Inspection on 15/11/04 for Stratton Road (27)

Care Homes For Adults (18 ­ 65)Stratton Road (27)27 Stratton Road Pewsey Wiltshire SN9 5DYAnnounced Inspection15th November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Stratton Road (27) Address 27 Stratton Road, Pewsey, Wiltshire, SN9 5DY Email address Tel No: 01672 562691 Fax No:Name of registered provider(s)/company (if applicable) Landlace Care Homes Ltd Name of registered manager (if applicable) Miss Beverley Britten Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number D010000340 Date first registered 24th April 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 11th July 2002 Yes NO 10/12/03 If Yes refer to Part CStratton Road (27)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 315th November 2004 09:30 am Alison DuffyID Code071519Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs N Lance and Miss B BrittenStratton Road (27)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementStratton Road (27)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Stratton Road (27). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Stratton Road (27)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 27 Stratton Road is registered to care for three people who have a learning disability. The home is one of three residential care homes owned by Landlace Care Homes Ltd and is managed by the Registered Manager Miss Bev Britten. Mrs Nan Lance is the responsible individual for the home and works closely with her daughter, Miss Britten. The home is situated in a residential area of Pewsey and is within walking distance of all local amenities. The property is semi detached and has four bedrooms. The home has submitted an application to the Commission for Social Care Inspection in order to use the additional room and therefore increase its capacity to four service users. All areas are decorated and furnished to a good standard and are domestic in style. Service users have single room accommodation and are supported to access a range of health care services and leisure facilities. The home has one member of staff on duty throughout the waking day and sleeping in cover is provided at night.Stratton Road (27)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) 27 Stratton Road is one of three homes owned and managed by Landlace Care Homes Ltd. On this occasion it was agreed that the announced inspections of all homes would take place together over a period of three days. This totalled eighteen hours. Common themes within the homes such as recruitment and policies and procedures were identified. These were then assessed in the context of each home. Mrs Lance and Miss Britten were available throughout the inspection. Discussion also took place with other staff on duty and service users as appropriate. The home is in the process of applying to register an additional room to increase its registration from three to four service users. The application process has not however been concluded so within this report the service relates to a care home accommodating three adults with a learning disability. Choice of Home (Standards 1-5) 2 of the 3 standards assessed were met It was identified at the last inspection that the homes Statement of Purpose and Service Users Guide were detailed and well written. Some additions however were required to meet regulation. Mrs Lance reported that these had been made although the documents were not viewed on this occasion. There have been no new admissions to the home since the last inspection. The home has an admission policy involving a series of visits as appropriate. An assessment period of three months would be undertaken following admission. In the event of the next admission Mrs Lance was informed of the need to gain a full assessment from the service users care manager. Service users have a standard contract with their placing authority although information is not fully stated as in the identified standard. Various options to address this matter were discussed with Mrs Lance and Miss Britten. All service users needs are being met within the home and therefore all placements are appropriate at this time. Service users are able to access a range of services and external events as they wish. The experience and motivation of staff members also clearly enable further opportunities and enable communication systems to be successful. Positive and respectful interactions were noted throughout the inspection, which demonstrated that productive and trusting relationships have been established. Individual Needs and Choices (Standard 6-10) Stratton Road (27)Page 6 5 of the 5 standards assessed were met Individual plans of care have recently been further developed and all are now detailed and comprehensive. Some attention is required however to ensure that instructions within individual plans of care are followed through. Service users are encouraged to take assessed risks and a number of risk assessments have been developed. Clear records of health care matters are maintained. Service users are encouraged to be involved in day-to-day house activities and the decisionmaking process. All such involvement is linked to ability and therefore may be restrictive at times. The home has a confidentiality policy and such principles are regularly revisited with staff. Records are stored securely. Lifestyle (Standards 11-17) 7 of the 7 standards assessed were met Service users continue to develop their skills both inside and outside of the home. All service users are given full assistance with personal care and all daily routines. External activity and family support is promoted and the home has its own transport to facilitate journeys as required. Two service users attend day services on a sessional basis and one service user through choice remains at home. Television, music and DVDs were reported to be popular. There have been no changes to the meal arrangements since the last inspection. Service users continue to have a snack at lunchtime and then a cooked meal in the evening. All food is based on healthy eating and menus are developed through known likes and preferences. Risk assessments and requirements for eating are clearly stated within individual plans of care. Personal and Healthcare Support (Standards 18-21) 3 of the 4 standards assessed were met Documentation demonstrates preferred routines and the high level of assistance required with everyday tasks