Inspection on 16/10/06 for The Elms

This inspection was carried out on 16th October 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Elms 18/10/07

The Elms 08/02/06

The Elms 14/06/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Elms (The) 28 Elms Way Southbourne Bournemouth Dorset BH6 3HU Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 16th October 2006 15:30 DS0000063293.V314204.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 DS0000063293.V314204.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. DS0000063293.V314204.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms (The) Address 28 Elms Way Southbourne Bournemouth Dorset BH6 3HU 01202 431886 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) Elms Care Limited Mrs Ana Maria Greenwood Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000063293.V314204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: The Elms is a small home set in its own mature grounds and is in keeping with all the properties in its immediate vicinity. It is situated in a quiet, residential area of Southbourne and is close to local shops and amenities. Bus routes to Bournemouth and Christchurch are easily accessed. The home is registered to accommodate a maximum of four adults of both sexes with a learning disability and had no vacancies at the time of inspection. The property has limited access to service users with physical disabilities. However, the facilities are appropriate for the intended service group, i.e. adults with learning disabilities. Three residents have single rooms on the first floor and there is a further bedroom on the ground floor. Residents share the use of an upstairs bathroom and downstairs shower room. On the ground floor there is a large lounge with a separate dining area and kitchen. The home is well kept and furnished. Outside there is a garden that provides a seating area for eating out and a storage shed. Service users are offered a wide range of opportunities both within and outside the home. Most service users attend day centres whilst one service user has a daily programme provided by the home. Current fees provided on 06/11/06 are between £750 and £1200 per week. Fees do not include personal items such as toiletries, hairdressing, cigarettes and sweets. For further information on fee levels and fair terms of contracts you are advised to referred to the Office of Fair Trading website www.oft.gov.uk. The home keeps copies of all inspection reports that are available in the office and can be seen by service users, relatives and professionals at their request. DS0000063293.V314204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place over approximately 4 ½ hours. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. This inspection was a key inspection and therefore, assessed all identified key national minimum standards for care homes for adults (18-65). The inspector spent time with Paul Greenwood and David Lallana, the registered providers of the home, and examined various records and documentation including care plans, risk assessments, staffing records, medication records, health and safety and maintenance records. The inspector conducted a tour of the premises viewing all communal areas of the home and a sample of three service users’ bedrooms. The inspector had the opportunity to talk to residents and observed other residents who had limited verbal communication skills. The inspector also spoke to a member of care staff who was on duty during the inspection. Additional information received by the inspector prior to the inspection was also taken into account. This included information gathered at previous inspections, monthly monitoring visit reports from the responsible individual of the home and any notification made under Regulation 37 of the Care Homes Regulations 2001. What the service does well: The Elms offers a small, family-type environment. Residents are able to contribute to the running of the home and enjoy flexible routines that cannot always be offered in larger homes. Residents spoke positively about their care and were clearly able to voice their opinions in front of the registered providers indicating an atmosphere of openness and respect. The Elms is ideally located in a residential area giving service users excellent access to the local community including shops and amenities. The premises are well maintained and decorated to a high standard providing a comfortable and homely environment. The home liaises well with other professionals ensuring the necessary information is obtained from them in order to make informed decisions about any potential new admissions to the home. Good links are formed with families and residents are supported to maintain and develop relationships. For example assistance is given such as arranging transport and making telephone calls. DS0000063293.V314204.R01.S.doc Version 5.2 Page 6 The home is well run and benefits from a well qualified and experienced leadership team who have an excellent knowledge of adults with learning disabilities including those with more complex needs. There is a small, competent staff team who spend a great deal of time working with service users and treat them with dignity and respect. In addition to training in health and safety topics, staff undertake courses to give them the specialist skills they need to meet service users needs such as communication skills, challenging behaviours and epilepsy. Staff have a good understanding of working with vulnerable adults, promoting and protecting the welfare of service users living in the home. What has improved since the last inspection? What they could do better: As a result of this inspection one requirement and eight recommendations have been made. There had been one complaint since the last inspection, which had been appropriately investigated by the home, and the care manager informed. The complaint had been unsubstantiated. However, as a notifiable incident a copy of this should have