Inspection on 30/04/07 for Staverton

This inspection was carried out on 30th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Staverton 06/02/06

Staverton 09/08/05

Staverton 16/02/05

Staverton 17/12/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Staverton 25 Murdoch Road Wokingham Berkshire RG40 2DQ Lead Inspector Mike Murphy Unannounced Inspection 30 April 2007 10:00 DS0000011359.V331574.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 DS0000011359.V331574.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. DS0000011359.V331574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Staverton Address 25 Murdoch Road Wokingham Berkshire RG40 2DQ 0118 977 1157 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) Anthony Toby Homes Trust Mrs Jennifer Basten Care Home 14 Category(ies) of Learning disability (14) registration, with number of places DS0000011359.V331574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: Staverton is a large detached house set within a residential area, and within walking distance to Wokingham town centre. The home is registered to provide care and accommodation for up to 14 people aged 18 to 65 who have a learning disability. The home provides communal facilities on the ground floor to a high standard, and has 14 single bedrooms over three floors. All bedrooms have a wash hand basin, and communal bathrooms are on each floor. There is an open plan garden and drive to the front of the house with parking spaces for several vehicles, and there is an attractive enclosed rear garden that has a patio and seating. Public transport is available and the recreational facilities in the larger towns of Bracknell and Reading are within a short drive. DS0000011359.V331574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector over the course of a weekday in April 2007. The inspection methodology included discussions with residents, managers and staff, examination of records, observation of practice, a tour of the home and garden, examination of care plans, consideration of feedback communicated through questionnaires from residents, families, and health and social care professionals, and reading of the organisation’s in-house magazine and the website of the Anthony Toby Homes Trust, the registered provider of the service. The inspection finds that this home provides a good service to residents and families. The home is a pleasant, spacious and comfortably furnished building located in a quiet residential area within walking distance of Wokingham town centre. The home provides a supportive environment for people with a learning disability. Processes for assessing the needs of prospective residents and of deciding whether the home can meet those needs are thorough. Each person receiving support has a key worker. Care and support is summarised in person centred plans. Entries in plans are in written, symbol and picture form – the mix varying according to the needs and preferences of individual residents. Residents participate in a wide range of activities. At the time of this inspection there were concerns about proposals to reduce the range of day services in the area. The home was exploring means of developing alternative services subject to sufficient funds being available. In the meantime, residents attended college, worked on a farm, gained paid work experience and participated in a range of leisure activities. Residents have two holidays a year and day trips out to places of interest. Staff turnover is low and staff. An audit of staff skills was carried out by a training and assessment agency and the results will inform the home’s training programme for the next couple of years. The home is performing well in supporting staff on NVQ training and is seeking to fill any gaps in training identified in the audit. Four residents have places on the Home’s Committee along with representatives of staff, managers and relatives. The aims of the Trust include ‘….providing opportunities and variety of experience’, ‘…create a stimulating environment within a comfortable and secure home’, ‘to encourage independence..’ and ‘to promote a valued social image within the community..’. On the basis of this inspection it is performing well in relation to these aims. DS0000011359.V331574.R01.S.doc Version 5.2 Page 6 What the service does well: 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. DS0000011359.V331574.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 DS0000011359.V331574.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): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The statement of purpose and the admissions process aim to ensure that prospective residents can satisfy themselves that the home can meet their needs and that they would be happy to live there. The needs of prospective residents are thoroughly assessed before admission to ensure that the home can meet the person’s needs. EVIDENCE: The Trust has an informative website (www.tobyhomes.org.uk) which provides a brief history of the development of the Trust from its foundation in 1975, details of what is provided in its two homes, and very useful links to other websites concerned with learning disabilities. The home has an informative, well written and well presented statement of purpose. This includes information on the foundation of the Anthony Toby Homes Trust, the home (Staverton), the aims of the service, equal opportunities, the organisational structure of the trust, daytime activities, leisure activities, the admissions process, liaison with friends and family, personal care, consultation with residents, health & safety, health & welfare, DS0000011359.V331574.R01.S.doc Version 5.2 Page 9 complaints procedure, care planning and a statement on the homes aims to enable people supported by the Trust to play an active part in the community. A typical referral to the home would involve the family of the prospective resident becoming aware of the service and talking to the care manager. The enquiry would initiate contact with the home and an assessment of the prospective resident’s needs by the care manager. The person and their family would visit the home, view its facilities and have tea