Inspection on 02/12/03 for Strawberry Field

Care Homes For Adults (18 ­ 65)Strawberry FieldMill Common Lane Walcott Norwich Norfolk NR12 0PFUnannounced Inspection2nd December 2003 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 Strawberry Field Address Mill Common Lane, Walcott, Norwich, Norfolk, NR12 0PF Email Address Tel No: 01692 650707 Fax No: 01692 650330Name of registered provider(s)/Company (if applicable) Janith Homes Limited Name of registered manager (if applicable) Mr Alfred Finlay Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number I070000609 Date First registered 30th July 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 24th October 2003 yes YES 25/04/03 If Yes Refer to Part CStrawberry FieldPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 32nd December 2003 10.00 am Mr Pearson ClarkeID Code074941Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mr A Finlay (manager ) the time of inspectionStrawberry FieldPage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementStrawberry FieldPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) 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 NCSC in respect of Strawberry Field. The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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.Strawberry FieldPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Strawberry Fields is a care home providing personal care and accommodation to 3 adults with a learning disability. The service is operated by a company and users attend day services at the companies main home The Rookery. Strawberry Fields stands on the outskirts of the Norfolk seaside village of Walcott.The home has its own transport. The home is located in a detached house and all users have their own bedroom. The home has a large garden.Strawberry FieldPage 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.) Choice Of Home standards 1-5 5 standards assessed and all met Admissions to the home are rare and new service users tend to have already lived in the companies main home. Adequate information is provided to allow prospective users and their representatives to make an informed choice. Individual Needs and Choices standards 6-10 4 standards assessed with 3 met and 1 partially met. The service needs to introduce its new care planning format in order to fully meet the standard. Service users exercise choice and appear to be having their needs met. Lifestyle standards 11-18 5 standards were inspected of which 4 were met and 1 was exceeded. Service users are offered a wide range of stimulating activity. The home functions as a domestic house and users are fully involved in its day to day operation. Personal Health Care and Support standards 18-21 2 standards assessed and met All service users appear to be having their personal and health care needs met Concerns Complaints and Protection standards 22-23 2 standards assessed with1 met and 1 partially met The service has received no complaints. Policies, procedures and staff training are in place to protect service users, however one service user did not have the current complaints policy and this needs to be issued. Environment standards 24-30 6 standards were assessed and all were met The service operates from an domestic house which provides a reasonable quality environment for those living there.Strawberry FieldPage 6 Staffing standards 31-36 5 standards inspected of which 4 were met and 1 was partially met. The staff team is small and appears to be motivated and generally well trained. However in order to comply with workforce training targets foundation training needs to be established.Conduct and Management of the Home standards 37-43 7 standards assessed of which 3 were met and 4 partially met The home is generally well managed and as a small unit needs less formal structure than a large establishment. Visits required by regulation 26 must be carried out.Strawberry FieldPage 7 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. No. Regulation Standard Required actions Timescale for action 1 12,23 YA42 That risk assessments of all safe working practices are carried out By 01/08/03Action is being taken by the National Care Standards Commission 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)Strawberry FieldPage 8 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 2 12,23 26 YA42 YA41 That risk assessments of all safe working practices are carried out That visits and reporting as required by Regulation 26 are carried out. 31/04/04 31/04/04RECOMMENDATIONS 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) No. Refer to Good Practice Recommendations Standard * 1 2 3 YA6 YA22 YA35 That the new format for service user plans is introduced as planned. That all service users are provided with an accurate accessible and up to date complaints policy That Foundation training consistent with national workforce training targets is established.* 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. Strawberry Field Page 9 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 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 YES NO YES YES NO NO NO YES YES YES NO YES YES NO NO NO YES NO YES 3 0 0 YES YES YES YES 4 0 02/12/03 10.00 2.5Strawberry FieldPage 10 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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.Strawberry FieldPage 11 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, 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. 618 X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Transport 3 Key findings/Evidence Standard met? In common with other homes owned by the company a statement of purpose and service user guide has been developed for the home. The management confirmed that the documents have been made available to users and staff have explained the content. There are plans to use other media to make the information more accessible to those lacking literacy.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. 3 Key findings/Evidence Standard met? There have been no recent admissions from outside of the company, however a formal assessment tool is in place which would be used if needed.Strawberry FieldPage 12 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? The home is domestic in size and as such the needs of individuals are well known to those working with them. All of those currently accommodated have moved to the home from the companies other services and as such judgements about the suitability of Strawberry Fields to meet need have been easier to make with confidence.