and maintaining health care needs. The home is not registered for nursing care and therefore any specialist nursing input would be referred to the community nursing services. Limited medication is in use and this is administered from original packaging. Monitored Dosage Systems facilitated by the pharmacist are in the process of being investigated. Administration records were satisfactorily maintained and a homely remedies policy signed by a GP is now in place. Staff have received training regarding the administration of rectal diazepam although general medication training has not been undertaken. All placements within the home are expected to be long term. In the event of significant deterioration in health, negotiation and further assistance from other agencies would be sought to enable the service user to continue with their placement. However through Stratton Road (27) Page 7 discussion it was also apparent that Mrs Lance and Miss Britten are realistic regarding the homes criteria of need, which may be met within the home. This matter requires formalising within a written ageing policy. Concerns, Complaints and Protection (Standards 22-23) 1 of the 2 standards assessed were met The home has a clear, well written complaints procedure that contains the information required by regulation. There have been no formal complaints since the last inspection. All adult protection material has recently been co-ordinated. A copy of the `No Secrets document and a chain of command for reporting suspicions or incidents is clearly accessible. Adult protection training to include the Wiltshire and Swindon Vulnerable Adults protocol is planned. Service users are unable to manage their own financial affairs and some money is kept for safekeeping. All monies were checked against the cash sheets and were found to correspond. Receipts however would benefit from greater order. Environment (Standards 24-30) 7 of the 7 standards assessed were met 27 Stratton Road is a semi-detached property, which is domestic in style throughout. There have been no significant changes to the environment since the last inspection other than a new fire safety system. The home has universal single room accommodation on the ground and first floor. All rooms other than the newly registered room measure more than 10sqm. The rooms are comfortable, well maintained and identify individuality. Lockable storage facilities and locks on doors are not appropriate at this time. The home has a downstairs shower room and toilet on the ground floor and an additional bathroom on the first floor. Facilities meet service users needs at this present time. There is a spacious kitchen and lounge-dining room and a separate utility room. The home has a garden generally laid to lawn at the rear of the property. The home has a non-smoking policy and therefore anyone wishing to smoke must do so outside. On the day of the inspection the home was cleaned to a good standard and odour free. Staffing (Standards 31-36) 2 of the 6 standards assessed were met There is a staff team of three including Miss Britten who cover the home and also generally cover for each other during times of annual leave and sickness. It was agreed that this gives little flexibility and also with Miss Britten covering the staffing roster additional implications are evident. Such matters are discussed in greater detail within the staffing section of this report. Staff continue to sole work during the waking day and at night a member of staff provides sleeping in cover. Mrs Lance was advised to give consideration to staffing arrangements as an additional member of staff must be deployed throughout the waking day Stratton Road (27) Page 8 in the event of the home accommodating an additional service user. All staff have job descriptions and the NVQ programme is progressing. Staff are experienced and appear very aware of service users needs. Motivation and the promotion of core values were also evident. Policies and procedures have recently been further developed and are now clear and well written. There have been no new staff since the last inspection. Mrs Lance was informed of the need to ensure a robust and effective system when recruiting in the future, as personnel files do not currently hold references. Documentary evidence of identity is also required. All staff have applied for their CRB disclosures but not all have been returned. Miss Britten has ordered a range of training materials in order to undertake training within the home. It was agreed that food hygiene must be a priority as all staff handle and cook food. A training plan is also required. Information about TOPSS induction and foundation programmes has been received and therefore these must be undertaken in the event of a newly recruited staff member. The development of formal structured supervision is also required. Conduct and Management of the Home (Standards 37-43) 2 of the 6 standards assessed were met Miss Britten is currently undertaking NVQ level 3 and is then planning to follow with the Registered Managers Award. Miss Britten is totally committed to her role and has a very clear awareness of service users needs. However Miss Britten is currently participating within the working roster and therefore time to fulfil aspects of her managerial role is at times difficult. Attention is therefore required to address this matter. Mrs Lance, Miss Britten and staff members appear committed to their roles and aim to achieve high standards within the home. The promotion of core values, preferred routines, involvement and a homely environment appeared paramount and positive interactions were noted throughout the inspection. The home has a quality assurance policy although this has not been fully developed in practice. Further work is therefore required. Questionnaires have been undertaken and information now requires evaluating with a development plan as a response. Policies within the home have recently been further developed and all are detailed, well written and easy to read. Some additions such as lone working and driving the homes vehicle would be of benefit. Record keeping within the home continues to be of a good standard. Attention is required however to ensure all personnel files contain documentary evidence of identity. The home is well maintained and the safety of the environment has been addressed. Radiators have low surface temperatures and window restrictors are fitted to windows on the first floor. Hot water however is regulated by an individual thermostat on the boiler and therefore hot water temperatures must be monitored and recorded on a regular basis. Individual fail safe devices must be installed as required. The home has recently had a new fire safety system. Miss Britten was informed of the need to document the visual checks of the fire fighting equipment and the means of escape. A fire risk assessment is also required. Stratton Road (27) Page 9 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 18(2) YA36 The registered person must ensure that all care staff receive regular supervision that covers all the areas listed in Standard 36. The Registered Person must ensure that personnel files contain information as stated within Schedule 2. 