Inspection on 30/10/07 for The Close Short Break Service

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Close Short Break Service 17/10/06

The Close Short Break Service 13/12/05

The Close Short Break Service 23/09/04

The Close Short Break Service 06/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 The Close Short Break Service Rock Lodge Road Roker Sunderland SR6 9NX Lead Inspector Elsie Allnutt Unannounced Inspection 30 October 2007 09:30 th The Close Short Break Service DS0000032753.V351357.R02.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 The Close Short Break Service DS0000032753.V351357.R02.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. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Close Short Break Service Address Rock Lodge Road Roker Sunderland SR6 9NX 0191 553 5425 0191 553 5430 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) Council of City of Sunderland Mrs Linda Margaret Gibson Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (3) of places The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: This short break service operates in a large detached building, which stands in enclosed grounds. The service provides personal care for younger adults with a learning disability and is situated close to the sea front at Roker in Sunderland. The house has its own grounds with mature trees, lawns and well cared for gardens and retains many attractive original features such as wood panelling and fire- places. The décor and furnishings reflect the style and period of the building. There is a large reception area that leads onto a large staircase up to bedrooms on the first floor. It has eight single bedrooms, two of which are on the ground floor and which provide accommodation for people with disabilities. There are also two twin bedrooms offering accommodation to friends or family members who request to share. A fridge, music centre, TV and DVD player are provided in each bedroom. The dining room and two lounges also lead off from the reception area and overlook the gardens. There is a main lounge that is very large and a smaller one that offers a more quiet area. The building provides four bathrooms and eight toilets. Three of the bathrooms also have showers and there is also one separate shower room. The top floor of the building accommodates a full sized snooker table, dartboard, music centre, and a wide screened TV and coffee corner. The majority of people who use the service are quite independent and are able to access all areas of the building. However, people with a physical disability are restricted to using the ground floor. The aim of the service is to provide a holiday type break for people attending the service while providing a break for the carers at home. A team of staff provide a programme of organised activities, as well as personal support, during each person’s stay. The home has developed a Service User Guide that informs prospective guests The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 5 about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fee charged by the home to guests is £90 per week. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. As this is a respite service that offers a holiday type experience, people who use this service are referred to as guests rather than service users. This will be reflected throughout this report. This unannounced but planned key inspection took 7.5 hours over one day in October 2007. Time was spent speaking to service users and staff, observing life in the home, reading care files and the home’s records and discussing issues with the manager including the Annual Quality Assurance Assessment (AQAA) submitted by the service. The views of six guests and four members of staff were sought. As some guests have difficulty with verbal communication, their satisfaction with the service was interpreted not only through speech but also through the observation of body language, interaction with staff and the examination of records. All guests were able to confirm that they enjoyed coming to The Close for a holiday. A tour of the building took place and a light lunch was taken with service users. What the service does well: This service provides accommodation to a very good standard. The way the daily routines are organised compares to that of a good quality hotel. The building is well maintained and as a result of effective cleaning routines, offers a clean and hygienic environment. The grounds are attractive, with well cared for garden areas where guests can relax and enjoy the surroundings. The friendly contact between guests and staff creates a warm and welcoming atmosphere in the home. So that guests are able to form and maintain relationships between each other, careful planning is carried out by the service so that friends receive breaks together. This is often at the request of guests, or as a result of an assessment carried out by staff, who try hard to create groups who get on well together. Guests are supported to live a full and active lifestyle. Guests confirmed that staff supports them to go shopping, enjoy a drink at the pub, go bowling, go to the cinema and visit many other interesting places One guest said that it is also nice to stay at home as there is always something interesting organised. Staff work with guests in a skilful way that allows guests to make decisions about how they want to be supported and what they prefer to do. This means that guests are in control of their lives and lead their own care. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 7 So that guests are supported to take part in varied activities of their choice, the management team uses a flexible approach to plan the staff rota. This means that the number of staff on duty may vary to support of the diverse needs of the guests staying there. What has improved since the last inspection? All of the requirements and recommendations made as a result of the previous inspection have been addressed and as a result of this many improvements have been made to the service. This means that the guests receive a service that aims to improve and develop in their best interests. Since the last inspection the service focus has been on improving the care plans. Although the structure of the care plans remains the same more detail is now included. This means that staff have more information and guidance to follow regarding how guests need and prefer to be supported. A new boiler has been fitted which means that there is an effective heating system to keep guests warm, comfortable and safe. Liquid soap and paper towel dispensers that have been fitted in the toilets and communal bathrooms and this promotes the systems in place to control the spread of infection. As a result of a request from guests when completing their service satisfaction surveys, all bedrooms now have a DVD and a fridge. This means that guests can use their bedrooms to enjoy their own company and privacy as well as entertaining other guests. A new barbecue has been purchased, again as a result of a suggestion from guests. Guests can now enjoy garden activities in the warmer weather and to assist them to access this area independently handrails have been provided down each side of the steps. The nature of this service allows people to receive a short break service in times of an emergency. To make sure that the placement is suitable and safe in this situation an Emergency Admissions policy has been developed that has clear criteria (rules). Staff are aware of the criteria and are also aware that the responsibility for agreeing to the emergency admission lies with the service manager, the registered manager or her deputy. This means that guests already staying at The Close are not put in a position that makes them unhappy or unsafe. Staff now receive training about particular needs of guests who might stay at The Close, this includes knowing how to support people who may not have speech or hearing. