal basis and as this was some time ago the home has assumed this has been satisfactory concluded. The home has clear guidelines in place for supporting residents who are distressed or presenting behaviours which may be perceived as challenging the service provided. These behavioural approaches contain a clear rationale, long-term goals, direct treatment, reactive strategies and restrictions. The home’s methodology appears to be drawn from a select variety of sources such as Studio 3 and Somerset County Council current best practice. Physical interventions used by the home have been recorded and shared with all appropriate parties e.g., family members, representatives, and Consultant Psychiatrists and Psychologists involved with the individual resident. The home also has up to date Risk Assessments in relation to physical interventions which may be used. Again the quality of record keeping in this area is excellent. This enables each resident’s approaches to be continually assessed and changes made when necessary. The home maintains clear records of each accident or incident which occurs in the home. I examined all reports of recent accidents and found each record to be clear and in accordance with all relevant legislation. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 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. The accommodation provides a safe and comfortable home for the residents, which is maintained to a very high standard. All remedial work identified during the last inspection visit has now been completed. Each resident is encouraged and supported to personalise their own room and contribute to the redecoration of communal areas. The home was clean and tidy on the days of the inspection visits. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 20 EVIDENCE: St Chads is a large detached property set in its own grounds just a short walk from the town centre of Midsomer Norton. There are car parking spaces at the front of the house. There is level access to both the front and rear of the home, however access to the first floor is by stairs only. The communal areas are all situated on the ground floor. These include a large and small lounge area and a kitchen/dining area. The conservatory has been reconfigured with a new partition wall added. This now provides a smaller sensory room (which still requires completion) and now houses the home’s office. These changes have allowed a dedicated sleep-in room for staff to be developed in the room previously used as office space. All furnishings and fittings are of a high quality, for example the stainless steel cooking range and fridge in the kitchen, leather furniture and wall mounted plasma screen television in the main lounge. The house is tastefully decorated and there are many photographs of residents displayed, which help to personalise the home and add to the homely feel. One relative who responded by comment card said “the atmosphere at the house is always relaxed, friendly and welcoming”. Upstairs there are four single rooms all with en-suite facilities. Each resident’s bedroom has been personalised with photographs, pictures and been decorated to reflect their own personal tastes and wishes. All bedrooms are fitted with a lock so residents can lock their bedroom doors should they wish to do so. The residents remain actively involved in the maintenance of their home. They are encouraged and supported to help choose furniture, fixtures, fittings and colour schemes and to help with both preparation and redecoration. The home has a large secluded garden, which residents are actively involved in maintaining. The exterior of the house is in good order. Repairs to an area of exposed brickwork on a side wall, replacement of some timber supports and window frames at the front of the house have now been completed. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The relationships between staff and those living at St.Chads are well established. This provides a supportive environment for each individual who lives in the home. The home has sound recruitment policies and procedures. These help to ensure the welfare and safety of each person who lives in the home. All staff must be provided with all mandatory training and any additional appropriate training to enable them to support individuals and promote their welfare and safety. A clear record of all staff training must also be maintained. All staff must be supervised on a regular basis and a clear record maintained in their personnel files. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 22 EVIDENCE: St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 23 There is a core of well-established staff with varying skills and abilities who meet the needs of each individual who uses the service. Many of these staff have been employed by the Trust for a number of years and therefore know each of the residents very well. The home has been successful in retaining staff. This ensures the core team remains consistent. This has led to a committed and skilled team being developed. The positive outcomes for each resident continue to reflect the commitment and cohesion of the staff team. Discussions with staff members and observation of their work practice demonstrated that they were approachable, good communicators and were comfortable with individuals living at St.Chads who were at ease with them. Residents spoken with said they liked the staff team and felt well supported by them. Each health care professional who responded by comment card said all staff members demonstrate a clear understanding of each residents care needs. One relative who responded by comment card said they “have utmost confidence in the staff’s ability to look after our relative in the manner we would wish”, whilst another said the staff were “top rate”. The home operates a robust recruitment process. The personnel records I examined included application forms, documents proving identity, medical questionnaires, at least two satisfactory references and Enhanced Criminal Record Bureau Disclosures. The home has also revised the application form completed by all prospective staff to ensure they provide a full employment history, rather than just the last five years. The staff training records, which I examined, showed varying levels of training which staff had attended. However, there was no clear evidence that each staff member had completed all mandatory training such as First Aid, Basic Food Hygiene or Manual Handling. The home now uses ‘Red Crier’ training materials, which can be delivered inhouse once staff within the home have been trained to both deliver the programme and assess the competence of staff. Both Mr.Maggs and Mr. Phillips have completed this training. This training package contains elements such as First Aid, Manual Handling, Fire, Protection of Vulnerable Adults, Health and Safety and Medication. Each staff ember should have their progress assessed and tracked using the ‘Training Progress Chaser’ forms provided. However, these had not been updated for several members of staff and it was not possible to see which training was still required and which had been completed. