Inspection on 02/07/08 for Swanton House Care Centre

This inspection was carried out on 2nd July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Swanton House Care Centre 22/08/07

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Swanton House Care Centre Dereham Road Swanton Novers Norfolk NR24 2QT Lead Inspector Lella Hudson Unannounced Inspection 2nd July 2008 08:15 DS0000069244.V369594.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000069244.V369594.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000069244.V369594.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swanton House Care Centre Address Dereham Road Swanton Novers Norfolk NR24 2QT 01263 860226 01263 863012 siva.armugam@swantoncare.com www.swantoncare.com Swanton Care and Community Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) John Hayes – not yet registered Care Home 55 Category(ies) of Learning disability (55), Mental disorder, registration, with number excluding learning disability or dementia (55) of places DS0000069244.V369594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Mental disorder, excluding learning disabilities or dementia - Code MD The maximum number of people who can be accommodated is 55. 2. Date of last inspection 22nd August 2007 Brief Description of the Service: Swanton House is a large country house situated in extensive and attractive grounds close to the small town of Melton Constable in North Norfolk. There are a number of cottages in the grounds that have their own kitchen/kitchenette facilities and offer the opportunity for more independent living by service users. In 2008 the registration increased to 55 with the provision of newly built accommodation which provides additional flats for single person use. The complex also has a purpose built activity centre. Fees £400 - £3000 DS0000069244.V369594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is ONE STAR. This means that the people who use this service experience ADEQUATE quality outcomes. This report contains information gathered about the Home since the last Inspection in August 2007. It includes information provided by staff from the Home, such as the completed Annual Quality Assurance Assessment (AQAA) and through notifications to the Commission. It also includes information gathered during an unannounced visit to the Home which was carried out by two Inspectors on the 2nd July 2008 between 8.15am and 5.20pm . The report also contains information gathered from surveys that were returned to us from residents (15), staff (16), relatives (2) and health/social care professionals (1). During the visit we looked around the accommodation, inspected records, spoke to the Manager, staff and residents and observed staff supporting residents. The organisation has recently completed building new accommodation which includes offices, additional communal space and individual flats as well as an extension to one of the houses. In June 2008 we agreed the variation in registration so that the Home are able to provide accommodation for up to 55 residents. There were 36 residents living at the Home on the day of our visit. There has also been changes to the management structure of the Home. In February 2008 three assistant managers were appointed to strengthen the management team. All three assistant managers are qualified nurses and all have responsibility for designated areas of the Home and needs of the clients. The previous Manager of the Home left in May 2008 and a new Manager, John Hayes, has recently been appointed. What the service does well: The residents enjoy the meals and said that they are given choices. Snacks and drinks are offered throughout the day and individual dietary needs are catered for. Staff provide support to residents at mealtimes in a respectful and caring manner. The residents who take part in the activities said that they enjoy them. The Home is set in large grounds and so there is space for residents to have small animals and to do gardening. Staff said that they receive good induction and training. The majority of staff views are that they all work well as a team. DS0000069244.V369594.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As already mentioned, the management team have only recently been appointed but have already identified areas in need of improvement and have started to implement action plans. There needs to be a consistent staff team and less reliance on agency staff. The staff team would benefit from additional training about specific needs relating to individual residents to ensure that they can meet their needs. Clarification is needed with regard to residents who should have 1:1 support so that the organisation can be clear that they are providing the appropriate levels of support to individuals. The activities co-ordinator is enthusiastic and works hard to provide activities for as many residents as possible but additional support is needed to ensure that all residents are able to take part in meaningful activities. The older parts of the Home are in need of redecoration and refuburbishment. The management team have already received quotes and have made plans for some of this work to be done. One of the small houses has a very unpleasant odour and this needs to be addressed to ensure that the residents live in a pleasant environment. DS0000069244.V369594.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000069244.V369594.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000069244.V369594.