been sent to CSCI under Regulation 37. A few minor recommendations related to improving care plans were made during the inspection, including ensuring they contained relevant details of service users support needs and the arrangements in place for the DS0000063293.V314204.R01.S.doc Version 5.2 Page 7 management of their medication and finances, and signing and dating them to evidence when reviews have been carried out. It was also recommended that when any restrictions were agreed with service users such as a limit to the number of cigarettes smoked during the day, this be signed by the service user to evidence their agreement. The inspector noted that the home is currently using 3 different methods to record visits to healthcare professionals and recommended using one system would be more consistent and less confusing for staff. Written strategies for managing risks are limited and more consideration needs to be given to providing an assessment framework that promotes and extends service user independent living skills. A quality monitoring system has now been set up by the home, but there needs to be more evidence of how service user feedback is incorporated into the annual plan to ensure their views are included in how the service is improved. Further minor recommendations about recording were noted such as preprinted medication sheets having the wrong dates on them, recording the times of fire drills to ensure these took place at various times of the day and keeping copies of staff qualifications and training certificates. 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. DS0000063293.V314204.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 DS0000063293.V314204.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 at least once during a 12 month period. 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. An admission procedure is in place that ensures prospective service users are only admitted on the basis of a proper assessment and subsequent trial period ensuring the home is confident the service they provide will meet potential service users’ needs. EVIDENCE: There had been no new admissions to the home since the previous inspection. Evidence from the last inspection demonstrated that care management assessments and plans and further information from other healthcare professionals had been obtained prior to service users being admitted to the home. There was further evidence from this inspection that service users and their relatives had been consulted prior to admission. The home provides information about its admission procedure in the statement of purpose that says “a potential resident will only be offered a room at The Elms after a thorough assessment process based on detailed information supplied in our Pre-Admission Assessment form, any existing care plans and input from professionals.” It also states that potential service users are encouraged to visit and welcome to stay overnight, if appropriate. DS0000063293.V314204.R01.S.doc Version 5.2 Page 10 Service users are given further information to help them decide if the Elms would be a suitable home for them in the Service User Guide that is available in an accessible format to adults with learning disabilities. DS0000063293.V314204.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide staff with information about service users’ daily support needs and ensure these are being met. A few minor improvements to ensure consistency would give a more comprehensive guide about all aspects of service users care. Service users are encouraged to make choices in their daily lives with staff giving appropriate support according to each individual’s ability to understand and make decisions. Written strategies for managing risks are limited and more consideration needs to be given to providing an assessment framework that promotes and extends service user independent living skills. DS0000063293.V314204.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of two resident’s files was case tracked as part of the inspection. The home has now completed person centred plans for all residents setting out their daily support requirements, personal likes and dislikes and future goals. For example one resident was working towards being more independent in meal preparation and exploring the possibility of new activities such as work placements/college courses. The inspector noted that one of the care plans was not dated and this needs to be recorded to evidence when the plan has been reviewed. A few other minor recommendations were made to improve the consistency of care plans by ensuring all plans contained relevant details of service users support needs and the arrangements in place for the management of their medication and finances. It was also recommended that when any restrictions were agreed with service users such as a limit to the number of cigarettes smoked during the day, this be signed by the service user to evidence their agreement. Further information was available to staff in service users files to provide specific guidance for dealing with particular issues. This included information about health conditions such as epilepsy and guidelines for dealing with epileptic seizures and other guidance for managing ‘challenging’ behaviour. Observation during the inspection demonstrated staff had a good awareness of service users needs and were able to appropriately deal with and diffuse potential incidents in the home. Discussion with service users during the inspection confirmed they were able to make decisions in their daily lives. This included decisions about activities, visits to family and friends, personal appearances and the style and contents of their bedrooms. One service user discussed her plans to move into more independent accommodation in the future and it was clear that the proprietors were supporting her decisions. Other service users in the home have more limited communication and are less able to articulate their choices. Observation