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 24 Staff are provided with 1:1 formal supervision meetings with either the Manager or a senior member of the team. These should be provided every six to eight weeks, although the records I examined showed that supervision meetings had become irregular, for example three staff had their last supervision meetings recorded as being held in May 2006. The Manager told me that supervision and discussions with staff took place informally each day, although he did acknowledge that the recording of these discussions must improve to evidence that regular staff supervisions were taking place. The new recording format now used for supervision meeting should assist in this process. St Chads House DS0000008189.V332398.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 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and has effective procedures in place to provide residents with the support they require to lead fulfilling lives. The manager is qualified and competent to run St.Chads, and meet its statement of purpose, aims & objectives. The ethos of the service is defined and clearly communicated. The health, safety and welfare of residents is promoted. Organisational legal accountability, monitoring and support of the service has now been improved through regular visits. However, the home must review the content and style of auditing reports. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 26 EVIDENCE: Mr Maggs, the home manager, has approximately 8 years experience of running this home and three years experience as the deputy manager. He holds the City & Guilds 325.3 Advanced Management in Care qualification, a NEBS supervisory management qualification and is working towards an NVQ level 4 in management. I again discussed the ethos, history, current issues and continued development of the service at some length with both the registered manager, Mr.Maggs and his line manager, Mr.Phillips during both days of my visit. The management approach appears open and positive, with a clear sense of direction and leadership. Both are long standing members of the Trust’s staff team and have considerable knowledge of the service and each resident. Mr. Phillips plays an active role in supporting Mr. Maggs with the running of the home and the support of the residents. Mr Phillips has considerable experience within the learning disabilities field with a particular clinical expertise in the management of challenging behaviour. Due to relatively small nature of Orchard Vale Trust, it is apparent that resources will always be limited and due to new pressures, some of which are required by changes to existing regulatory legislation, this will remain a difficult issue for the home to address as it does not to wish to reduce resources, and in particular time, spent directly supporting the residents. Whilst I am sympathetic to this issue it is important for the home and the Trust to make the best possible use of all resources available to ensure the home complies with all relevant legislation and principles of good practice. The home has a quality assurance policy and procedure. This system monitors any errors made by staff members and these are collated on a monthly basis. This information can be used to identify areas of improvement in staff practice, for example. The Manager told me that the home does not formally seek feedback from stakeholders regarding the quality of the service, but may consider introducing this process in the future. During my visit the home’s staff team were seen to be supportive of each other. There was an open and inclusive atmosphere in the home and staff and residents interacted well. Staff members spoken with said that they had regular staff meetings and residents are actively encouraged to participate in the general running of the home. Each member of staff I spoke with said they enoyed working in the home and felt extremely well supported by the management team. They each felt they could contribute ideas and felt that they are always listened to. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 27 The management systems and structures are efficient. The record keeping is of a good standard. Files and documentation are well-organised and easy to access. There are recording systems in place to support the maintenance of health and safety in the home. I examined the records of hazardous substances used in the home, portable electrical appliance tests, electrical wiring checks, vehicle maintence checks, fridge, freezer and water temperature records. All of these records were up to date. The home’s fire log shows that the fire alarm system is tested each week, the emergency lighting monthly and vsisual check are carried out on all fire fghting equipment each month. Regular fire evacuation drills are carried out, the latest one on 5/02/07. The home also has an up to date Fire Risk Assessment. Other Risk Assessments are in place in the home. These are both generic and person centred. These are clearly written and subject to regular review. During the two previous inspections it was noted there had been a lapse in the organisation’s Chief Executive carrying out monthly auditing visits. These visits resumed in September 2006 and an auditing visit has been conducted every month since. However, these records must be reviewed as the current format does not describe how the audit process was carried out, who was spoken with or provide an ‘opinion of the standard of care provided’ in the home as required by the Care Home Regulations. It may be useful for the organisation to consider the new Annual Quality Assurance Assessment (known as an AQAA, pronounced ‘aqua’) as part of this review process. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 28 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 3 2 X 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 4 25 4 26 X 27 4 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 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 4 3 X 3 3 3 X 3 3 2 St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1)(2) Requirement Each care plan must be subject to regular review and a clear record of the review process maintained. All staff must be supervised regularly and a clear record maintained. 1) All staff must be provided with training:Which meets all National Minimum Standards. Which provides all staff with additional relevant skills to support residents. 4. YA43 26 The home should review the style and content of each auditing visit report to ensure it complies with the Regulations. Timescale for action 15/03/07 2. YA36 18(2) 15/03/07 3. YA35 18(1) 15/09/07 15/09/07 St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA35 Good Practice Recommendations The home should continue to review its record keeping and terminology to promote a person centred approach. The staff training record should be regularly updated and maintained in good order. St Chads House DS0000008189.V332398.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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