with staff and residents. Where the enquiry progresses the home would also begin acquiring information on the person’s needs. The aim would be to acquire sufficient information to come to a judgement on whether it could meet those needs. Where this is likely to be the case then an extended visit and overnight stay is arranged. A review meeting is then held and a decision on admission made. Where admission is agreed a review meeting is held after about two months. The home has had one admission since the last inspection. The records were examined and confirmed that the home conducts a thorough assessment of needs and takes account of assessment information provided by the NHS and Social Services. The records included correspondence with relevant agencies, numerous risk assessments, notes of review meetings and evidence of the service user in the process. As indicated above a review meetings was held two months after admission. The home maintained good liaison with the care manager throughout. DS0000011359.V331574.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive care plan is in place for each resident. Care plans include risk assessment and evidence of liaison with relevant agencies in the community. People living in the home are involved in drawing up their care plan. Together, these aim to ensure that the needs of people receiving support are met, that independence is supported, and that they can influence life in the home. EVIDENCE: Each resident has a key worker. A ‘service user’ plan is in place for each resident. Service user plans are linked to care management plans and take account of the community care plan for each resident. Four care plans were examined. Care plans are based on a ‘Person Centred’ approach and have some excellent features. These include photographs of people and events which are important to the person. Care Plans do read as if they’ve been drawn up with the resident’s participation. Care plans include, a DS0000011359.V331574.R01.S.doc Version 5.2 Page 11 copy of the licence agreement in written and symbol forms, a statement of rights, and pictures and symbols scanned in to the ‘planning book’ – including many of life in the home. A summary of the activities in which the person participates or has an interest was noted in each care plan examined. Food preferences are noted. Any particular matters relating to communication are recorded. The care plans had numerous risk assessments. Assessed health needs (including medication) are recorded. Each care plan had a diary for the week outlining the activities planned with the person. Correspondence with other agencies was noted, indicating good liaison with health and social care agencies in the community. All care plans are reviewed annually or more often if required. Care plans reflected the participation of the person in their formulation and support by staff in making decisions about their lives. Residents are encouraged and supported in making decisions in day to day life in the home. Meetings of the ‘Home Committee’ include four resident representatives. The home’s approach to risk assessment appears thorough. Risk is carefully assessed during the course of referral. Risk assessment is a routine part of care planning and review. In the care plans examined on this inspection risk assessments covered (among others); using escalators, preparing packed lunches, using domestic cleaning products, crossing the road, handling money, using electrical equipment, checking the temperature of hot water, using the shower (danger of seizure), and going in to town. DS0000011359.V331574.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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. People living in the home lead a varied lifestyle according to their individual interests, abilities and wishes. This ensures that people experience a range of social, leisure and other activities, are involved with the wider community, and have a good quality of life. EVIDENCE: People supported by the home currently attend a variety of activities in the local community. However, it was reported that the range of activities in the area is contracting and that the home is exploring ways of developing alternative activities to compensate for this. The aims are to develop activities off-site, to be available to both homes in the Trust. Discussions were taking place with relevant bodies but no firm plans had emerged yet. Any developments will depend upon sufficient funding being available. It was reported that there is some anxiety about the changes taking place and DS0000011359.V331574.R01.S.doc Version 5.2 Page 13 perhaps, a fear that services will close before alternative arrangements are in place. Some residents work at a farm near Basingstoke – growing vegetables and learning horticultural skills. Others attend college and learn cooking, computer skills and drama. One resident was gaining part-time work experience in a kitchen, another in a laundry in Wokingham. The residents concerned get paid for their work. All residents have two holidays a year. The cost of one holiday is included in the cost of their stay; the second is paid for by the resident. A small group of four or so residents and two staff go on holiday together. In 2006 residents had holidays in Suffolk, Bognor Regis, Scotland, Weymouth and Bournemouth. Plans for 2007 to date include Bognor Regis, Weymouth, Devon, and Cornwall. The home produces a periodic newsletter – ‘The Staverton Times’. The issue for February 2007 was made available for this inspection. The newsletter is a bright, well presented and informative publication containing numerous photographs of residents and staff and others involved in a variety of activities, Christmas parties, horse riding, holidays and Halloween celebrations. It had quizzes, comments by residents, information, and letters from families. The publication acts as a useful record of life in the home All residents maintain some contact with their family – the amount of contact varies. Residents maintain contact with friends, and friends may visit the home as often as the resident desires. The Trust has a policy on personal relationships. The daily