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed appropriately prior to them moving to the Home to ensure their needs can be met. EVIDENCE: The organisation has appropriate procedures in place which enable full assessments to be carried out prior to a resident being offered accommodation at the Home. The Manager said that there are currently several referrals being considered and that the compatibility with residents already living at the Home is given serious consideration as part of the assessment. The Manager is also aware of the need for staffing to be increased as the number of residents living at the Home increases. DS0000069244.V369594.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care plans contain information about the residents needs and guidance to staff about how these are to be met. Residents are not fully involved in making decisions about issues that affect them EVIDENCE: We looked at four of the care plans and risk assessments. These contain a lot of information about the residents needs and how the staff should meet these. Assessments are carried out prior to the resident moving to the Home and we saw evidence that these are reviewed and updated as needed. At the last Inspection (August 2007) we were told that there were going to be improvements made to the care planning process. Improvements have only recently started to take place. Discussions with staff and the management DS0000069244.V369594.R01.S.doc Version 5.2 Page 11 team provided evidence of recent improvements that have been made to the care planning process and to the paperwork that is in use and gave examples of further improvements that are being planned to ensure that the residents are much more involved in the process. The majority of the staff surveys returned to us state that they receive up to date information about the residents needs but six stated that this does not always happen. The staff that spoke to us said that the handovers have recently improved and so they get better information now about any changes to a residents care plan. On the day of our visit two of the residents were taking part in a training session at another Home about their views of how they would like to be involved in care planning and the format that they would prefer to be used. The care plans provide evidence that generally risks are identified and assessed with plans in place to manage those risks although the staff and management team recognise that further improvements need to be made with regard to the management of behaviours that are challenging. The care plans also contain information about the reasons for any restrictions that may be in place. For example one of the care plans contains details about why the amount of cigarettes has been limited for one of the residents. In February 2008 a referral was made through Safeguarding procedures relating to the care provided to one of the residents who had recently moved to the Home. As a result of this referral the Operations Manager of the organisation was asked to investigate the complaint and one of the outcomes was that improvements to the care planning system needed to be made and also to the communication between amongst the staff team to ensure that all staff are aware of how to meet the needs of the residents. At the last Inspection a requirement was made about the need to consult with residents about their preferences and choices about the way in which their care is provided. The management team have started to implement plans for improvement. For example, residents meetings are planned to take place shortly after our visit to the Home and the way in which staff are deployed is being reviewed so that staff have more time with individual residents. One of the outcomes of the investigation carried out by the Operations Manager following the Safeguarding referral was the need to improve communication with those residents who do not use verbal communication. This work has not yet been carried out. There is little, if any, signage around the Home to assist residents with finding their way around the Home and plans to use pictures, photos and symbols to assist residents with understanding written information, such as menus, has not taken place. The care plans are not clear about the ways in which residents communicate. For example, one of DS0000069244.V369594.R01.S.doc Version 5.2 Page 12 the care plans seen describe the form of communication that the resident uses but staff said that they actually use a different form. DS0000069244.V369594.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some residents are supported to take part in social and leisure activities but these are not available to all residents on a consistent basis Residents receive an appealing, balanced diet but the dining arrangements are institutionalised EVIDENCE: At the last Inspection a requirement was made for the residents to be consulted and for meaningful activities to be provided. This requirement has not yet been met although many improvements in this area have been made with further improvements planned. Currently none of the residents attend formal day services or go to work. The Home employs one activities co-ordinator who works hard and is enthusiastic about organising as many meaningful activities as possible, both DS0000069244.V369594.R01.S.doc Version 5.2 Page 14 away from, and within the Home. She liases with the care staff to support them to be involved in activities with the residents. She is also arranging residents meetings so that the residents views about how they would like to spend their time can be gathered. The activities co-ordinator also carries out a monthly audit which records the level of activities offered and those taken up so that she can see which activities were enjoyed and which may need to be changed. The Manager said that there is currently some confusion about the amount of 1:1 support that some of the residents should be having and that he is arranging reviews to ensure that there is clarity about these staffing situations. The residents who do have 1:1 support are more likely