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? All new users have a trial period before their placement is confirmed. There have been no recent admissions from outside of the company, however the admission process used would involve appropriate introductory visits.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. 3 Key findings/Evidence Standard met? The inspector saw copies of the contact/statement of terms and conditions within the records of two service users. The management confirmed that the other user has had a statement and that these are always issued to service users.Strawberry FieldPage 13 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? Service user plans for all three residents were inspected. Whilst all plans contained a wide range of appropriate information, one plan was in the new format and the others were not. It would be desirable to introduce the new format to all users and as such a recommendation is made. See recommendationStandard 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? Users are not subject to any particular restrictions, however two people have been assessed as having no road sense and to need accompanying by staff in these circumstances.Strawberry FieldPage 14 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? The service is run as a domestic house. As such service users are involved in all household tasks including gardening, cleaning, shopping and cooking.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. 0 Key findings/Evidence Standard met? standard not inspectedStandard 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? The company has appropriate policies and procedures relating to the need to the need to promote and protect confidentiality. The manager stated that he is aware of his responsibilities in respect of data protection.Strawberry FieldPage 15 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? On the day of inspection a member of staff was observed working with service users carrying out domestic tasks around the home. As already indicated users develop independent living skills through involvement in household tasks. The company has extensive day services offering opportunities to expand communication and social skills.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? Each service user has a weekly activity programme which offers a wide range of opportunities. The inspector was told of one user who attends a number of courses at a local college. No users currently have a job.Strawberry FieldPage 16 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? The service is rurally located and as such the opportunities for community contact reflect this. None the less service users are provided with transport to enable them to reach the wider community. One resident uses their bicycle to go to the local town. Service user plans indicate that the service provision does encourage wider community contact.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 4 Key findings/Evidence Standard met? In common with users at the providers other homes, residents have access to a wide range of leisure activity. The company has extensive day facilities including a working farm, an art barn, educational facilities and outdoor pursuits. Service users are encouraged to have holidays and one user told of how he is learning to scuba dive in order to have a diving holiday later in the year.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). 0 Key findings/Evidence Standard met? standard not inspectedStandard 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? The house functions as a normal domestic environment and there is an absence of rules , but an expectation that users respect each other. Staff and users confirmed that it was a relaxed flexible place to live.Strawberry FieldPage 17 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. 0 Key findings/Evidence Standard met? standard not inspectedStrawberry FieldPage 18 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 procedure 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? The manager and staff demonstrated a good awareness of the personal and care needs of service users. The services policies, procedures and staff training are promote an approach to care delivery based upon maintaining users privacy, dignity, independence and control over their lives.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) Key findings/Evidence standard not inspected Standard met? XX 0Strawberry FieldPage 19 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. 0 Key findings/Evidence Standard met? standard not inspectedStandard 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. 3 Key findings/Evidence Standard met? None of the current residents are elderly or suffering from a serious illness. In the past the home has dealt with terminal illness and death and the inspector was told that service users were helped to deal with this and were given counselling at the time.Strawberry FieldPage 20 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days 0 0 0 0 0 0 100 2 Key findings/Evidence Standard met? The home does have a complaints procedure and a record which accords with meeting of this standard. However examination of service user files showed that in one users file the policy was out of date and this needs to be rectified. See recommendationStrawberry FieldPage 21 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 YES03 Key findings/Evidence Standard met? Since the last inspection a company wide Adult Protection policy has been developed and applied as required. Staff have been provided with training to support this.Strawberry FieldPage 22 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? The service is located in a detached house near to the companies main service. The accommodation is domestic in style and in reasonable order. In line with the requirement made at the last inspection the fire officer has been consulted and hard wired smoke detectors and emergency lighting have been fitted. The unsafe garden wall has been demolished and will be rebuilt.Strawberry FieldPage 23 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 Key findings/Evidence YES NO NO 3 0 0 0 Standard met? 3 3 00 0 0 0All service users have attractive bedrooms with sufficient space for their possessions and interests.Strawberry FieldPage 24 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? Service users showed the inspector their bedrooms all of which were highly personalised and full of their possessions.