routine varies according to individual wishes and needs. In general it was said that residents are up quite early and have an early breakfast. Most residents have a ‘key worker day’ once a week. Most people go out to various activities between 8:30 am and 4:00 pm – this was noted on the day of this inspection visit. On return, people normally have a cup of tea and some time alone if they wish. The evening meal is taken around 6:00 pm and supper around 8:00 pm. On the day of this inspection visit two residents were in the home for the day (one went out with staff for an appointment with an optician), one was in Bracknell and the others in day services in the Wokingham area. Relationships between residents and staff appeared good. There were a few residents around during the day, the majority returned to the home around 3:30 and 4:00 pm. The home had a positive and lively atmosphere. The routine at weekends is different. People might have a cooked breakfast if needed. Weekends are often a time for people do tasks around the home. A roast is usually served for Sunday lunch. DS0000011359.V331574.R01.S.doc Version 5.2 Page 14 Meals are an important part of home life. Individual likes and dislikes are taken into account when menus are drawn up. The annual stakeholder and service user surveys include questions on food. Menus supplied for this inspection listed the food for a typical two week period. Breakfast is usually fruit juice, cereal, toast and hot drinks. Lunch is a sandwich followed by fruit and a sweet or savoury snack. Dinner, served in the evening on weekdays, is the main meal of the day and consists of a main course, vegetables and dessert. Menu items on offer included Turkey escallops followed by Smarties ice cream, Fish Pie followed by Yoghurt, and Shepherds pie followed by fresh fruit. Sunday lunch, on both weeks, was Roast turkey, followed on week one by Raspberry meringue and on week two by apple strudel. A record is kept of alternative meals chosen by residents not wishing the main selection for the day. DS0000011359.V331574.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide support to residents as required. Arrangements for liaising with health and social care services in the community and for the control of medicines are satisfactory. This aims to ensure that the healthcare needs of people living in the home are met. EVIDENCE: Arrangements for personal care are set out in individual care plans. There is a statement on respecting the privacy and dignity of residents in the service users guide. The home has both male and female residents and staff. All residents are registered with a GP. Other health care services are accessed either through the GP or through direct contact. All residents have an annual eye check. On the day of inspection a resident was accompanied by a member of staff on a visit to an optician. Dental services are provided by the resident’s own dentist or through an NHS dental department at a local hospital. A chiropodist visits every six weeks – there is an additional charge of £9.00 for this. Support aids are provided as required. Grab rails are installed in some areas. The bathroom floor is non-slip. The ground floor is accessible for wheelchairs (there are five bedrooms on the ground floor). DS0000011359.V331574.R01.S.doc Version 5.2 Page 16 Each resident has an annual health check carried out by their GP and practice nurse. Medical examinations in the home take place in privacy of the resident’s own bedroom. Medicines are prescribed by GPs. The prescription is retained by the pharmacist. Medicines are collected weekly by staff. Medicines are supplied in NOMAD packs which have been filled by the pharmacy. Medicines required at lunchtime are supplied in separate bottles, again filled by the pharmacy. Records are maintained of medicines received and of any returned to pharmacy. The arrangements for the storage of medicines appear satisfactory. The assistant manager has a lead responsibility for the home’s arrangements for the administration of medicines. Staff are trained on induction. Staff are observed in the administration of medicines and competence is assessed by the assistant manager. There is currently no provision for update training. While this approach is considered to have served the home well to date it might be useful to develop a more structured approach – in particular in recording the assessment of competence and perhaps in introducing update training to ensure that staff skills are maintained. The home’s arrangements are audited by a pharmacist and the report of the most recent audit was available for inspection. References for staff include a MIMS 2003 (a more recent copy should be obtained if this particular reference is considered useful), a copy of The Royal Pharmaceutical Society of Great Britain guidelines for the control and administration of medicines in care homes) and a British Medical Association text. DS0000011359.V331574.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 excellent. This judgement has been made using available evidence including a visit to this service. The home has a sound procedure for investigating complaints. It has a framework of policy, staff training and information for residents with regard to the protection of vulnerable adults (POVA). Together, these aim to protect the people living in the home from abuse and to ensure that complaints are properly investigated. EVIDENCE: The complaints procedure is included in the home’s statement of purpose. Each resident has a copy in their service user’s guide presented in symbol format. The procedure lists the process for complaining, both at home level and, if unresolved, at Trust level. The procedure states that the home will endeavour to resolve a complaint within 7 days and the Trust within 14 days. The procedure correctly states that a complaint may also be made to CSCI. The address of the CSCI office need to updated in view of the move from Theale to Oxford and there is no need to include the name of the inspector. The procedure also includes contact details for the Local Government Ombudsman who deals with complaints about local authorities and some other