to take part in activities as they have the staff support to do so. The management team are considering how best to staff the different areas of the Home to ensure that all residents have their needs met, including those relating to meaningful activities and how they spend their time. They gave examples of how they intend to make changes to facilitate this better. The Home is set in large grounds and there is an area set aside for gardening projects and for keeping small animals. One of the residents said that they really love having the animals there to look after. Another resident told us that they know that they can take part in activities if they wish to but that the staff respect their choice not to do so. Some residents were away on holiday at the time of our visit. The surveys completed by the residents all state that they are able to choose how they spend their time and the majority said that they are supported to make decisions about their life. The responses within the staff surveys are mixed with regard to the question about whether there are enough staff or not. The additional comments made on the surveys which indicated that there are not always enough staff are about the wish to provide more activities and to be able to support residents on an individual basis more often. The Home only has one large kitchen in which meals are prepared for all residents, regardless of where they live. There is seating in the dining room for the residents who live in the main house but all other residents take their meal on a tray back to their own flat/house. They all walk with trays of hot food outside for varying distances to access their own flats. They have to do this whatever the weather. The residents who spoke to us said that they enjoy their meals and that they are able to have drinks and snacks in between mealtimes. One said “I can have a cup of tea when I get up at 6am”. Another resident told us that they are on a diet and showed us their separate menu. We spoke to the cook and she said that she received a good induction and is receiving ongoing training. She gave examples of the different meals being provided that day for residents who do not want what is on the menu or who have specific dietary needs. DS0000069244.V369594.R01.S.doc Version 5.2 Page 15 We observed staff supporting residents with meals and drinks throughout the day. Residents are offered a choice of drinks and snacks, including fruit and yoghurts, between meals. During the lunch time meal we observed staff providing support to residents who needed full assistance with meals in a caring and sensitive manner. The Manager said that they are reviewing the times of the midday meal and about how residents are supported at this time as currently some residents start having lunch very early and may not have finished breakfast until late in the morning. Also some residents prefer to be supported at mealtimes when it is quieter and so they currently wait until the other residents have finished their meal. The Home employs domestic staff and residents are not generally supported to take part in household tasks. One of the residents showed us around her home and said that she does the cleaning there. She said that the staff help her if she needs them to but discussions with staff show that this is not taking place for many of the residents. One of the issues raised in the complaint that was investigated by the Operations Manager included the fact that the resident was not being supported to carry out household tasks despite this being part of her care plan. DS0000069244.V369594.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The basic personal and healthcare needs of the residents are met but the system in place for managing some medication does not ensure that all residents will receive medication at appropriate times. EVIDENCE: The residents are all registered with the local GP and also have access to specialist health and social care services as necessary. For example, the care plans show that some residents have support from the local learning disability or mental health teams. The AQAA completed by the previous Manager states that improvements need to be made to ensure that residents receive appropriate dental care. The care plans include health assessments such as pressure care and moving and handling although one of the residents who is at risk of falling had not had their falls risk assessment completed. The comment card completed by a health/social care professional contained positive comments about the care provided to the resident that they work with. The relatives surveys all state that they feel that their relatives needs are met at the Home and that the staff have the right skills and experience to do so. DS0000069244.V369594.R01.S.doc Version 5.2 Page 17 Two of the surveys contain additional comments about the need for clarity about staff responsibility with regard to agreements for healthcare and about whose responsibility it is to purchase items such as glasses. The staff surveys are mixed with regard to whether there are enough staff and there are additional comments made about the need for additional staff so that more time can be spent supporting individual residents. Staff who spoke to us also said that there are some residents who need additional time due to their specific needs but that there is not always time to do this in the way in which they would like to. The staff survey responses are mixed with regard to whether staff receive training which is relevant and which enables them to meet the needs of the residents. They also contain mixed responses with regard to whether they feel that they have the right skills and experience to meet the needs of the residents. The Manager said that he is aware of the need for additional training with regard to specific needs of individual residents and that this is being planned with the training manager. The complaint which the Operation Manager investigated was brought by a healthcare professional who felt that the needs of one of the residents was not being met at the Home. One of the outcomes of the investigation was that there needs to be clearer guidance about the circumstances in which a resident should be given PRN (as required) medication. We looked at the medication system and there was no written guidance available for PRN medication. In general, apart from PRN medication, the system in place enables residents to receive their medication at appropriate times and ensures that it is stored securely. Only the qualified nurses are responsible for administering medication. DS0000069244.V369594.