28th February 2004 31st January 2004217 Schedule 2YA41Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Stratton Road (27)Page 10 Stratton Road (27)Page 11 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 12(1)(a) YA6 The Registered Person must ensure that all information/instruction is followed through within individual plans of care, daily records and risk assessments. The Registered Person must ensure that a policy is developed in relation to the ageing process. The implications of this to service users placements must be clearly identified. The Registered Person must ensure that the Wiltshire and Swindon Vulnerable Adults protocol is discussed within the planned training. Allegations as discussed within the inspection must be referred to the service users care manager. The Registered Person must ensure that the system for managing service users personal money gives greater order and clarity. This includes the numbering of receipts. The Registered Person must ensure that the staffing levels within the home are increased by one member throughout the waking day in the event of an additional service user. The CSCI must be notified of this event. 31st January 2005 31st January 2005212(1)(a)YA21313(6)YA2331st January 2005413(6)YA2331st January 2005518(1)(a)YA3328th February 2005Stratton Road (27)Page 12 618YA34The Registered Person must ensure that two written references are received before the staff member commences employment. Documentary evidence of identity must also be in place. The Registered Person must ensure that all staff receive food hygiene training. The Registered Person must ensure that a training plan is developed. The Registered Person must ensure that all new staff undertake induction and foundation programmes which meet TOPPS specification. The Registered Person must ensure that a formal system of staff supervision is developed and maintained with records kept. The Registered Person must continue to develop a system for monitoring and improving the quality of care provided in the home. The Registered Person must ensure that policies continue to be developed such as accepting gifts, driving the homes vehicle and lone working. The Registered Person must ensure that hot water is monitored and results are fully recorded. Individual fail-safe devices must be fitted in the event of unpredictable or high temperatures. The Registered Person must ensure that control measures are in place in relation to driving the homes vehicle.31st January 2005 28th February 2005 31st January 2005 31st January 2005 28th February 2005 28th February 2005 31st January 2005718(1)(c)YA35818(1)(c)YA35918(1)(c)YA351018(2)YA361124YA391212YA401313(4)YA4231st January 2005 31st January 20051413(4)YA421523(4)YA42The Registered Person must ensure that the means of escape and fire fighting equipment 31st are visually checked and recorded within the January fire log book. A fire risk assessment must also 2005 be completed.Stratton Road (27)Page 13 1613(4)The Registered Person must ensure documentation is available to demonstrate the testing of the portable electrical appliances.28th February 2005RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 YA5 The Registered Person should ensure that service users contracts include the information as stated within standard 5. The Registered Person should ensure that various systems of dispensing medication are investigated and all staff receive medication training.2YA20* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Stratton Road (27) YES YES NO YES YES NO NO NO YES NO YES NO YES YES NO Page 14 Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)NO NO YES NO YES X X X NO NO YES YES X X 15/11/04 09:30 6.0The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Stratton Road (27)Page 15 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Personal items, toiletries, clothing, hairdressing 0 Key findings/Evidence Standard met? At the last inspection the homes Statement of Purpose was detailed and well written. To fully meet regulation however greater information was required in relation to some aspects such as room sizes and the accommodation. Miss Britten reported that this work had been undertaken although the document was not seen on this occasion. Due to the increase in registration the newly registered room will need to be clearly identified within the Statement of Purpose as being below the identified space criteria. Miss Britten was also informed of the need to document the omission of hand washbasins within private accommodation. Additions were reported to have been made to the Service Users Guide although again this document was not seen on this occasion.Stratton Road (27)Page 16 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was not addressed on this occasion, as there have been no new admissions to the home since the last inspection. Mrs Lance was informed however that in the event of a service user taking the newly developed vacancy, a full assessment undertaken by a care manager must be received before admission. Discussion also took place regarding the suitability of the placement to which it was apparent that Mrs Lance and Miss Britten have given careful consideration. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Various discussions with Mrs Lance, Miss Britten and staff members demonstrated that all placements are currently successful. All service users are well at present and their needs are being met in a positive way. Staff members appeared very aware of specific needs and gave clear strategies of individual communication and assistance required in relation to personal care. Documentation demonstrated such involvement and preferred routines were clearly identified. Two service users continue to attend sessions at day services and one-toone staff support is given to achieve this for one service user. Community events are accessed as appropriate and the organisation has its own transport to facilitate journeys as required. Service users are given full assistance to manage their health care needs. The building is fit for purpose and has downstairs accommodation in place. Positive relationships and interactions were seen between staff and service users and it noted that service users rights were promoted at all times. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? It was not possible to assess this standard in practice, as there have been no new admissions to the home since the last inspection. The home does however have an admission policy and through discussion it was evident that a series of visits would be undertaken before admission. The visits of varying durations would involve meeting staff and other service users. Staying for a meal and an overnight stay would then be arranged if appropriate. An assessment period of three months would be undertaken following admission and the placement would be confirmed during a formal review setting.Stratton Road (27)Page 17 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? All service users have a standard contract with their placing authority and the home. The documents do not however fully contain all information as stated within this standard. This was discussed with Mrs Lance and Miss Britten and it was advised in order for this standard to be fully met additional information would be required.Stratton Road (27)Page 18 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Since the last inspection attention has been given to individual plans of care and their development. All plans were detailed and clearly identified individual needs and preferences. Assistance with personal care and social needs were evident and a timetable gave evidence of weekly activity. Involvement within the day-to-day running of the home and decisionmaking processes in relation to ability were noted. Some attention is required however to ensure that instructions within individual plans of care are followed through. For example in one plan it is identified that an identified service users weight should be monitored on a fortnightly basis. The weight record however is inconsistent with this. Risk assessments have been developed and there is a clear record of health care appointments and health care matters such as seizures. All plans are up to date and copies of review notes are available on file. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Through various discussions, viewing documentation and general observations it was apparent that service users are encouraged to make decisions. Such decisions may be limited however and due to varying abilities staff are required to use their experience and judgement to determine body language, emotion and gestures in response to need. Service users decisions appeared to be fully respected. For example one service user declined an offer of going out and his decision was fully supported without any encouragement or pressure to change his mind. Service users are unable to manage their own financial affairs and all have an official `appointee. Some money is kept within the home for safekeeping. This is discussed in standard 23 of this report.Stratton Road (27)Page 19 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Service users are encouraged to be involved in day-to-day house activities although the level of involvement is linked to individual ability. Such activities may involve polishing, laying the table or folding laundry. Service users do not enter the kitchen while food is cooking due to health and safety issues although communication during this time was noted to be taking place. In order to further some service users involvement, practices such as hand over hand may be used if appropriate. Service users however always control their level of participation and are never encouraged to be involved if they do not wish to be. Involvement with recruitment procedures and the development of the homes policies is not appropriate at this present time. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Within the inspection it was evident that service users are encouraged to take assessed risks and continue with activity in the event of possible negative factors. For example in the event of a service user having frequent seizures, external activity is promoted although staff would ensure control measures are in place. Another example would be a risk of choking whereby staff would not discourage a service user from eating out. Risk assessments have been developed and a missing persons procedure is in place. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Mrs Lance has recently developed a policy regarding confidentiality. Confidentiality is also addressed within staff members job descriptions and raised through discussions. Records are securely stored within the home.Stratton Road (27)Page 20 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users continue to develop their social, emotional, communication and independent living skills within the home and within external opportunities. Such involvement however is linked to ability. Two service users attend sessions at day services undertaking topics such as art, yoga and communication. The sensory room is also used. Social interaction is gained as appropriate although through discussion it was apparent that service users generally enjoy their time in the evening within the home environment. All service users are given assistance with personal care and are encouraged to undertake associated tasks such as choosing clothing. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Developing employment skills and voluntary opportunities are not appropriate at this time although stimulation, communication and relaxation are paramount. Two service users attend day services on a sessional basis and one service user through choice remains at home. Miss Britten reported that alternatives have been investigated although so far all have been unsuccessful. A newly opened day service was reported to be the next opportunity although if refused it would be accepted that the service user does not want any such attendance. One service user receives one-to-one support from a staff member from the organisation when at day services. When at home attention is given to general relaxation, interaction and trips out. This could be for a walk, into town or a trip to the local garden centre.Stratton Road (27)Page 21 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? 