public bodies. The home has a record of receiving one complaint since the last inspection. CSCI have not received any complaints about this home. A number of compliments about the home were also on file but their receipt was not dated. DS0000011359.V331574.R01.S.doc Version 5.2 Page 18 The home had a copy of the local multi-agency guidelines for the protection of vulnerable people (POVA) and details of key contacts. The subject is included in the induction programme for new staff. All staff had attended POVA training provided by the local authority. A ‘sign’ version of what to do if a resident has concerns about abuse was on the notice board. Systems are in place for managing money on behalf of residents. The system is administered by a financial administrator. Individual records are maintained and there is a record book for each resident. Cash is stored in secure locked boxes. All transactions are recorded. Balances are checked before funds are withdrawn. The manager checks the system fortnightly. A sample of wallets were checked by staff during the course of this inspection and were found to be in order. DS0000011359.V331574.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good quality and well maintained home environment which provides those living there with a comfortable and safe place to live and enhances well-being. EVIDENCE: The home is a large detached house, located in a quiet residential area within walking distance of Wokingham town centre. Wokingham is accessible by train and bus. There is limited parking space (for about five cars) to the front of the house. Parking is also available in the nearby street. The ground floor accommodation is comprised of the entrance hall, dining room, kitchen, a quiet room, lounge, conservatory, staff sleep-in suite, bathroom with shower, WCs and some resident sleeping accommodation. It was noted that the windows on bedrooms on the ground floor can be opened wide. Staff report that all windows are checked and closed at night. It would be DS0000011359.V331574.R01.S.doc Version 5.2 Page 20 advisable for managers to review the security of those bedrooms and consider fitting a device which limits the extent to which the window can be opened. The first floor accommodation comprises bedrooms, bathrooms and WCs. The ground floor is accessible for someone in a wheelchair. The home does not have a lift. The home is carpeted and well furnished and overall provides a pleasant, spacious and very comfortable home for people living there. Two residents were happy for their rooms to be viewed in their presence. The bedrooms were a comfortable size and well furnished. Rooms reflected the person’s taste and interests. None of the bedrooms have en-suite facilities but all have a hand basin with hot and cold water. The residents were happy with their rooms and in living in the home. The garden to the rear of the home is a good size and very well maintained. There is a large area of lawn, flower beds, mature trees and shrubs and a good sized patio. The garden is suitable for a range of activities. Since the last inspection the exterior of the property, main hall, stairs, landing and lounge have been redecorated. On this inspection all areas of the were tidy, very clean and well maintained. DS0000011359.V331574.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, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, procedures for the recruitment of new staff and for staff training, development and support are satisfactory. These aim to ensure that there are sufficient numbers of appropriately trained and supervised staff to meet the needs of people receiving support from the service. EVIDENCE: Staff turnover is reported to be low and only one part-time staff appointment had been made since the last inspection. Staff seen on this inspection visit had a positive attitude towards the work of the home. The ‘atmosphere’ in the home was described in positive terms – “A nice place to work”, “Good for residents”, “A variety of things to do”, “Residents are amazing”, “[Good] Standards of cleanliness” and “Encouraging the independence of residents”. Staff had a clear view of the aims of the home and were strongly in support of those. The manager said that all staff had been given a copy of the GSCC codes of conduct. The home reports that 75 of staff have acquired NVQ2 or above. DS0000011359.V331574.R01.S.doc Version 5.2 Page 22 The recruitment process was outlined by the manager. All applicants are required to complete an application the form. The structure of the form enables managers to track the employment record of an applicant and to note any gaps. Applicants are short listed for interview by the manager. Candidates for interview are required to provide two references. Staff appointed do not take up post until references and preferably an enhanced CRB certificate have been received – although the results of a ‘POVA First’ check may be accepted pending receipt of the CRB certificate. It was reported that there is no fixed probationary period but that it tends to be around six months. The organisation ‘Skills2Care’ carried out an audit of staff skills in 2006. The results of this will inform the training plan for the next couple of years. The home has a comprehensive folder containing details of training events attended by staff. Training falls broadly into three categories: National Vocational Qualifications, mandatory training and updates, and discretionary or other training. Details of when mandatory training was last carried out and when next due are recorded. The home is doing well with NVQ training. Other training included autism and dementia. It would also be advisable for the home to include training on the administration of medicines (to include periodic updates). All staff have a personal supervisor. Personal supervision takes place quarterly. Meetings are booked in advance and notes are taken. All staff have an annual appraisal. Staff meetings are held every two months. DS0000011359.V331574.R01.S.doc Version 5.2 Page 23 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, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home where a positive approach to the