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are aware of how to make a complaint and feel that they are listened to. EVIDENCE: The residents surveys all state that the staff treat them well and that they listen to what they have to say. They all state that the residents know who to speak to if they are unhappy about something. The relatives surveys all state that they know how to make a complaint and that any issues that they have raised with staff have been dealt with appropriately. The staff surveys all state that they know what to do if relatives or residents want to make a complaint. Residents told us that they feel confident in talking to staff. However, as previously mentioned in this report, further work needs to be done to improve communication with those residents who have difficulties with verbal communication as this will better enable them to raise any concerns they may have. The introduction of residents meetings will also improve the opportunities for residents to discuss issues and raise concerns. The record of complaints was seen and these need to include more information about the outcome of complaint investigations. There have been two referrals through Safeguarding procedures since the last Inspection. One relates to the DS0000069244.V369594.R01.S.doc Version 5.2 Page 19 situation previously referred to in this report and the other relates to an allegation of theft in which the member of staff has been dismissed. Staff who spoke to us were all aware of the correct procedure in the event of concerns about any form of abuse and aware of the whistle blowing procedure. Records show that the majority of the staff have attended Safeguarding training and the Manager said that dates are planned for those staff who have not yet attended or who need updates in this area. DS0000069244.V369594.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The standard of accommodation is varied across the different areas of the Home but mainly provides accommodation which is homely and comfortable EVIDENCE: The organisation has recently completed building new flats as well as extending one of the individual houses. The standard of these is extremely high. Some of the residents said that they are looking forward to moving into these new rooms and are waiting for confirmation of dates for this. The majority of the smaller houses as well as the main house are in need of redecoration. There is also a need for recarpeting and refurbishment of some areas. The Manager showed us quotes and plans for some of this work to be completed. There have been some delays as they are waiting for residents to be able to move into other areas before decorating the older buildings. DS0000069244.V369594.R01.S.doc Version 5.2 Page 21 The individual houses have their own kitchens but residents said that they do not use these except to make drinks in and that their meals come from the main kitchen. There is a lot of evidence of residents being able to personalise their own rooms/houses. There is a very unpleasant odour in one of the smaller houses. Staff described the action that they are taking to address this with one of the residents but which is not currently working. There are other residents living in this house and so this situation needs addressing as a matter of urgency. The site is large and the staff can often be spread out over a large area and so they use hand held radios to communicate with each other. The use of these was seen throughout the day and appear to be intrusive although staff said that the system works well as a way of communicating with each other and that they provide them with a sense of security in case of emergencies. DS0000069244.V369594.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 7 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet the basic needs of the residents and staff receive mandatory training to enable them to carry out their role EVIDENCE: Staff who spoke to us were enthusiastic about supporting the residents and about the improvements that have been made since the new management team has been in place. They said that they are being kept informed of changes and that they feel able to discuss these with the management team. They said that they feel that the improvements are in the best interests of the residents. Staff also said that there are times when staffing levels are too low to provide a good service to the residents as there is less time to provide individual support or to provide meaningful activities. The rotas confirmed that on occasions there are only three staff on duty in the main house. The Manager said that the usual staffing levels should be for there to be four care staff plus a nurse on duty in the main house and for there to be eight staff plus a nurse on duty to cover the houses/flats in the grounds of the main house. DS0000069244.V369594.R01.S.doc Version 5.2 Page 23 The Manager said that there are currently some vacancies for which they are recruiting