of practice showed that all service users were offered choices by members of staff where possible including being able to spend time alone in the privacy of their rooms and choices about food and drink. All service users have their own bank accounts and are supported by staff in varying degrees to manage their finances. A sample of two service users’ financial records was checked as part of the inspection. These were found to be up-to-date and accurate with records and receipts kept for all transactions made. Service users now sign their record books where appropriate to evidence when they have received their money. DS0000063293.V314204.R01.S.doc Version 5.2 Page 13 There was evidence on service users’ files that some risk assessments had been undertaken, however, these were limited and the inspector recommended that consideration be given to how risk management strategies could be used to promote and extend service users independent living skills. Risk assessments for various aspects of service users daily lives such as accessing the community, independent living skills and health and safety awareness provides a framework that can identify potential risks. Staff can then work with service users to see how these risks can be eliminated or minimised to promote service users independent living skills. DS0000063293.V314204.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users had a weekly programme of suitable activities and were able to access the community on a regular basis ensuring they have a range of social, leisure and educational opportunities. The home encourages service users to remain in touch with their families and residents are supported to contact and visit relatives and friends. Service users’ individual privacy was respected and they were clear about their own areas of responsibility in the home. A varied and healthy diet was offered and service users enjoyed the food provided by the home. DS0000063293.V314204.R01.S.doc Version 5.2 Page 15 EVIDENCE: Each service user has a weekly plan recorded on their personal files. A range of activities are offered with residents attending day centres or college courses or following an in-house programme including activities such as swimming, shopping, arts and crafts and accessing local leisure amenities. On the day of the inspection, one resident told the inspector about her day that she had spent at college, another resident was observed going out to an evening cookery class supported by a member of staff. The Elms is located in a residential area of Southbourne and both the local amenities of Southbourne and Christchurch are easily accessible from the home giving service users opportunities to access the local community by visiting the local shops, cafes, pubs, beaches and leisure centres. The home records service users outings and there was evidence they were going out on a regular basis. Information about service users’ relationships are recorded on their care plans and details of their family and friends are kept. The home has an ‘open door’ policy and welcomes visits from relatives. Service users confirmed they make regular visits to their families and friends and family were welcome to visit the home. Service users are also able to use the home’s telephone to contact their relatives and support with transport arrangements to visit relatives can also be given. Service users rights were recognised and their responsibilities to domestic tasks were identified on their care plans. The service user guide clarifies service users responsibilities and sets out that residents agree to respect each other and not go into another person’s bedroom unless invited. Observation of practice demonstrated that staff knocked on doors before entering service users’ bedrooms and showed that staff interacted fully with service users who were treated with respect. Service users were seen to have unrestricted access to all communal areas of the home and could choose to spend time in the privacy of their rooms. A sample of menus was viewed as part of the inspection. These were found to be varied and nutritious. The proprietor said residents were involved in the planning of the menu and picture formats were used to assist service users in making choices. Healthy eating was promoted in the home and service users told the inspector they liked the food and were able to assist with meal preparations. DS0000063293.V314204.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users privacy was respected and their preferences were taken into account when providing personal care/support. Service users were able to access a range of healthcare services including specialist support to ensure their physical and emotional health needs were met. Current arrangements for the administration of medication in the home meet the needs of the service users and ensure their well being. EVIDENCE: Service users’ records showed that their personal care needs were kept along with their daily support requirements. Service users personal likes and dislikes were noted and observation during the inspection showed staff supported service users in a sensitive way promoting their dignity. The home operates a key worker system and the service user guide specifies keyworkers are responsible “for seeing that you have all the help you need to live in the way DS0000063293.V314204.R01.S.doc Version 5.2 Page 17 that you want”. Discussion with staff demonstrated they had a good understanding of service users individual care needs. Each service users physical and mental health needs are identified in their individual care plans and a record of any medication is listed. In addition there is further guidance to staff about the management of particular medical conditions such as epilepsy. Two service users have copies of the personal health records (yellow books) that also list their up-to-date needs and a record of any appointments with healthcare professionals. Other service users have their appointments listed