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 8 The manager and staff have spent a lot of time discussing what is expected of staff who work at The Close and how they should refer to and behave towards guests and each other. This is referred to as having the right values and attitudes. This means that guests will be treated with respect at all times. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 9 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 The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Guests are provided with good information about the service. This is in a format that is easy to understand and that helps service users to make an informed choice about where they would like to stay for their short break. Futhermore a contract is in place that informs guests of the service’s terms and conditions and the fees to be paid. Good multidisciplinary preadmission assessments demonstrate service users’ needs and aspirations and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: This service has developed a comprehensive Statement of Purpose and Service User Guide both of which are regularly up dated so that the information in them is current and accurate. Both documents have been reviewed since the last inspection and plans are in place for another review to take place so that the changes to the local authority’s charging systems can be reflected. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 11 Prior to guests receiving a service for the first time a detailed assessment of need is received from the referring agency with a current plan of care. When received a senior representative and the allocated key worker from The Close visits the person in their own home and carries out their own assessment of need. One guest staying at the service for the first time looked very comfortable in their surroundings and happy to be there. They described how they had visited The Close for tea and an overnight stay prior to making a decision to stay for their holiday. The service works closely with other professionals who may be involved in the individual’s care and they also provide information in the assessment process. The Close works closely with schools regarding the transition process of young people transferring from children’s into adult services, however this does not include supporting young people within the service at The Close who are under 18 years old. Individual contracts that describe the terms and conditions of the service are in place. The document has been developed into picture format and this enables guests to have a better understanding of the content. This document, which is signed by the guests or their representative is recorded in the care file. An information pack that informs guests about the service is in each bedroom. This includes a copy of the Statement of Purpose, The Service User Guide and the most recent CSCI Inspection Report. This makes sure that all guests have the important information about the service. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Detailed care plans guide staff to support guests appropriately, however these could be improved so that they demonstrate how guests are empowered to lead their own care. Guests are supported to take risks safely in order to develop independence and achieve their aspirations. EVIDENCE: Care plans that include detail about guests’ healthcare, social and emotional needs are in place and each time individual guests take a break at the service, staff check whether the needs remain the same and if needed make changes to the plan. Signed agreements are in place regarding the limitations of the rights of individual guests. This includes being responsible for taking medication and dealing with personal finances. The signature of the guest or their representative is included on the agreement to confirm that they understand and agree with the content. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 13 Risk assessments support guests to take part in activities safely and guide staff to support guests to maintain their independence. Staff have received training in Person Centred Planning and this is reflected in the care plans that now have a more person centred focus. This has been achieved by including more detail about the individual service user’s needs, preferences, likes and dislikes. Staff have also supported guests to develop information about themselves, by developing a small booklet, referred to as a Communication Passport. This is designed in a practical way that is easily carried around. The booklet is put together to reflect the individual’s needs, their likes, dislikes and preferences and is an empowering way to introduce themselves to other people/services. The manager has also worked with a self advocacy group, known as Sunderland People First, to develop a guide for people with learning disabilities about the end of life. It is aimed to support people who may not have support at home, to make choices and preparations for their funeral. The information is personal and is put together with the individual, acknowledging their diverse needs. It is illustrated with pictures and supported with information written in the basic word. Both documents include important information about the person and are written in the first person, so when reading them, the person who the information is about can be heard. This is a good way to empower guests to express their needs and to state their choices and decisions directly. A discussion took place with the manager acknowledging the different ideas used to empower guests while staying at The Close. It was agreed that the way information is recorded could be empowering. By using the first person when recording personalises the information and empowers the person to lead. It was suggested that the same concept could be used when recording in care plans. Currently care plans are written in the third person, which means that staff are directed what to do and how to assist the person. By writing them using the first person would empower the individual to lead staff regarding their care needs and to be in control of their care. The manager was receptive to these ideas. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 14 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): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live fulfilling lifestyles both at the short break service and in the community. The service supports service users’ rights and promotes their independence, while successfully supporting them in maintaining relationships with family and friends. Meals are healthy, nutritious and attractive, and are prepared to meet the individual dietary needs of each service user. EVIDENCE: Six guests were staying in this service and three members of staff, the deputy manager and the manager were on duty to give support to them in their chosen activities. The staff rota is organised in a flexible way and is determined by the assessed needs of the individual guests and the amount of support that they might need The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 15 to enjoy their planned activity programme. The availability of staff might also reflect the number of guests accommodated. Care plans include information about guests’ aspirations and the sort of activities and interests they hope to take part in during their stay. One care plan stated that the guest had requested to visit the theatre and although this was not to take place on this visit, plans are in place to achieve this during the guests next planned stay. The guest was happy to discuss this and other activities that they enjoyed, all of which were recorded. Guests enthusiastically discussed the activities they had planned and were particularly excited about a Halloween party that was planned for the evening and all had brought something special to wear. Staff confirmed that although a wide variety of activities take place in the community, some people often choose to stay at The Close to take part in activities there. One guest who had planned to go out on a chosen activity had changed their mind and requested to stay at home. This change was accommodated by the service. Guests choose the activities they want to take part in at the beginning of their stay. So that guests can make informed choices staff have developed a file that includes visual aids of different activities, including live music and theatre opportunities. Although this service is mainly focussed on arranging leisure activities, guests often discuss other aspects of their lives. This includes aspirations they might have to gain paid employment. In such cases guests are directed to the appropriate service called Workline and staff support the guest to make the initial contact. Guests are also introduced to various Friendship Groups that have been developed throughout the City of Sunderland by the Tenants and Residents Groups. This has opened up the opportunity to making new friends and joining new activities that can be accessed in the guests’ local communities from their own homes. The service at The Close is run and organised to promote respect, privacy and the rights of the guests who stay here. Staff care practices and attitudes reflect this. Guests’ rooms are respected as their private space and guests move around the building with confidence, demonstrating familiarity and comfort in their environment. A sample of menus confirmed a variety of food on offer and guests said that the meals offered were good. A pictorial menu book developed by staff, guides guests to make informed choices about what they wish to eat. Their food preferences are recorded in the care plan. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 16 A light lunch was enjoyed with guests and this proved to be an occasion where guests and staff exchanged relaxed conversation. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support appropriate to their needs and in a way that enables their privacy and dignity to be respected. Medication arrangements are appropriate for the needs of the guests, however procedures are not always followed appropriately. This means that mistakes could be made and guests could be put at risk. EVIDENCE: Many of the people using this service are independent, however records demonstrate that, when needed, guests are supported appropriately with personal tasks. One guest said, “Staff remind me to wear something warm when we go out,” and another said “I need help to blow dry my hair.” Another guest discussed how their key worker gives support if they are worried about anything and commented that they liked having one particular member The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 18 of staff to go to if needed. Guests had a good understanding of the key worker role. One guest had chosen to attend their college course during their stay. While waiting for a taxi to arrive they were caringly supported by staff and reminded about the arrangements for the day. The home is not equipped with any special mobility appliances, however a bath seat is available in one of the bathrooms. For guests who cannot manage stairs there are two bedrooms and bathing facilities on the ground floor. However neither are adapted or fitted with special facilities. The nature of the service does not generally include supporting service users with their healthcare needs. However if a GP is needed during anyone’s stay a local GP is contacted. Records are in place in relation to this. If behavioural support plans are needed, these are developed with the guidance of health professionals, who work closely with the staff team to monitor and adapt them if needed. The manager is currently reviewing the medication policy following an investigation into why a guest returned home without their medication. Although this error did not put the guest or any other guest at risk of harm, the manager is carrying out a full investigation into it. In the interim guidelines have been put in place for staff to follow when guests are discharged from The Close with medication. All staff have received training regarding the Safe Handling of Medicines and issues surrounding medication are regularly monitored and addressed. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 19 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. Arrangements in the service protect service users from abuse and seriously address any complaints and concerns about the service. EVIDENCE: The service has a complaints procedure that is picture format, making it easier for guests to understand. This is regularly discussed with the guests and a copy of the procedure is placed in each bedroom. At the end of each guest’s stay staff support them to discuss the service they have received and to make comments about it. Any concerns raised are recorded in the complaints book and are addressed following clearly defined procedures. Three complaints have been made over the past twelve months and all have been satisfactorily addressed following the appropriate procedures. Staff receive training in relation to verbal and physical aggression and in relation to the local authority’s protection of vulnerable adult procedures. A copy of the procedures is available in the office for staff to refer to when needed. Staff are aware of these and were able to confirm the process to follow. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 20 The manager discusses the procedures, the importance of treating guests with respect and reporting unacceptable behaviour towards guests within staff supervision sessions. There have been two safeguarding issues reported to the service over the past 12 months and both have been appropriately addressed. Records are in place to demonstrate this. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 21 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 excellent. This judgement has been made using available evidence including a visit to this service. The Close is well maintained, homely, and clean and offers guests a pleasant, comfortable and safe environment in which to stay. EVIDENCE: The standard of the furnishings and fittings in this home are good and reflect the period and character of the building, presenting an attractive and comfortable environment for guests. They were observed sitting in comfort in their surroundings and moving around with ease. A good maintenance programme promotes the high standard of décor and furnishings throughout this building and the maintenance person works with discretion and interacts with guests positively. The cleanliness of the home reflects good and effective cleaning routines as well as effective procedures relating to infection control. Staff receive training The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 22 in relation to this and domestic staff have successfully worked through NVQ training relevant to their role. The building is surrounded by well-kept and well-designed gardens that guests can safely access. Good quality garden furniture and a barbecue allow for varied outdoor activities and the steps down into the garden area now have hand rails so that guests with mobility problems have the support needed to promote their independence. The building is a large listed building that that does not have a lift, however the majority of people who use this service are physically able and can manage the stairs. There are two rooms on the ground floor that people that find it difficult to access the stairs use and a bath seat and grab rail in the bathroom supports bathing needs. The limitations that the building presents are stated very clearly the Statement of Purpose. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 23 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): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Staff interact with guests in a respectful and sensitive manner and clearly demonstrate that they have the appropriate skills and knowledge relating to guests’ needs. They show enthusiasm about their role and work effectively with the manager to further develop the service. One member of staff has developed a service user questionnaire using pictures and basic words so that guests have a greater chance of understanding the questions. Other staff have worked hard to establish a varied programme of activities and information that is accessible, to meet the diverse needs and interests of guests. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 24 Staff receive a good and varied training programme that offers appropriate opportunities to develop and learn skills related to their role. All staff are up to date with mandatory training and have recently attended training including: Autism, Team Building, British Sign Language (BSL) and other training related to sensory impairment. Staff files are well organised and clearly demonstrate the individual training undertaken. For one new member of staff a Learning and Development Record is in place that clearly records structured induction training based on the Skills for Care and the Learning Disabilities Award Framework (LDAF) standards. The outcomes of the training and the follow up dates for mandatory training are also in place. Recruitment records confirmed that the service’s robust recruitment procedures are followed. The appropriate information is in place including application forms, 2 references and CRB checks. However for one person evidence of a CRB check had not been received from the organisation’s central office. This was brought to the attention of the manager who agreed to follow this up. Guests who use the service are involved with the recruitment of new staff and at a previous inspection a guest discussed the questions they had asked. Staff discussed the training attended and demonstrated their interest and enthusiasm about the development of the service. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The manager operates a well-run service, in a way that creates an atmosphere of openness and respect, in which guests, their families and staff feel valued, listened to and empowered. EVIDENCE: The manager has now been in post for 12 months and during this time she has been successful in registering with the Commission for Social Care Inspection (CSCI) as the registered manager and has worked hard to establish her position within the home. The manager is qualified in NVQ Level 4 in Management and Care and has recently completed the Registered Managers Award (RMA). She is up to date The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 26 with mandatory training and attends regular training sessions related to her role. The manager, supported by her deputy manager, administrator and staff team, has worked hard to establish a service that is run in the best interests of the guests that visit the service. All guests spoke very highly of the service received and emphasised how much they enjoyed visiting The Close. One person said “It is excellent here I love coming.” A Quality Assurance System has been developed that is based on the National Minimum Care Standards and which the manager monitors on a monthly basis. Monthly visits from the local council’s Performance and Governance Team also monitor the standard of service delivered and guests are consulted at each of their visits about their satisfaction or otherwise with the service received. Questionnaires are sent out to families and carers and the responses are recorded and acted upon. Plans are put in place for annual developments for the service based on the outcomes of the surveys. Records kept in the home, including the accident and fire records are well maintained and securely stored and staff work reflecting their knowledge of health and safety procedures. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 27 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 4 2 3 3 4 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 3 X X 3 X The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Timescale for action Medicines in the custody 30/11/07 of the service must be handled according to the requirements of the Medicines Act 1968 and the guidelines of the Royal Pharmaceutical Society. The registered manager 30/11/07 must ensure that the CRB clearance received for new staff is available to be checked by CSCI. Requirement 2 YA34 19(1) 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 Consideration should be given to further improving care plans so that the individual is empowered to lead their care. The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Shields Area Office St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Close Short Break Service DS0000032753.V351357.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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