Inspection on 16/07/07 for St Edwards (6).

This inspection was carried out on 16th July 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Edwards (6). 04/07/06

St Edwards (6). 23/09/05

St Edwards (6). 25/05/05

St Edwards (6). 22/11/04

St Edwards (6). 21/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Edwards (6) 6 St Edward`s Close New Addington Croydon Surrey CR0 0EL Lead Inspector Peter Stanley Key Unannounced Inspection 16th July 2007 9:30am St Edwards (6) DS0000025839.V345268.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 Edwards (6) DS0000025839.V345268.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 Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edwards (6) Address 6 St Edward`s Close New Addington Croydon Surrey CR0 0EL 01689 800 960 01689 800 861 croydon@nas.org.uk Vanessahalfacre@nas.org.uk National Autistic Society 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) Post Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: St Edwards is situated in a quiet close in New Addington near to local shops and trams. The National Autistic Society leases the building from Croydon Churches Housing Association. All service users have been identified as having an autistic disorder. The service provides residential care for twelve residents, who are divided between two houses, which are separated by an attractive garden area. The houses no longer have a gender divide and are divided into two resident groups. These are determined by the level of dependency, more highly dependent residents tending to be placed in the Conifers. All residents have a single room; all contain a wash hand basin although some are not in use. This is due to the particular needs of the person occupying those rooms and has been agreed with the registration authority as being in their best interests. The furniture in some bedrooms has also been specially adapted where necessary. In addition to the bedrooms there is a communal lounge, dining room, a kitchen, toilets and bathroom in each house. Each house has its own staff team, with one waking member of staff allocated to each and one member of staff sleeping in. All residents attend day care from Monday to Friday, with day care provision being provided according to differing types and levels of need at one of three NAS day centres. These centres provide day care for adults with autism who live in both residential care and within the community. The Coney Hall Day Centre (in West Wickham) provides day care for service users with high dependency, and is housed in the same building as many of the National Autistic Societys regional administrative functions such as personnel. Another day centre, Mansfield House, opened in 2007, provides day care for those users who range from being medium to high dependency, while the Transitions Day Centre in Croydon provides a specialist day care resource for service users who have aspergers syndrome. The NAS provides its own minibuses for transporting service users to and from the day centres. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over one day, and involved extensive discussion with the recently appointed manager, Andrew Lewis, and the NAS area manager. The inspector spoke with the deputy manager and to support workers on duty, and spoke with two residents, observing others with whom it was not possible to engage in discussion. This unannounced inspection was conducted over five hours, during which the inspector examined policies, procedures, staff and service user records, and other documentation relating to the management and running of the home. Service user records included residents’ assessments, risk assessments, care plans, life plans, and records of reviews, together with minutes from residents’ meetings. Staff records included staff rotas, recruitment records, and records relating to supervision, appraisal and training. The home has also completed an annual quality assurance assessment (AQAA), which provided a further source of information for this inspection. The home provides a pleasant and congenial environment, with a homely atmosphere pervading each of the two residents’ houses. The home provides good facilities and attention is paid to detail in ensuring that the home provides a safe, accessible, empowering and inclusive environment. Staff present as being skilled and knowledgeable, and there is a wide range of training provided which is specific to meeting the needs of this client group. There is a highly developed programme of day care, which is now spread across three separate sites, each of which provides for a specific area of needs and abilities. The key worker system in place allows for focussed support for each individual, with dedicated day care staff providing more specialised inputs. There is an excellent programme of outdoor and indoor activities offered with individuals being encouraged to pursue their interests and achieve their goals. There is a person-centred emphasis in the home’s approach and philosophy that permeates all of its thinking and work with service users. From the interactions observed between staff and residents, there was evidence of a focussed and enabling one-to-one approach, with evidence of respectful and caring engagement, and attention to meeting individually expressed needs. The evidence from this inspection indicates that the home is maintaining a high standard of care and support, with residents presenting as settled and at ease with staff. The home has a new manager who is gradually developing his role and who demonstrated a good awareness and understanding of the needs of people with autism. There was evidence of a positive and caring commitment by the manager and staff towards meeting the complex and challenging needs presented by service users, and in providing opportunities for enabling the development of individual abilities and potential. There is also a very positive view of risk taking with individual residents being encouraged to develop their St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 6 independent abilities and potential whether in learning new skills or engaging in physical and risk-taking activities. As a result of this inspection there are 8 requirements. This includes 5 new requirements and 3 requirements (2 partly met) from the previous inspection. There are also 3 recommendations. The inspector identified some concerns, the main one being the failure to ensure that all staff at the home are receiving regular supervision. The frequency of supervision has fallen off over the last year and a half, and was identified as an area of concern in the last inspection report in July 2006. The new manager, Andrew Lewis, provided an assurance that changes are in hand to ensure that supervision will be provided on a regular basis to all staff. The inspector was advised that a new structure has been developed to allow more division of supervision between the manager, deputy manager, and senior care workers. Supervision and appraisal training should, however, be provided for all senior staff who provide supervision. The inspector understands that four new staff have yet to complete statutory adult protection training, but that places have been booked for training on 14 August 2007. The inspector would like to thank the manager, area manager and staff for their cooperation throughout this inspection. He would also like to extend his thanks to those residents whom the inspector met and engaged with during the inspection. What the service does well: Residents are being provided with accessible and up-to-date information about the home. This is sufficient to provide a clear understanding of the services provided and whether the home is able to meet their needs. Any prospective resident can be assured that their individual needs will be appropriately assessed, and that their views and wishes regarding the delivery of their care will be fully respected. Residents and their relatives can be assured that staff have the necessary training, support and knowledge base with which to meet residents’ individual needs. Residents are having their health, personal and social care needs and goals set out in an individual plan of care, and are fully involved in the care planning process. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 7 Residents are enabled to participate fully in decisions that affect them and their day-to-day lives in the home. Staff engage with residents in an enabling and person-centred way. Residents are positively encouraged and supported to develop an independent lifestyle, with thorough risk assessments being carried out for any activities that involve responsible risk-taking. Residents are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Residents are being enabled to participate fully in decisions that affect their day-to-day lives, and are being enabled to exercise choice and control in their daily routines and activities. Residents are being encouraged to develop their interests and abilities, and are being provided with opportunities for participating in a wide and varied range of activities. Residents are being encouraged to maintain contact with their family and friends, and to maintain links with the local community. Residents’ rights and responsibilities are being fully respected and recognised in their day-to-day lives. Residents are being offered a varied and healthy diet, in pleasant and homely surroundings, and are being enabled to make an informed choice regarding their food preferences. Mealtimes are flexible and take account of residents’ activity schedules. The personal support, physical and emotional health care needs of residents are being well met in this home, with support being planned and tailored according to the individual needs presented. Residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. Issues relating to bereavement and loss are being handled with respect, and in accordance with individuals’ wishes. Training in this area is planned to take place. Residents, and their relatives/representatives, can be assured that the home has an appropriate policy and procedure in place for raising any concerns or complaints. This provides clear information and is available in an appropriate format for adults who have communication difficulties. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 8 The home’s policies, procedures and practice indicate that residents are generally being well protected from abuse and are living in a safe, secure and trusting environment. Residents are living in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Residents have rooms that are suited to their individual needs. They present as being safe, comfortable and pleasantly decorated, and reflect residents’ individual identities. Residents are living in a home that presents as being clean, pleasant and hygienic. Training in infection control is being rolled out to all staff. Residents are having their needs well met by staff, in sufficient numbers, who are appropriately trained and qualified, and who have clearly defined roles and responsibilities. Residents are being protected by the home’s recruitment policy and procedures. Residents are living in a home that is being well managed and run in their best interests, and which provides an open, positive and inclusive atmosphere. The home is able to demonstrate that it is obtaining widespread feedback regarding the extent to which the home is supporting residents and meeting its aims and objectives. Generally, the rights and best interests of residents are being safeguarded by the home’s record keeping policies and procedures. However, up-to-date hard copies need to be kept on file together with a checklist. What has improved since the last inspection? Both the Statement of Purpose and the Service User Guide have been reviewed and updated. A copy of the minutes of residents’ meetings is now being kept in each house. The home has been assessed by an occupational therapist, and recommendations to improve safety are being implemented 16 out of 23 staff have received infection control training. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 9 A new manager has been appointed, although registration with the CSCI has still to be completed. The deputy manager is undertaking studies leading to the award of an NVQ Level 4 management qualification. A questionnaire has been developed for care managers and professionals to provide feedback regarding their views of the home.. A Development Plan has been put in place. 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 Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 10 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 Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 11 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 to 4 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are being provided with accessible and up-to-date information about the home. This is sufficient to provide a clear understanding of the services provided and whether the home is able to meet their needs. Any prospective resident can be assured that their individual needs will be appropriately assessed, and that their views and wishes regarding the delivery of their care will be fully respected. Residents and their relatives can be assured that staff have the necessary training, support and knowledge base with which to meet residents’ individual needs. EVIDENCE: The home has compiled a statement of purpose. This outlines the aims and objectives of the home, and the facilities and services that it provides. The Statement of Purpose includes all the information detailed in Schedule 1 of the Care Homes Regulations (2001). St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 12 The home’s service user’s guide is called a ‘Welcome Pack’, and includes all the elements of regulation 5(1)(2)(3). This is available in a format and language that is appropriate to meeting the varying communication difficulties experienced by residents. The pack contains information that is relevant to residents’ day-to-day lives and involvement in the home. This includes the upkeep of their room, their laundry and their contribution to communal household tasks. It also gives general information in reasonably simple statements about the running of the service. Both the statement of purpose and the service user’s guide have been reviewed and updated in March 2007. There have not been any admissions to St Edwards since 2002. Vacancies at this home are few and far between, all but one resident having lived in the home for 10 years or more. A decisions regarding any admission is taken by a panel from St Edwards. This includes senior staff and a range of other professionals who have knowledge of the person. Staff from St Edwards carry out thorough and detailed assessments, with assessment visits being made to meet with the individual and his/her family. A comprehensive history is obtained which includes a history of behaviours and a medical diagnosis. There is the opportunity for any prospective resident to visit the home, usually with family members, when a placement is being considered. The initial visit has previously taken place when other users are not present. The prospective resident is then invited to make a transitional visit, to see the home, meet with staff and residents, and possibly stay for an meal. Overnight stays may be arranged, but this depends on the needs and wishes of the individual. Prior to admission, a transitional plan is drawn up .Following an admission, there is a six-month trial period with a review after three months. This is to allow for a full assessment and is normal professional practice within the NAS (National Autistic Society). The home aims to meet the specialist needs of people diagnosed with autism and asperger syndrome. All residents have communication difficulties, and some present challenging behaviour. Individuals’ cultural and religious needs are met in consultation with family members. While some residents possess varying degrees of verbal understanding and ability to communicate, others are unable to do so and use Makaton or other systems for communicating. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 13 The inspector observed staff on duty interacting with residents. Staff presented as being enabling and person-centred in their approach, using verbal and nonverbal means of engaging with residents. Residents presented as being settled and at ease in their home environment, and to have good relationships with staff. Staff are trained to develop relevant communication and social skills with which to interact in a patient, caring and skilled way. There is an emphasis on one-to-one working, with a key worker being allocated for each resident. Key workers escort residents to their day care setting, where there are day care staff with specific skills, including social skills, art, dance and drama therapy. The NAS has a comprehensive and ongoing programme of staff training, which includes autism awareness training and training in specialist teaching techniques. Training in how to manage challenging behaviour is also provided. The home’s approach is to try and identify triggers and take preventative action if possible, using the least intrusive method of control if this is required. Two assistant psychologists are available for assessment and support sessions with residents, with access to consultation from a clinical psychologist. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 14 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 to 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are having their health, personal and social care needs and goals set out in an individual plan of care, and are fully involved in the care planning process. Residents are enabled to participate fully in decisions that affect them and their day-to-day lives in the home. Staff engage with residents in an enabling and person-centred way. Residents are positively encouraged and supported to develop an independent lifestyle, with thorough risk assessments being carried out for any activities that involve responsible risk-taking. Residents are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 15 EVIDENCE: The inspector examined a sample of four residents’ files. These detail a range of individualised health and social needs with guidelines on necessary interventions for each user. The home’s approach is to try and identify triggers and take preventative action if possible and use the least intrusive method of control if this is required. There is a detailed care plan, individual learning plan and life plan for each resident, together with individual risk assessments, a health check and a medication profile. Care plans provide information relating to residents’ support needs and short-term goals throughout the year. These are being signed and dated. However, of four care plans examined by the inspector, three had not been reviewed for 12 months, the other being at six-monthly intervals. Standard 6.10 stipulates that all care plans must be reviewed at least six-monthly and updated to reflect any changing needs or agreed changes. The manager advised that between formal reviews, care plans are being monitored on a month-by-month basis by each resident’s key worker. There was not, however, anything on file to evidence that this was taking place. The inspector is, therefore, making it a requirement for all care plans to be formally reviewed at least six-monthly, and for any ongoing review to be recorded on the care plan (or appendix) to indicate the date of review, the name and status of the person undertaking this, and noting what (if any) changes have been agreed with the service user. The inspector sampled four residents’ files and evidenced that annual reviews are being held. Those invited include the resident, his/her key worker, care manager, and nearest relative(s), friend or advocate, and any professionals who are involved. Residents are assisted to make choices and decisions in regard to their daily lives, including those relating to their health, personal care and support, and those relating to their daily living, learning and development, interests and activities. Each resident has a key worker who provides individualised support, assists day-to-day decision-making, and provides support at reviews. Independent advocates are used, whenever possible, in drawing up and reviewing the individual care plan. Residents are assisted to make decisions about admission to the home and the activities which interest them. Each resident has a key worker who provides individualised support, assists day-to-day decision-making, and provides support at reviews. Independent advocates are used, whenever possible, in drawing up and reviewing the individual care plan. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 16 There are regular weekly residents’ meetings in which residents are consulted regarding their daily lives including their preferred activities and choice of food. The inspector examined the minutes of recent meetings, and found these to be well maintained. A copy of the minutes is being kept in each house. Residents are also involved in staff recruitment. Short listed candidates are invited to the home prior to the final offer of appointment and the views and reactions of residents are taken into account. Feedback and observation indicates that residents are involved in making choices and decisions for themselves regarding their day to day routines and activities, and that their views and feelings are being respected. Residents are being consulted regarding their support and care needs, their interests and activities, their likes and dislikes, preferred choice of food, and wishes regarding holidays away with relatives, friends or staff. Service user questionnaires, written in an appropriate format, cover all aspects of day to day living and activities, and provide a means for ascertaining individuals’ wishes and choices. Residents are actively enabled to exercise choice through the use of choice photos and symbol boards, and the use of makaton. These are tailored to individuals’ specific communication needs. Staff are trained to use a communication learning package called TEACCH. This includes the use of symbols, pictures, photos, objects, makaton, written and verbal communication. The finance officer of Croydon NAS (National Autistic Society) acts as appointee for some residents, while others are represented by their families. Financial records are appropriately maintained. Residents are actively encouraged to manage small amounts of money where possible. Where support is needed, the reason for, and manner, of support is documented in care plans and regularly reviewed. All the home’s residents have Bank accounts. The home has a policy of encouraging positive risk taking. Each activity undertaken is risk assessed. The inspector examined a sample of residents’ files. These included a range of risk assessments covering a range of identifiable risks, together with risk management strategies. These indicate that residents’ potential for developing independence is encouraged and enabled wherever possible, subject to safe strategies for managing risks being in place. Files contain personal details relating to risk and photos. Residents are supported to use local shops independently and to undertake small monetary transactions. There is training with view to enabling individuals to access public transport and travel independently. All residents are given ID cards to carry with them when going to places they are not familiar with. Staff have mobile phones when supporting residents in the community. A Missing Persons Policy is in place. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 17 The home has a confidentiality policy in respect of personal information held in relation to service users. The policy states that residents have the right to access personal information held about them by the home. The NAS is a registered organization under the Data Protection Act. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 18 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): St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 19 11 to 17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are being enabled to participate fully in decisions that affect their day-to-day lives, and are being enabled to exercise choice and control in their daily routines and activities. Residents are being encouraged to develop their interests and abilities, and are being provided with opportunities for participating in a wide and varied range of activities. Residents are being encouraged to maintain contact with their family and friends, and to maintain links with the local community. Residents’ rights and responsibilities are being fully respected and recognised in their day-to-day lives. Residents are being offered a varied and healthy diet, in pleasant and homely surroundings, and are being enabled to make an informed choice regarding their food preferences. Mealtimes are flexible and take account of residents’ activity schedules. EVIDENCE: St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 20 The evidence provided in key information documents, such as the statement of purpose and the service user guide, emphasises the need to promote independence and develop individual abilities and potential. Respect for the rights of residents is characterised in both the philosophy of the home, and in the wealth of detail, contained in care plans and activity programmes, that relates to residents’ day to day living, routines and activities. This is a home with an excellent track record in providing a wide and varied range of activities. Residents are fully consulted regarding their interests and choice of learning and activities. Residents’ activity programmes are reviewed at six-monthly intervals. This involves full consultation with each individual regarding his/her choice of activities and learning, and whether there are any changes that he/she would like to see introduced. Staff maintain records relating to the daily routines and progress of residents. These are well maintained and evidence an ongoing record of each service user’s attendance, activities and development. The NAS provides a range of day care activity, which is now spread across three separate sites. These centres provide a day care resource for both residents at St Edwards and for adults with autism who live within the community. The Coney Hall Day Centre (in West Wickham) provides day care for adults who have more severe communication or behavioural difficulties A recently opened day centre, Mansfield House, in Croydon (opened in 2007) provides day care for those adults whose difficulties range from being moderate to severe, while the Transitions Day Centre in Croydon provides a specialist day care resource for those adults who have aspergers syndrome. The NAS provides its own minibuses for transporting residents to and from the day centres. The day centres provide each individual with a structured programme of activities, which is tailored according to his/her needs. Activities include art, woodwork, drama, computer use, writing skills, and communication sessions. A sensory room is also available at Coney Hall. The inspector has previously visited the Coney Hall and Transitions day centres and has been impressed with the knowledge, skills and commitment evidenced by the staff present, and with the positive interactions observed between staff and service users. Lunch, snacks and drinks are provided at each centre, pictorial symbols being used to denote the choices on offer. Residents are assisted to develop their daily living skills through participation in daily routines at the home. Close working relationships with the day service staff enables individuals to benefit from continuity of care and behavioural management. There are Behavioural Management guidelines for individual residents, with staff having access to specialist advice from psychiatrists and psychologists. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 21 The philosophy of the home is a positive one, encouraging and assisting residents to realise their full potential and to participate as fully as possible in the wider community. Residents’ care plans and activity programmes confirm that individuals are being offered varied choices regarding their interests and activities. There is a wide and varied range of community-based activities offered at the home. Physical activities include rock climbing, canoeing, cycling, horse riding, swimming, ten-pin bowling, badminton, basketball and other ball games, and swimming. Other activities include snoozelan, pottery, drumming, and handcrafts. One resident goes water skiing once a week at a water sports centre, while four others attend trampolining sessions at a local sports centre. There is a regular weekly swimming session at a local swimming baths, attended by four residents, and a weekly visit to the gym by two others. All residents have a yearly holiday, which can be taken with relatives or individually/small groups, with key workers escorting them. The cost of this holiday is included in the basic contract price. The inspector spoke with a support worker who informed the inspector that she would be escorting two residents on two separate week-long holidays to the West Country and the Norfolk Broads. Residents are able to attend Further Education classes at Sandown F.E College where subjects offered include English, mathematics, cookery, assertiveness and crafts. Some residents have been able to train for accredited qualifications while others have been able to gain work experience through taking part in employment projects. The home supports residents in maintaining close links with family and friends, both by telephone and through visits. Many residents have extensive contact with relatives and visit them at weekends. Telephone contact is maintained with some relatives who live abroad. A Visitor’s Policy is in place, with relatives and friends being able to visit at any reasonable time. From comments previously received by relatives, the home provides a very homely and welcoming environment. The home encourages the close involvement of relatives and friends with the home’s operation and activities. As part of this involvement, a Partnership Day, to which relatives and friends are invited, is held every three months, where relevant issues are discussed and a buffet provided. Family barbecues are also held from time to time in the summer months and a party organised at Christmas. Residents are also assisted to develop daily living skills through guidance/support with participating in daily routines within the home, and are encouraged to access shopping, leisure and educational facilities in the local community, within a risk management framework. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 22 Each of the two houses has a pleasant dining area where residents can take their meals. Meals are provided at the day centre at lunchtime and at the home at breakfast and in the evening. Mealtimes are relaxed and flexible to suit individual work and activity schedules. The inspector looked at the kitchen areas and found there to be good standards of cleanliness and hygiene. Fresh foods are being stored appropriately, and records relating to fridge/freezer and oven temperatures are being routinely maintained. Residents are encouraged to assist with food preparation, as they wish, and according to their capabilities. This includes preparing snacks and drinks between meals. The NAS has a corporate food policy which states a commitment to healthy eating. A rotating menu, developed by the University of Sunderland, aims to ensure a nutritious and well balanced diet. The menu for the week includes pictures of the meal options for which residents take it in turn to make a choice for the main option each day. A random sample of menus indicates that a wide variety of different food options are available in the home. Where the published menu option is not desired on the day alternatives are provided as residents wish, and a detailed record is kept of the food actually provided. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 23 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 to 21 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The personal support, physical and emotional health care needs of residents are being well met in this home, with support being planned and tailored according to the individual needs presented. Residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. Issues relating to bereavement and loss are being handled with respect, and in accordance with individuals’ wishes. Training in this area is planned to take place. EVIDENCE: St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 24 As detailed in residents’ assessments, risk assessments and care plans, there are a varied range of personal support needs that are being presented. The support offered is provided according to individuals’ needs, wishes and goals. From his observations, and the feedback provided in residents’ reviews and surveys, the inspector finds that there is a positive and enabling ethos in the home, and that residents’ personal care and support needs are generally being well met. The inspector spoke to three staff on duty and observed staff interaction with residents. Staff on duty presented as being calm, caring and professional in their approach, demonstrating skill, insight and understanding in their response to individually expressed needs and behaviours. Guidelines are in place to assist staff, in their interaction with residents, with objects of reference for those who require help with knowing which activity is about to take place. The healthcare needs of residents are evidenced as being well monitored and met. The physical, behavioural and psychological health of residents is routinely monitored, with detailed health records being maintained. Residents receive regular annual health checks from a GP. Any potential complications or health problems are identified and referred to the appropriate health care professional. Residents are registered with one of two GP practices. All medical/health appointments or visits are recorded in the resident’s file. Records indicate that GP’s and other community based medical/health care professionals are contacted as and when appointments are required. These include a community dentist, optician, audiologist, chiropodist, and specialist community nurses. The services of an aromatherapist and reflexologist are also available. The home is able to seek advice and consultation from the service’s own assistant psychologist, who assists with developing guidelines and programmes to support individual behaviours, and offers one to one support sessions. A clinical psychologist provides external professional support. Weekly weight charts are being maintained for all residents. For one resident who has had problems with weight gain, the advice of a dietician has been sought, and a dietary programme put in place. Allergy testing and nutritional specialist advice are available as and when these are required. The home has appropriate medication policies and procedures in place. This covers the administration of medication and medical treatment, risk assessment and the protection of residents. The home has appropriate secure storage for medication and for the separate secure storage of any controlled drugs. The inspector was advised that there are no residents using any controlled drugs. The Homely Remedies Policy requires that GPs state in writing which home remedies each resident can have administered. These are reviewed on a St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 25 regular basis, with a record of any administration of homely remedies being maintained on residents’ medication charts. All residents have annual medication reviews with their GP and six-monthly reviews, where necessary, with a psychiatrist. The inspector was informed that the home’s new manager, Andrew Lewis, is currently training to become an accredited medication trainer. This will enable him to roll out training to staff. An internal accredited medication training pack has been developed by the service.. Both Boots and Opus pharmacies presently provide accredited medication training to staff on a rolling basis. At the time of the inspection all but two new staff had completed this. The home has had an up-to-date pharmacy inspection within the last six months. All residents have a medication profile and a photograph in their medication file. There is an individual medication risk assessment for each resident. While a resident can, in theory, be supported to take their own medication, none of the residents at St Edwards has been risk assessed as being safely able to do so. The wishes of residents and their relatives concerning the eventuality of their death are recorded and placed on their files. A questionnaire is sent out to relatives to request clarification of their wishes in the event of their own death or, subject to the individual’s agreement, their wishes in the event of his/her death. The need for staff to undertake training in the area of bereavement and loss has not, as yet, taken place. The inspector was advised, however, that a training package has been developed, which provides comprehensive information and training materials on bereavement and loss. The inspector was advised that training sessions, using this package, are being planned St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 26 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, and their relatives/representatives, can be assured that the home has an appropriate policy and procedure in place for raising any concerns or complaints. This provides clear information and is available in an appropriate format for adults who have communication difficulties. The home’s policies, procedures and practice indicate that residents are generally being well protected from abuse and are living in a safe, secure and trusting environment. However, four recently recruited staff have not, as yet, completed statutory adult protection training; this presents a potential risk and must be prioritised. EVIDENCE: The home has a complaints procedure that has been given to all the homes residents and care staff. The complaints procedure is made available in the language/format appropriate to the communication needs of each resident. Information about the complaints procedure is also included in the statement of purpose. A simplified copy of the complaints procedure is on display in both homes, using large print and makaton symbols for the benefit of residents. The home maintains a complaints record, no complaints having been recorded since the last inspection. The record of complaints is appropriately maintained, St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 27 and includes details of any investigation, its outcome, and action taken. All complaints are responded to within twenty-eight days after the date on which the complaint was made. A concerns and compliments log is kept in the reception area, so as to provide a channel for both criticism/concern and positive feedback from relatives and other visitors. Staff are trained to understand their role in promoting, respecting and safeguarding the rights of residents. This is achieved through NVQ training and training in equality and diversity, the rights of residents and POVA. The rights of residents are further protected through the use of independent advocates. Access to an advocate is facilitated for any resident who has an unresolved grievance or concern. The home has an adult protection policy and procedure, which is in line with Croydon’s multi-agency vulnerable adult procedures. The home also has an appropriate whistle blowing procedure. Physical and verbal aggression by a service user is understood and dealt with appropriately, in accordance with the homes physical intervention policy. All staff have undertaken restraint and breakaway techniques training in accordance with Department of Health guidelines. The home has a rolling programme to ensure that all staff undertakes statutory adult protection training. There are, however, four recently recruited staff who have yet to complete this training. The inspector understands that training has been booked for these staff on 14/8/07. A requirement applies. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 28 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 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Residents have rooms that are suited to their individual needs. They present as being safe, comfortable and pleasantly decorated, and reflect residents’ individual identities. Residents are living in a home that presents as being clean, pleasant and hygienic. Training in infection control is being rolled out to all staff. EVIDENCE: St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 29 St. Edwards was purpose built for people with learning disabilities. The home is well laid out and meets the needs of the service users. The garden is well laid out and maintained. There is a ramp to the front door but no lift. In style it blends in well with the local community. The premises were inspected and found to be homely, comfortable and safe. Fittings, adaptations and equipment are of good quality, and domestic in scale. The home is divided into two separate houses, each of which has six residents, with six single rooms in each house. Each house has a lounge, dining room, and a quiet room. The home is decorated to a reasonably high standard throughout and presents as being pleasant and comfortable. There is consultation with residents regarding any redecoration or refurbishing of rooms that takes place, and a planned programme of maintenance for the redecoration of the home. There are four toilets and two bathrooms in each house. One of the toilets is on the ground floor where there is also a shower. All afford privacy to users. There are plans to renew one of the bathrooms. The two houses share a pleasant, reasonable sized garden area with covered seating. Each house has a separate lounge and domestic style kitchen and dining room. These are homely, with comfortable furniture and pictures. There is a small room in each house, which can be used as a quiet room. The medication is also stored here as is the white board with information about shift plans. There has been some refurnishing of both houses with both communal lounges having new furniture. The internal doors for one house (The Willows) have been replaced with more homely looking white doors. There are plans to replace the doors in the other house (The Conifers). The entrance hall and office have been recently refurbished and the garden fences have been upgraded. Both houses have been redecorated within the last two years. Residents are encouraged to participate in choosing colour schemes and furniture, by looking through catalogues and visiting stores. Since the last inspection three bedrooms have been redecorated and re-carpeted, and there are plans to redecorate more bedrooms. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 30 Residents’ rooms have individualised symbols on the door, indicating whose room it is. These present as being pleasantly arranged and decorated, reflecting individuals’ personalities and tastes. Each bedroom is decorated in low arousal colours, with safe and secure furniture. Furnishings and fittings are adapted to meet the needs of individual residents. While these are suited to the needs of the present residents, they would not be suitable for anyone who uses a wheelchair. All rooms have washbasins. Some of these are not in use as residents are not able to use these appropriately. This is indicated in the individuals’ care plans as not being appropriate. Generally, the home presents as being a safe environment, and has the necessary aids and adaptations in place with which to safely meet the needs of the present residents. The environment has been adapted to meet the needs of the residents and to reduce any risk of harm. Since the last inspection (on 10/4/07) the home has been assessed by an occupational therapist and has received a generally good report. Some recommendations were made which are in the process of being implemented. The home presents as being clean and hygienic in most areas. The houses have separate laundry areas, which are domestic in scale. The laundry facilities are suitably positioned to ensure that any soiled articles/foul laundry is never carried through areas where food is stored, prepared or eaten. The homes washing machine is capable of thoroughly cleaning foul laundry at appropriate temperatures (minimum of 65 Degrees Celsius). The inspector was advised that due to problems with breakdowns of equipment, the home is to change contractors and that new washing machines and driers are due to be installed. The homes policies/procedures manual contains various policies for the prevention and control of infection including dealing with spillages, HIV and Hepatitis B. A requirement for staff to attend accredited infection control training has been partly met, 16 out of 23 staff having completed this. The inspector understands that due to the cancellation of a training session it was not possible to complete all the training on time. An extension to the time-scale, for meeting this requirement, has therefore been agreed. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 31 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): 31 to 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are having their needs well met by staff, in sufficient numbers, who are appropriately trained and qualified, and who have clearly defined roles and responsibilities. Residents are being protected by the home’s recruitment policy and procedures. While, generally, residents’ best interests are being protected through the service’s training and support of staff, this is being offset by the home’s continuing failure to ensure regular staff supervision. EVIDENCE: The evidence from this inspection indicates that staff are appropriately trained and qualified, and have clearly defined roles and responsibilities. There are clearly defined job descriptions, and a key worker system is in place. Each key worker has a clear responsibility for developing a one-to-one relationship with St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 32 an allocated resident, providing both a supportive and enabling role. Key workers escort residents to a wide range of community-based activities, and accompany them to their day care service, where they work alongside specialist day care staff. This is seen as encouraging a consistent approach to the support and care of each individual. Staff are evidenced to be sufficiently skilled and qualified, and available in sufficient numbers, for meeting the high level of needs presented by this vulnerable client group. There is a high staff ratio of 2:1, with several residents receiving 1:1 support at key times during the day. There is a senior support worker on site, and a senior on call, at all times. The staff rota is organised on a 3-week rolling rota and confirms that there are 3 staff on duty in each house at all times during the day, with 1 waking night staff for each house at night. There is also a sleep in member of staff who is shared between the two houses. Staff photo boards are used to enable residents to know which staff are working at any given time. The home’s manager is on-call during weekdays from Monday to Friday, and covers alternate weekends in tandem with the deputy manager. There is also an on-call Out of Hours Service provided within the organisation for providing cover for any emergencies that may arise. Residents are able to meet potential new staff when they visit the home following their interview. There is also a questionnaire for residents to complete in order to register their satisfaction levels with any new staff. All new staff undertake a six-week induction programme, which is followed by six-months of foundation training, when they commence employment. Staff receive an induction pack which includes a copy of key policies and procedures. The induction programme starts with two weeks of training, which includes ‘autism awareness’ and introduces staff to the aims and objectives of the service, policy and procedures. This includes observation at the home and at the three day services. Weeks 3 to 5 are spent observing practice and procedures while week 6 is spent shadowing an experienced staff member. The home offers a 3-day induction programme for bank staff and specialist autism training is provided for all staff who work at the home. The six months of foundation training includes training in basic autism and aspergers syndrome, and covers the use of techniques for communicating and working with autistic adults. There is also basic training in Health and Safety, First Aid and Food Hygiene, with opportunities being provided for visiting other services within the NAS. There is evidence of a strong commitment by the service towards meeting the training and development needs of staff. Staff possess relevant qualifications and experience and are actively encouraged to develop their skills and abilities, and to work towards obtaining their NVQ Level 2, 3 and 4 qualifications. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 33 The NAS organises an extensive and ongoing programme of generic and specialised training. Staff at the home are able to access in-house training, both locally and at the NAS national training centre, and also attend relevant external training courses. The region has developed an autism specific rolling training plan for all staff. All staff attend training on autism awareness, and on how to manage challenging behaviour. There is a commitment to using a person-centred approach in drawing up residents’ care plans and life plans, and in fully consulting and involving residents in all areas of their daily lives and activities. The manager, Andrew Lewis, advised the inspector that a senior support worker has attended a PCP Facilitator course and that the home is aiming to extend its person-centred approach to drawing up care plans, with a training day in person-centred planning being arranged for all staff. Staff records provide documentary evidence of qualifications obtained by staff. This includes statutory training in adult protection, basic food hygiene, first aid, health and safety, fire safety, medication, equality, diversity and rights, person centred planning and epilepsy training. The service has an appropriate recruitment policy and procedures in place. These are based upon equal opportunity principles, and with the safety and well being of service users in mind. Four new staff members have been recruited since the last inspection on 4.7.06. The staff files were checked; this evidenced that up-to-date CRB checks had been completed for these staff, together with all the other necessary recruitment and identity checks. Generally, staff are well supported through close day-to-day support, training and development. The inspector was, however, concerned to find that a requirement relating to the need for regular staff supervision has not yet been met. According to Standard 36.4 each staff member should be receiving formal, recorded supervision at least six times a year. This is approximately once every two months. Feedback from the manager, and inspection of a sample of staff files, indicated that supervision has not been taking place on a sufficiently regular basis. The recently appointed manager, Andrew Lewis, advised the inspector that a new structure for supervising staff is being put in place, and assured him that regular supervision will from now on be provided for all staff. This will mean that supervision is divided between the manager, deputy manager and four senior support workers. The inspector will be looking for evidence of significant improvement in this area, and for this requirement to be met within the extended time-scale. The inspector also recommends that all senior staff who undertake supervision should receive accredited supervision and appraisal training. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 34 Annual appraisals are undertaken to review staff performance against job descriptions and to agree career development plans. The area manager informed the inspector that all staff have completed an appraisal in the period April to May 2007. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 35 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): St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 36 37 to 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is being well managed and run in their best interests, and which provides an open, positive and inclusive atmosphere. The home is able to demonstrate that it is obtaining widespread feedback regarding the extent to which the home is supporting residents and meeting its aims and objectives. Generally, the rights and best interests of residents are being safeguarded by the home’s record keeping policies and procedures. However, up-to-date hard copies need to be kept on file together with a checklist. Generally, the health, safety and welfare of residents are being appropriately protected. However, some concerns were identified. These relate to the need for up-to-date gas and electricity certification, and for an incidents and accidents logbook to be maintained. EVIDENCE: The home appointed a new manager, Andrew Lewis, in January 2007. He has had 14 years experience of working with people with learning disabilities. This includes 7 years experience in his previous post as an assistant manager at a social services day centre for adults with learning disabilities. Mr Lewis referred to a further 2 years experience of working with people who have mental health problems. Mr Lewis’s appointment followed a period of some 9 months when the home was without a named manager, following the departure of his predecessor. The area manager has been covering this role during this period. This is a home with a very good track record, and there is a loyal and committed staff group who work to very clear guidelines and values. Since being in post Andrew Lewis has been settling into his role and has been looking afresh at the day-today management of the home. From his discussion with the manager and the area manager, and the feedback received by staff and residents, the inspector feels that Mr Lewis is able to demonstrate a sound knowledge and understanding of the difficulties and challenges that are presented in working with this client group. The inspector noticed a good atmosphere in the home and St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 37 observed good communication by the manager with both staff and residents. Those residents with whom the inspector was able to engage indicated that they were very satisfied with the home and with the support provided. The manager consults regularly with staff, holding regular weekly house meetings with senior staff, and individuals house meetings for all staff once a fortnight. A staff training day is being planned. Mr Lewis confirmed that he is in the process of undergoing the necessary checks for registering with the CSCI to become the home’s registered manager. This process needs to be completed, for which a requirement applies. The Deputy Manager, who has been in post for just over a year, has been studying for his NVQ Level 4 management qualification and is due to complete his studies. He has had many years experience of working at the home as a senior care worker and presents as being very knowledgeable and professional in his approach. The home has a robust and innovative approach to Quality Assurance using an accepted tool ‘Accreditation for People with Autism.’ This includes an evaluation over a period of 2-3 days carried out by a panel of 4-5 people, which includes a layperson. There is also a Service Support Committee, which consists of the landlord, Housing Association, relatives, staff and a community representative. This committee carries out unannounced visits at the home, reports of which are produced. There is active involvement by some parents and relatives in the support of St Edwards, and their views regarding the home are sought and taken into account. Feedback from relatives has been generally very positive, with the home being well regarded and valued. Questionnaires are sent out to relatives and friends twice a year and through parental involvement in organised activities and events. This includes Partnership Days, held every 3 months, to which relatives and friends are invited, and at which issues relating to the home are discussed. Since the last inspection a questionnaire has been developed for care managers, professionals and other workers so as to provide more general feedback regarding their views of the home and the services provided. The views of relatives/representatives, care managers and health care professionals are also obtained at residents’ annual statutory care reviews. There is a strong ethos in the home towards fully involving residents in decisions which affect their day-to-day lives and the running of the home. This is evidenced in the detailed individual care and learning plans, and in the feedback received from residents. The minutes of residents’ meetings indicate that their views are regularly canvassed, with discussion of such topics as St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 38 forthcoming choice of activities, the upkeep of the home, their daily routines, and food choices for the week ahead. The home has developed strategies for facilitating effective communication with residents. This includes the use of role play, newsletters and questionnaires, and the use of listening and talking cards within residents’ meetings. An annual assessment questionnaire is completed with residents, with these being produced in an appropriately comprehensible format, using widget symbols. A requirement from the previous inspection has been partly met with the compilation of a Development Plan in March 2007. The home has, however, still to complete a QA audit for summarising the feedback and findings elicited from surveys and other sources. The home’s policies and procedures are being centrally reviewed and updated on an ongoing basis via the NAS intranet. All staff have access to the homes’ policies and procedures, which are brought to their attention during the induction period, and any changes are bought to their attention. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 39 The inspector wishes to see an up-to-date hard copy of all policies and procedures being included in the Policies and Procedures manual for the reference of staff and for inspection purposes. There should be a checklist at the front of the manual to indicate the date when each policy was last reviewed, and the status of the person completing the review. The health and safety of residents is generally being well protected in this home. All but two health and safety checks were evidenced to have been completed and to be up to date. However, there has not been a gas inspection within the last 12 months (12/4/06) and the inspection for electrical installation (3-year) is overdue for renewal (15/6/04). These need to be arranged without any further delay and a copy of the inspection certificates forwarded to the CSCI. A requirement applies. The home has in place a rolling programme of training, which includes manual handling, food hygiene, first aid and medication. Infection control training is being rolled out to all staff. Hazardous substances are being appropriately stored in a locked COSHH cupboard. Following an accident or incident, a record sheet is completed. While available for inspection, these are individual records and do not provide an easily accessible checklist. The inspector identified the need for an incidents and accidents log to be maintained on site to provide brief details of all incidents and accidents that occur. This is an essential tool for monitoring safety in the home and for identifying any patterns relating to the health and safety of individual residents. A requirement applies. The home has had a recent fire inspection, on 4/6/07, and has held fire awareness training for staff, in March 2007. Fire drills are now taking place on a regular monthly basis, most recently on 20/6/07.A Fire Risk assessment was last completed in July 2006 and all recommendations implemented. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 40 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 4 3 4 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 3 27 3 28 4 29 4 30 3 STAFFING Standard No Score 31 4 32 4 33 4 34 3 35 4 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 3 3 4 3 3 3 X St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 41 Are there any outstanding requirements from the last inspection? Yes 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(2)(b)(c)&(d) 17(3)(a)&(b) Requirement Service users’ care plans To ensure that residents’ care and support needs are being appropriately met, all service users’ care plans must be formally reviewed at least sixmonthly (Standard 6.10). Any additional ongoing reviews must be recorded on the care plan. These entries should indicate the date of review, the name and status of the person undertaking this, and a record of any changes that have been agreed with the service user. If there are no changes, this should be recorded. 2 YA23 13(6) Protection of vulnerable adults. 30/09/07 Timescale for action 30/09/07 St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 42 All new staff must complete statutory adult protection training. Without this training service users are potentially at risk. At the time of inspection four recently recruited staff had not completed this training. The manager advised that training has been booked to take place on 14/8/07. 3 YA30 13(4)(a)&(c),18(1)(c) Maintaining hygiene. All staff must receive accredited infection control training. Partly met. 7 out of 23 staff have still to complete this. 4 YA36 18(2) Staff supervision. All staff must receive regular supervision at least once every 2 months. Without regular supervision, service users are potentially at risk. Not met from previous inspection. Time-scale extended. 5 YA37 8(1)&(2) Management of the home. The manager must complete his registration with the CSCI to become the St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 43 30/09/07 30/09/07 30/09/07 home’s registered manager. 6 YA39 24(1)&(2) Quality assurance The home must produce a quality assurance audit report so as to evidence the feedback received from surveys and other sources. 7 YA42 12(1)(a), 13(4) Health and Safety To assist in monitoring the safety of residents, brief details of all incidents and accidents should be logged in a logbook. This should provide a record of all incidents and accidents that have occurred. 8 YA42 12(1)(a), 13(4) Health and Safety A gas inspection (12 monthly) and inspection for electrical installation (3-yearly) are both overdue and must be arranged without any further delay. A copy of the inspection certificates must be forwarded to the CSCI. 30/09/07 30/09/07 31/12/07 St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 44 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA21 YA36 YA40 Good Practice Recommendations The inspector recommends that staff undertake training in the area of bereavement and loss. All senior care staff who undertake supervision should attend accredited supervision and appraisal training. The inspector recommends that a Policies and Procedures checklist is included at the front of the manual, to include the date when each of these was last reviewed and the signature/position of the person undertaking the review. All policies and procedures must be reviewed at least 12 monthly. St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 45 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 St Edwards (6) DS0000025839.V345268.R01.S.doc Version 5.2 Page 46 - 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. 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