on specially designed sheets that record visits to G.P.s, dentists, opticians and other healthcare professionals. Some service users also have these visits recorded in their care plan. It was recommended that the home consider using one method of recording these visits for all service users to improve consistency and ensure there is no confusion for members of staff. There was evidence that the home liaised with healthcare professionals such as psychiatrists, psychologist and community nurses and there were examples of assessments that had been used to give staff for guidelines for managing behaviour. The home has a policy in place concerning the administration of medication. No service users are currently assessed as being able to manage their own medication. The home’s medication is kept in a small locked cupboard in the kitchen. Medication records were checked as part of the inspection and staff had been signing these appropriately. The inspector noted that the dates of the printed MARS sheets were not accurate and queried this with the proprietor who said that he would check this out with the pharmacy. DS0000063293.V314204.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective complaints procedure that enables residents to raise concerns knowing they will be acted upon and dealt with. Staff in the home have a good awareness of adult protection issues and work effectively to promote and safeguard service users welfare. EVIDENCE: The home has a complaints procedure that complies with the regulations. A copy is available in an accessible format for adults with learning disabilities. Information about advocacy services is also available in the home and there was evidence that service users are enabled to access this service to help them express their views. A record is kept of all complaints and there had been one complaint since the last inspection. This had been appropriately investigated by the home and the care manager had been notified. The complaint had been unsubstantiated, however, as a notifiable incident a copy of this should have been sent to CSCI under Regulation 37. The home has good policies and procedures in place concerning the protection of vulnerable adults and previous inspections have demonstrated staff know how to respond to allegations and deal with them correctly. Staff have undertaken POVA training to ensure their knowledge of procedures is kept upto-date. DS0000063293.V314204.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Elms maintains a good standard of décor and furnishings that provides the residents with an attractive, comfortable, homely environment. The standard of cleanliness is good with procedures in place to prevent the spread of infection providing service users with a hygienic environment. EVIDENCE: A tour of the premises was carried out as part of the inspection. All the communal areas were seen and 3 of the service user’s bedrooms. The premises were well maintained and decorated in a homely way that was suitable for its stated purpose, i.e. providing care and support to adults with learning disabilities. The home has a large, comfortable lounge with a dining area and a separate kitchen. Several improvements to the environment were noted including a new front door that had been fitted, the upstairs bathroom had been fully refurbished and a suitable lock had been fitted to the downstairs cloakroom/shower room, in response to a requirement made at the last DS0000063293.V314204.R01.S.doc Version 5.2 Page 20 inspection. Observation during the inspection showed service users have unrestricted access to all communal rooms in the home and they told the inspector they liked their living environment. On the day of the inspection the home was seen to be clean, hygienic and free from offensive odours. A policy and procedure was seen for the control of infection and staff had attended training courses on this topic. DS0000063293.V314204.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a small, experienced staff team who are well qualified and have a good understanding of working with people with learning disabilities. The home’s recruitment procedures ensure that staff are appropriately vetted safeguarding the welfare of service users living in the home. The home provides training courses that equip staff with skills and knowledge they need to meet service users’ care needs. EVIDENCE: The home currently employs 10 members of care staff who have a range of skills and experience. There is a mix of male and female staff and most staff had previous experience of working in social care. There are currently 6 members of staff who hold a qualification of NVQ level 2 or above. The staff rota was observed and showed that the home was staffed 24 hours a day, usually with one member of staff on duty. DS0000063293.V314204.R01.S.doc Version 5.2 Page 22 The home has a policy for the recruitment of staff. As part of the inspection a sample of 3 staff records was seen. There was evidence that appropriate recruitment procedures had been followed with application forms, references, proof of ID and CRB/POVA checks in place. Since the previous inspection the proprietor has designed a checklist for each member of staff’s file to ensure the appropriate documentation is in place. It was noted that some of the staff employed also work in the providers’ other registered services, however, specific contracts are given for each position held so their terms and conditions are specific to their place of employment. The proprietor monitors the training in the home and ensures staff up-date statutory training as necessary. In addition to courses in fire training, first aid, manual handling, medication, adult protection and food hygiene, staff have had the opportunity to undertake courses linked to the specialist needs of service users such as Makaton, challenging behaviour and epilepsy. As some of these courses are completed at the providers’ other registered services, certificates were not always available on the staff files the inspector viewed at the Elms, it was recommended that when this was the case copies of certificates are kept on the files held at the Elms. The proprietor has set up an in-house induction programme that covers topics such as the aims of the home, fire precautions, health and safety and the care of the residents. The inspector informed the manager about the new guidance from skills for care setting out standards for a new 12-week induction programme and advised the manager to ensure his current induction was up-dated if necessary to accommodate this. Discussion with staff during the inspection confirmed they felt they had good access to training and were well supported. DS0000063293.V314204.