involvement of residents is providing good care outcomes for the people it serves. Arrangements for health and safety are generally thorough and aim to ensure the safety of residents, staff and visitors. EVIDENCE: The Trust is a registered charity. The governing body of the Trust is comprised of five Trustees. The Trustees appoint the Trust Manager. The Home Manager (the registered manager) reports to the Trustees through the Trust Manager DS0000011359.V331574.R01.S.doc Version 5.2 Page 24 The registered manager has managed the home for just over one year. Prior to this the manager has had a number of years experience as an assistant manager, in working in services for people with a learning disability. The manager was on the point of completing the Registered Managers Award (RMA) at the time of this inspection. She had acquired an NVQ4 and over the past year attended update training in the protection of vulnerable adults and moving and handling. With regard to future training and professional development the manager had recently completed a skills analysis carried out by ‘Skills2Care’ , the results of which would inform her personal development plan for the next two to three years. In developing a systematic approach to quality assurance (QA) the home had acquired a CD based QA package which had been developed by a commercial organisation for the care sector. This will support periodic audit of a range of activities. Regulation 26 visits are carried out by one of the Trustees of the Trust and reports are completed. The Trust manager is responsible for the organisation of the ‘Home’s Committee’ which meets quarterly. The Committee has four service user representatives, as well as representatives of families, management, staff and the community. A service user survey is carried out annually. The form had been specially designed for residents in the home. The report of the most recent survey carried out in November and December 2006 was not yet available for general circulation. A wider stakeholder survey is also carried out annually. 9 completed survey forms were received from residents in advance of this inspection. It is noted that residents had received support from staff in completing the forms but in noting this it not suggested that this directly influenced the outcome in any way. In answer to the question ‘Do you make decision about what you do each day?’ 4 said ‘Always’. 4 said ‘Usually’. 1 said ‘Sometimes’. In answer to the question ‘Can you do what you want to do?’ 8 of 9 residents said ‘Yes’. All 9 resident residents said that they knew who to talk to if unhappy and knew how to make a complaint. All 9 residents said that the home was ‘fresh and clean’ and that the staff treated them well. In answer to the question ‘Do the carers listen and act on what you say?’ 6 said ‘Always’ and 3 said ‘Usually’. Additional comments indicated that residents participate in activities such as gardening, shopping and going to college. Two residents added ‘I like it here’. The single survey form returned from health and social care professionals indicated a high level of satisfaction with the home. DS0000011359.V331574.R01.S.doc Version 5.2 Page 25 The home has an extensive range of policies and it was said that all policies and procedures were to be updated. It is noted that the Trust has an equal opportunities policy which is included in the statement of purpose. Arrangements for health and safety are generally satisfactory. The deputy manager has a delegated lead role for health and safety matters. The Trust has a health and safety policy. A fire risk assessment was completed in February 2006. The precise date of the most recent fire training session could not be confirmed at the time of this inspection visit. It was recorded as ‘2006’ in pre-inspection information (‘PIQ’) supplied by the manager. Managers should ensure that all staff have received training in fire safety. This matter was also raised at the last inspection. The home had been inspected by an Environmental Health Officer in February 2007. Gas systems had been checked in December. Portable Appliance Testing (‘PAT’ tests) of electrical items had been carried out in May 2006 and was therefore, due in May 2007. The home’s fixed electrical wiring had been checked in July 2002. Emergency lighting is checked by staff weekly. The temperature of hot water outlets is tested weekly. According to the PIQ the hoist was last checked in September 2006. It is important that such equipment is tested by a competent person in accordance with the recommended schedule. Arrangements are in place for dealing with ‘COSHH’ (control of substances hazardous to health) substances – mainly cleaning materials. Numerous risk assessments were noted on the care records of residents. The manager may wish to review the security of the windows on the ground floor, consulting the local crime prevention officer if necessary. Systems are in place for recording accidents. Regulation 26 visits by Trustees include a check on health and safety matters. In the PIQ the manager reports that ‘All mandatory courses are up to date, with exception of few awaiting course dates’. ‘Mandatory courses’ include first aid, food hygiene, infection control, fire safety and moving and handling’. DS0000011359.V331574.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X DS0000011359.V331574.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations The manager should liaise with the fire authority to establish how often staff should attend fire safety training on the homes fire procedure. Management should refer to the Fire Precautions Act 1971 and Fire Precautions (Workplace) Regulations 1997 as amended. The manager should review the home’s procedures for the administration of medicines with a view towards developing a more systematic approach to the assessment and recording of staff competence in the process. The manager should review the security of the windows on the ground floor, particularly those in the bedrooms of people living there. 2 YA20 3 YA24 DS0000011359.V331574.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000011359.V331574.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!