and in the meantime they are using agency staff. He said that usually the agency staff have been at the Home before and know the residents quite well. This was confirmed by the staff who spoke to us. The staff surveys contained mixed views with regard to the staffing levels and provision of training and supervision. Additional comments were also mixed as can be seen from the following: “management are approachable” “handover is brilliant” “good team work” “managers are not interested” “sickness can cause staffing problems” “insufficient contingency for staff sickness” “staff work excessive hours” The organisation has a training manager who is responsible for ensuring that all staff receive induction as per the Common Induction Standards and mandatory training. The Manager said that he is working with the training manager to ensure that the staff also receive training with regard to specific needs of the residents, such as diabetes, working with people with challenging behaviour, mental health. We looked at a selection of recruitment files. A requirement was made at the last Inspection for these files to contain evidence of the necessary checks having been carried out. There were still some omissions within the files that we saw and so this requirement has not yet been met. Staff told us that they receive good induction when they first started working at the Home. This seems to have improved since the management team has been increased and the organisation has dedicated training staff. Staff also told us that they enjoy working at the Home and that they feel that there is good team work and that they receive support from their colleagues as well as the managers. Residents said that the staff are kind and that they listen to them. We observed staff supporting residents in a way which was kind and respectful. There was lots of interaction between residents and staff. DS0000069244.V369594.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents benefit from the new management team at the Home who are seeking the views of the residents on a more regular basis EVIDENCE: The organisation appointed three assistant managers in February 2008 to strengthen the management team at the Home. The three assistant managers have specific qualifications relevant to different areas and they have started to take on responsibility for different areas of the service provided at the Home. The previous Manager had worked at the Home for several years but left in May 2008. A new Manager, John Hayes, was appointed in June 2008 and is not yet registered with the Commission. The Manager has previously been DS0000069244.V369594.R01.S.doc Version 5.2 Page 25 registered with the Commission in his role as manager of other Care Homes. He has appropriate qualifications and experience to manage this Home. We spoke to the Manager and to one of the assistant managers and they gave lots of examples of improvements that have already been made and of further improvements that are planned. These are mainly with regard to involving the residents more in the decisions affecting them individually and in the way that the Home is run as well as improvements to the accommodation. Staff who spoke to us said that they feel that the management team are approachable and that they provide good support to the team. The organisation has a range of ways in which the quality of the service should be measured on a regular basis. A look at the records show that these have not been completed on a regular basis but the Manager is aware that these need to be implemented. The residents meetings will also provide another way of gathering the views of the residents. A selection of records relating to Health and Safety were seen. These show that regular servicing and maintenance of equipment, including fire safety equipment, takes place. However, the weekly fire alarm tests had not taken place for the previous six weeks. The Manager had already identified this and has already taken steps to ensure that this will take place on a regular basis. DS0000069244.V369594.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 3 2 X X 3 X DS0000069244.V369594.R01.S.doc Version 5.2 Page 27 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement Timescale for action 31/08/08 2. YA14 3. YA30 4. YA34 5. YA34 6. YA39 Clear guidance must be available with regard to PRN (as required) medication to ensure that residents receive medication at appropriate times 16(2m)(n) The home must ensure residents living in the house are consulted and have available activities and facilities for recreation that suits them as individuals The previous date of 01/11/07 was not met 16 (2)(k) The Home must be free from offensive odours to enable the residents to live in a pleasant environment 19(1)(c) The home must ensure that all relevant paperwork required to be held on staff who are employed is held within the home as stated in Schedule 2 of the National Minimum Standards The previous date of 01/11/07 was not met 18 (1)(c) Staff must receive training about issues relating to individuals clients needs to enable them to meet the clients needs 24 There must be an appropriate quality assurance system in DS0000069244.V369594.R01.S.doc 31/10/08 31/08/08 31/08/08 31/12/08 31/10/08 Version 5.2 Page 28 place to ensure that the views of the residents are sought and listened to RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The care plans need to reflect more aims and objectives for individuals as care plans develop and information is recorded on person, social and emotional well being. The content of the care plans need to reflect the individual personal care needs of the resident. 2. YA18 DS0000069244.V369594.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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