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from an experience and qualified leadership team who have excellent knowledge of the needs of adults with learning disabilities. The registered provider has identified ways to improve the quality of service provision over the forthcoming year; however, incorporating feedback from service users into the annual plan is needed to demonstrate how their views are taken into account. Management and practices in the home ensure that the health and safety of service users is promoted and protected. DS0000063293.V314204.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager of The Elms is Ana Greenwood. She has substantial experience of working with adults with learning disabilities and is a Registered Nurse (LD). She has previously managed homes for adults with severe learning disabilities and complex challenging behaviours and additional health needs within the health authority. Her past experience included staff supervision and training, and recruitment and selection. She has completed the Registered Managers award (NVQ 4 in management). There was further evidence she was up-dating her training and she had completed courses in adult protection, makaton, epilepsy and first aid since the previous inspection. Ana is supported in her role as manager by the other registered providers, Paul Greenwood, David and Sharon Lallana who are also all Registered Nurses (LD). There was evidence that the registered provider had begun to develop a quality monitoring system in the home. Service users had completed questionnaires about the quality of the service in June 2006 and an annual development plan had been produced. The inspector was shown the plan that identified forthcoming improvements for the service over the next year; however, the inspector recommended that further evidence was needed to demonstrate how service users views were taken into account. For example, identifying when ideas for service improvement had been as a result of feedback from service users either through an annual survey or other methods such as resident’s meetings. Reports from the Dorset Fire and Rescue Service and the Environmental Health Department confirm the home meets their requirements. Records showed that services and equipment was being inspected at the required intervals. Records of fire drills and safety checks were up-to-date, although it recommended that the times of fire drills were recorded to ensure these took place at various times of the day. The proprietor is aware of the relevant legislation regarding health and safety and policies and procedures reflected this. Staff confirmed they had undertaken various courses in safe working practices and observation of practice throughout the inspection demonstrated staff followed correct procedures. There was a “Health and Safety Assessment Policy” and risk assessments had been undertaken e.g. fire risk assessment. DS0000063293.V314204.R01.S.doc Version 5.2 Page 25 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X DS0000063293.V314204.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 YA22 Regulation 37 Requirement The registered provider must ensure that they notified CSCI of any incidents in the home as specified in Regulation 37 of the Care Homes Regulation 2001. This includes incidents that turn out to be unsubstantiated. Timescale for action 01/12/06 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 It is recommended that all service users’ care plans contain relevant details of service users support needs and the arrangements in place for the management of their medication and finances. It is also recommended that plans are signed and dated to evidence when reviews have been carried out. It is recommended that when any restrictions were agreed with service users such as a limit to the number of cigarettes smoked during the day, this be signed by the service user to evidence their agreement. 2. YA6 DS0000063293.V314204.R01.S.doc Version 5.2 Page 27 3. YA9 It is recommended that the home expands it risk assessment framework to provide more comprehensive strategies to minimising/reducing risk and that these are regularly reviewed to ensure service user have the opportunities to learn new skills and increase their independence in a framework designed to manage and minimise risks. It is recommended that the home consider using one method of recording service users’ visits to healthcare professionals to improve consistency and ensure there is no confusion for members of staff. It is recommended that the home checks the accuracy of dates recorded on pre-printed medication sheets with the pharmacist. It is recommended that copies of all staff qualifications and training certificates are kept on their files at the Elms. It is recommended that the home’s quality monitoring system demonstrates how feedback from service users is incorporated in the home’s annual development plan. It is recommended that the times of fire drills are recorded to ensure these take place at various times of the day. 4. YA19 5. YA20 6. 7. YA35 YA39 8. YA42 DS0000063293.V314204.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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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