27 Stratton Road is situated in a residential area of Pewsey within walking distance of local amenities. Service users regularly walk into the village with staff assistance and are well known with local shopkeepers. The home has its own transport to facilitate journeys as required. There is clear evidence that staff view external activities as part of their role and believe involvement with the local community is important. Staff generally lone work however, which may at times restrict spontaneous external activity. Such arrangements are later discussed within the staffing section of this report. Service users are not at present on the electoral role. This has been considered by the home, but felt not to be appropriate. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Miss Britten reported that in house activity is generally limited due to service users abilities. However television, music and DVDs were reported to be popular and one service user enjoys cooking. User-friendly recipe cards are in place for this purpose. Service users have entertainment equipment in their bedrooms if they wish. External activity is promoted although not particularly popular with one service user. Trips are therefore linked to abilities and individual interest. Regular trips are made into town and general walks are undertaken. Holidays are arranged and some service users have recently returned from a holiday park. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Through discussion and viewing documentation it was apparent that family links are promoted. Such contact however varies in extent in relation to individual circumstances. Service users are able to meet with their visitors in the privacy of their own room or in any of the communal areas. Often service users go out with their visitors either for a meal, to the local garden centre or to the parental home. Hospitality is promoted and this was evidenced throughout the inspection. Service users receive peer support during attendance at day services and forums such as Gateway club. Service users also spend time with other service users within other homes owned and managed by Landlace Care Homes Ltd. A record of visitors is maintained.Stratton Road (27)Page 22 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users at this present time are given full assistance with all daily routines and are unable to fully make decisions within this area without staff support. Routines in the morning vary according to daytime activities and identified preferences. Night-time routines are also based on observations and apparent tiredness. Service users have access to all areas of the home other than other service users private accommodation and the kitchen when cooking is taking place. Service users currently however require assistance or supervision to move around safely. Service users do not a key to their private accommodation based on an assessment of ability. This matter is addressed within individual plans of care. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users continue to generally have a snack such as sandwiches at lunchtime and then have a cooked meal in the evening. All food is based on healthy eating with fruit and vegetables being an integral part. Menus are developed through known likes and preferences and also picture cards have recently been developed so one service user is able to visually make her choice. Service users sometimes participate with food preparation and cake making but are not encouraged into the kitchen while the oven is on due to health and safety issues. The kitchen is spacious and domestic in style and a record of food is kept. Service users eat at the table within the lounge diner with staff assistance and support as required. Such assistance was undertaken sensitively during the inspection. Risk assessments and requirements for eating are clearly stated within individual plans of care.Stratton Road (27)Page 23 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Through discussion and viewing individual plans of care it was evident that a high level of assistance with personal care and other aspects of daily life are given. Detailed documentation described preferred routines and management guidelines as appropriate. Mrs Lance confirmed that the staff team are well established and undertake this provision with a clear understanding of service users needs. The home is not registered for nursing care and therefore any specialist nursing input would be referred to the community nursing services. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Service users continue to be given full assistance to meet their health care needs. Documentation demonstrated health care services are accessed as required. All service users are registered with the same GP and appointments are made as required. Discussion took place regarding the refusal of treatment and Miss Brittten was advised to ensure documentation demonstrates such. Optical checks are undertaken at the opticians in the village and dental checks take place within a special needs clinic. Daily records demonstrated the general awareness of staff and instances when service users are observed as `not being 100 . Any identified marks, scratches or bruising are recorded in written form and within body charts. Guidelines are in place regarding epilepsy and a record is kept of all seizures. Involvement also occurs with the epilepsy clinic.Stratton Road (27)Page 24 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The home has very limited medication and staff administer this from original packaging. At present Miss Britten organises the medication systems and therefore develops medication administration sheets on the computer. Discussion took place regarding Monitored Dosage Systems facilitated by the pharmacist and it was agreed that this system would be a positive development for the home. Miss Britten reported that she would investigate such. Records were satisfactorily maintained and a homely remedies policy signed by a GP is now in place. Following a requirement at the last inspection staff have had training regarding the administration of rectal diazepam. Prescribed suppositories are no longer used. The home has a clear medication policy and a copy of the Royal Pharmaceutical Society Guidelines on Medication in Care Homes is available. Miss Britten has photocopied patient information sheets in order for them to be included in service users files and therefore easily accessible. Staff have not received any formal training regarding medication administration and therefore this matter is recommended. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 2 Key findings/Evidence Standard met? It was very evident through discussion with Mrs Lance, Miss Britten and staff members that 27 Stratton Road is very much considered the service users home. It was therefore reported that all placements were expected to be long term and service users would be given further assistance if appropriate to stay at the home in the event of any significant deterioration. Commitment to enable this from the staff team was clearly evident and additional services such as the Community Nursing Service would be accessed as required. Mrs Lance and Miss Britten were however realistic and gave clear criteria regarding needs which would not be able to be accommodated within the existing home environment. Mrs Lance was informed of the need to formalise this view and document such within a written ageing policy.Stratton Road (27)Page 25 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? The home has a clear, well written complaints procedure that contains the information required by regulation. The procedure encourages complaints to be addressed within the home and then be forwarded to the Commission for Social Care Inspection if unable to be satisfactorily resolved. The procedure also states that a service user, their family or staff member may contact the CSCI at any time. There have been no formal complaints since the last inspection. The home has a file for complaints that are dealt with on a day-to-day basis although no entries are recorded.Stratton Road (27)Page 26 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES02 Key findings/Evidence Standard met? Since the last inspection Mrs Lance has co-ordinated all adult protection material. A copy of the `No Secrets document is now clearly accessible with the homes policy. A chain of command for reporting suspicions or incidents is also available. Miss Britten has ordered an adult protection training package so that she can facilitate in house training with all staff. In this event Miss Britten was informed of the need to include the Wiltshire and Swindon Vulnerable Adults protocol. Discussion took place regarding specific comments raised. Miss Britten was advised to discuss the matter with the service users care manager. Service users are unable to manage their own financial affairs and some money is kept for safekeeping. All monies were checked against the cash sheets and all were found to correspond. Receipts however would benefit from greater order and it was agreed that all would be numbered and attached to the balance sheet in use.Stratton Road (27)Page 27 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? 27 Stratton Road is a semi-detached property within a residential area of Pewsey. The home is domestic in style throughout and therefore is in keeping with its stated aims. Mrs Lance reported that there have been no significant changes to the environment since the last inspection although CSCI is currently processing an application to increase the homes registration to four. The identified room has been registered with a previous registration authority and is within the existing building. It has not however ever been used to accommodate a service user. All areas are comfortably furnished in a homely manner. A new fire safety system has recently been installed and the Fire Officer has visited to conclude its satisfactorily completion. The home has not had a recent Environmental Health Inspection.Stratton Road (27)Page 28 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 3 0 0 0 3 00 0 0 03 Key findings/Evidence Standard met? The home has universal single room accommodation and all rooms measure more than 10sqm. However the room identified to increase the homes registration from three to four is below the identified space criteria. Mrs Lance was informed of the need to clearly address this within the homes Statement of Purpose. Two service users have rooms on the ground floor and another service user is able to manage the stairs so is accommodated on the first floor. Rooms do not have en-suite facilities and do not have hand washbasins.Stratton Road (27)Page 29 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? All private accommodation is comfortable, well maintained and identifies individuality through furnishings and personal possessions. All have sufficient storage although do not have a lockable facility. It was agreed however that service users would not be able to manage such. Mrs Lance was therefore advised to record this within individual plans of care. Miss Britten reported that service users do not spend a great deal of time in their room and currently have the furniture they require. Service users do not have the facility of locks on doors although this is noted within individual plans.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home has a level access shower room and toilet on the ground floor and an additional bathroom on the first floor. Both are comfortable, warm and lockable and are within close proximity to bedrooms and communal areas.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home has a spacious homely lounge-dining room that is comfortable and decorated to a good standard. The kitchen is also spacious and there is a separate utility room. The home has a garden generally laid to lawn at the rear of the property. Doors leading from the dining room lead to a patio and seating area. A room on the first floor is allocated to the sleeping in room for staff usage at night. Service users do not smoke and therefore the home has a nonsmoking policy. Anyone wishing to smoke must do so outside.Stratton Road (27)Page 30 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? Two service users have private accommodation on the ground floor and there is also a downstairs shower room. Miss Britten reported that a referral had been made regarding an assessment for a walking aid. The process however was reported to be taking a considerable amount of time. Miss Britten was therefore advised to continue to contact the service stating the aid is required for the service users safety. Other environmental adaptations were reported not to be required at this time.