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 service has one toilet and a separate bathroom. Both rooms have non slip floors and the doors are fitted with privacy locks. Bathroom facilities are in line with those found in a normal domestic house and appropriate for the needs of those living at the home.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 one large lounge dining room with a range of furniture which is in reasonable condition. Contained within the room are an exercise bicycle and a computer. The home has large gardens which the users are helping to plant and develop.Strawberry FieldPage 25 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? All service users are fully ambulant and there is no need for environmental adaptations.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 inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? standard not inspectedStrawberry FieldPage 26 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? The member of staff on duty was interviewed by the inspector and appeared confident about his role and duties. He confirmed that he had a job description and a contract of employment. The staff team is small and was said to work well together.Strawberry FieldPage 27 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. 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 XXX3 Key findings/Evidence Standard met? The manager confirmed that there are currently 4 members of staff and 3 of these are undertaking NVQ level 2.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. 3 Key findings/Evidence Standard met? The homes staffing rota shows a level of cover consistent with the size of the home and the level of need of service users. One user has no speech and staff have been trained to sign to aid communication.Strawberry FieldPage 28 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. 0 Key findings/Evidence Standard met? standard not inspectedStandard 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? The manager described the range of training offered to staff which is extensive and on going. Sector skills induction training targets are being met , however foundation training is not fully in place. The latter needs to be established in order to fully comply in this area. See recommendationStandard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Whilst there is no formal supervision system at the home, the member of staff with spoken felt well supported and able to easily gain advice and guidance when needed. Staff meetings are held and the inspector formed the opinion that staff are able to work effectively.Strawberry FieldPage 29 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 or equivalent. NO3 Key findings/Evidence Standard met? The service manager is very experienced and does hold a qualification at degree level relating to care. He has also enrolled in an NVQ 4 in management and care.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? The inspector experienced a relaxed atmosphere on the day of inspection. The interaction between the manager, the member of staff on duty and service users was relaxed and natural. The member of staff spoken to was positive about the management style.Strawberry FieldPage 30 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. 2 Key findings/Evidence Standard met? The company as a whole is working towards Investors In People status, however this is not yet achieved hence the scoring of 2. Strawberry Fields is a very small home and the inspector formed the view that service users views are heard and respected.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 Younger Adults. 3 Key findings/Evidence Standard met? The manager stated that policies and procedures were now in place covering the topics set out in appendix 2 of the National Minimum Standards for Younger Adults.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 ? Although most records are maintained it was established at this inspection that visits as required under Regulation 26 are not being carried. These visits must be carried out and appropriate reporting arrangements established. See requirementStandard 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? Since the last inspection of the home water temperatures have been regulated at the point of delivery to prevent scalding. Staff members have also received Health and Safety training. A requirement was made to complete risk assessments for safe working practices and as this is still not fully complied with the requirement is repeated. See requirementStrawberry FieldPage 31 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. 3 Key findings/Evidence Standard met ? The company has audited accounts and is developing a business and financial plan as part of the investors in people process. The manager stated that all necessary insurances were in place, but that policies etc were held at the companies main office.Strawberry FieldPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSYES Condition Compliance The service is registered to care for 3 adults of either sex who have a learning disability. CommentsCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Locality Manager DatePearson Clarke Gillian WarrenSignature SignatureStrawberry FieldPage 33 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Strawberry FieldPage 34 PART EE.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 2nd December 2003 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments and any action plan are available at the Area Office, where these have been submitted.Strawberry FieldPage 35 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments 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 accurateYESNote: 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. E.2 Please provide the Commission with a written Action Plan by 13th April 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 planYESOther:Strawberry FieldPage 36 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of 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 E.3.2 I of 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.Strawberry FieldPage 37 - 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!