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home has a separate utility room, which houses a washing machine and tumble drier. The facilities were reported to meet the needs of service users at this present time. Due to the positioning of the utility room however laundry must be carried through a section of the kitchen. A written policy therefore states that all laundry must be carried in a basket with a lid. Protective clothing is available as required. Staff are able to access the NHS Infection Control Guidelines and Miss Britten is planning in house infection control training. On the day of the inspection the home was cleaned to a good standard and odour free.Stratton Road (27)Page 31 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? All staff have job descriptions and have been given a copy of the General Social Care Councils Code of Conduct. Through discussion with staff and by observing interactions it was evident that staff are very aware of service users needs. Positive relationships have been built and staff have established the most productive ways of communicating with service users. Mrs Lance reported that all staff members are very experienced and therefore competent within their roles. Motivation and the promotion of core values appear evident and a commitment to place service users at the centre of the service is clear. Mrs Lance has worked hard to address the homes written policies and staff are currently in the process of viewing such. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Miss Britten reported that the NVQ programme is progressing well and all staff spoken to reported benefit and an enjoyment with undertaking the course. Within the organisation three members of staff are undertaking NVQ level 2. Miss Britten and another staff member are undertaking NVQ level 3. One member of staff has NVQ level 2. On completion of the course it was reported that some staff would progress to the next level. Other staff are reluctant however to undertake such training. It is therefore expected that the identified criteria of qualified staff will be met although there is no flexibility in the event of any staff changes.Stratton Road (27)Page 32 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX2 Key findings/Evidence Standard met? Three members of staff including Miss Britten are currently covering the home. Staff continue to sole work during the waking day and at night a member of staff provides sleeping in cover. Within the staffing rota it was noted that Miss Britten is currently undertaking a high level of care shifts including sleeping in provision. Discussion took place regarding the limitations of sole working and the implications of Miss Britten being on the staffing rota. It was also identified that staff are generally covering each other during times of sickness or annual leave. This appears to give additional pressure and leaves little flexibility. In addition, with Miss Britten sole working, attention to the leadership and general management and administrative tasks of the home are restricted. At a time when Mrs Lance is aiming to increase the registration of the home to four, staffing levels must be addressed. Discussion regarding this matter took place and it was agreed that with the current dependency of service users, the home would need an additional member of staff throughout the waking day.Stratton Road (27)Page 33 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The staff team are established and all have worked within the home for a number of years. It was therefore not possible to assess current recruitment procedures. Staff files were viewed and although application forms were in place there were no written references. Mrs Lance reported that all staff were recruited before this requirement although is aware of the need to undertake such within future recruitment. It was noted that the application form has recently been developed. The form is now much improved, as more detail is requested. Staff files contain a health declaration although there was no documentary evidence of identity. Miss Britten reported that all such documents were seen in order to apply for CRB disclosures. The documents were not photocopied however as required. All staff have applied for their disclosures but not all have been returned. Discussion took place regarding future requirements when recruiting and Mrs Lance was informed of the need of a robust and effective system. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? Through discussion it was apparent that some staff appear resistant to external training. In order to address this matter Miss Britten has ordered a number of training packages to be undertaken in house. Such subjects include adult protection, infection control and food hygiene. It was agreed that food hygiene must be a priority as all staff handle and cook food. All staff are up to date with their first aid training although a training plan is required. Miss Britten has received information about TOPSS induction and foundation programmes. These must therefore be undertaken in the event of a newly recruited member of staff. Viewing the TOPSS website may also be of benefit. Staff reported recently undertaking epilepsy training. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 1 Key findings/Evidence Standard met? At present Miss Britten is undertaking a high level of sole working within the home. Due to the limited flexibility of time available, spending time with staff in a supervisory capacity is difficult. During previous inspections it was apparent that supervision was undertaken informally although a requirement was made at the last inspection to develop formal structured supervision. Due to certain restrictions however this matter has not been addressed. A written policy regarding supervision is in place so attention must now be given to apply the policy in practice. It must also be recognised that attention needs to be given to the staffing rosters in order for this to successfully take place.Stratton Road (27)Page 34 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO3 Key findings/Evidence Standard met? Miss Britten commenced employment with Landlace Care Homes Ltd in 1997. Miss Britten is currently undertaking NVQ level 3 and is then planning to follow with the Registered Managers Award. As stated earlier in this report Miss Britten is currently undertaking many shifts as part of the working roster. Discussion therefore took place regarding the need to be given sufficient time to undertake the required qualification and also to complete management tasks as identified within this report. Through discussion it was apparent that Miss Britten is totally committed to her role and has a very clear awareness of service users needs. It was evident that Miss Britten continually promotes core values and expects service users to be at the centre of all practice. Positive interactions and established relationships with service users were observed throughout the inspection.Stratton Road (27)Page 35 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Through discussion it was evident that Mrs Lance, Miss Britten and staff members are committed to their roles and aim to achieve high standards within the home. All staff spoken with demonstrated enthusiasm regarding their post and a clear understanding of service users needs. The promotion of core values, preferred routines, involvement and a homely environment appeared paramount. Positive relationships and interactions were observed throughout the inspection. Staff members reported that they felt supportive and were quite happy with the management styles currently in place. Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 1 Key findings/Evidence Standard met? Through various discussions it was apparent that Mrs Lance, Miss Britten and the staff team aim to achieve high standards and maintain a service user led service. A wish for compliance with regulation is apparent. Questionnaires have been developed in order to gain views from service users and their families. All information received was positive although matters now need to be coordinated and displayed accordingly. The home has a quality assurance policy stating that regular audits will take place. These need to occur in practice with an annual development plan developed from the results. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 2 Key findings/Evidence Standard met? Mrs Lance has considerably developed the policies within the home. All are detailed, well written and easy to read although are not dated. Policies recommended at the last inspection such as smoking, alcohol and drugs have been undertaken and a policy regarding the management of service users financial affairs is now in place. Mrs Lance was advised however to include matters such as gifts and service users offering to buy drinks or snacks for staff when out. Discussion took place regarding continually adding to the policies. Within the inspection it was noted that a policy regarding lone working and driving the homes vehicle was required.Stratton Road (27)Page 36 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? Record keeping within the home continues to be of a good standard. All service users records are well maintained and up to date and generally all other records required by regulation are in place. Documentary evidence of identity however including copies of birth certificates and passports are required within personnel files. Miss Britten reported that all such docmentation was seen when applying for CRB disclosures although a photocopy of each document was not taken at the time. The home has a visitors book and a record of food comsumed. An inventory of service users personal furniture is maintained and accidents are appropriately recorded within the accident book. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Radiators within the home have low surface temperatures and window restrictors are fitted to windows on the first floor. All hot water is regulated from an individual thermostat on the boiler and therefore Mrs Lance and Miss Britten were informed of the need to monitor and record hot water temperatures on a regular basis. If the temperature was found to be irregular or of a temperature which may place service users at risk, individual fail safe devices must be installed. All portable electrical appliances have been tested as required although documentary evidence was not availble. The home has recently had a new fire safety system installed. Miss Britten was informed of the need to document the visual checks of the fire fighting equipment and the means of escape. External contractors service the fire fighting equipment on a yearly basis. A number of environmental and individual risk assessments have been undertaken although a fire risk assessment is required. Mrs Lance was also advised to address control measures within the homes vehicle. Such controls involve gaining a copy of the staff members insurance certificate and driving licence and requesting staff to sign a declaration stating that Mrs Lance would be informed of any driving incident. When traveling staff should also carry a mobile phone. All staff are up to date with first aid training and a series of sessions are planned including manual handling, food hygiene and infection control. Food hygiene training must be undertaken as a priority as all staff prepare and therefore handle food. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not addressed at this inspection.Stratton Road (27)Page 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureStratton Road (27)Page 38 Public reports It should be noted that all CSCI inspection reports are public documents.Stratton Road (27)Page 39 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Stratton Road (27) Page 40 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 7th January 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOStratton Road (27)Page 41 ANNOUNCED INSPECTION 15TH NOVEMBER 2004 D.3 PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I, Nanette Lance of 27 Stratton Road confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Nanette Lance of 27 Stratton Road am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Stratton Road (27)Page 42 Stratton Road (27) / 15th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000028213.V187073.R01© This report may only be used in its entirety. 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