Inspection on 13/11/06 for The Elms [Stapleton]

This inspection was carried out on 13th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Elms [Stapleton] 21/10/08

The Elms [Stapleton] 05/11/07

The Elms [Stapleton] 20/06/06

The Elms [Stapleton] 03/03/06

The Elms [Stapleton] 17/08/05

The Elms [Stapleton] 18/08/04

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 The Elms Park Road Stapleton Village Bristol BS16 1AA Lead Inspector Sandra Jones Key Unannounced Inspection 13 & 17th November 2006 09:30 th The Elms DS0000026632.V319526.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 The Elms DS0000026632.V319526.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. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Address Park Road Stapleton Village Bristol BS16 1AA 0117 9584506 0117 9699000 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) www.brandontrust.org The Brandon Trust Mrs Tanya Abbott Care Home 14 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (2) of places The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate nine named residents whose primary focus of care is their mental health needs (Registration will revert to LD with no additional mental health care needs when these residents leave) The manager must be supernumerary at least three shifts per week. 2. Date of last inspection 20th June 2006 Brief Description of the Service: The Elms is operated by the Brandon Trust and managed by Tanya Abbott. The purpose of the home is to provide accommodation and personal care for up to fourteen adults with learning disabilities. Within the numbers, nine individuals with learning disabilities for whom mental health care needs is the primary focus of care, are accommodated. The property is situated within its own extensive grounds on Stapleton Village close to shops, bus routes and other amenities. It is arranged over two floors with shared space on the ground floor and bedrooms on both floors. The fees at the home range from £ 422.55 -£630.68 per week. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key visit was conducted unannounced over two days in November 2006 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the residents, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from resident, visitors and staff. “Have your say” surveys were sent to residents in the home prior to the inspection and six were returned. In addition to the surveys, feedback about the standards of care was also sought from GP’s, relatives and friends through comment cards. Information from these sources has been collated and is detailed throughout the report. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). What the service does well: Surveys were used to seek the views of the residents, relatives and outside agencies about the standards of care at the home. Overall the comments received were positive and indicate the standards of care are improving. Six completed surveys were received from residents and stated that they always make choices about their daily lives and staff treat them well. Residents indicated that they know the complaints procedure and who to speak to if they are not happy. Three positive responses were received from people that visit the home and supplementary comments were made about the skills of the staff and their dedication. Members of staff were observed using a friendly yet respectful approach when they interacted with residents. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 7 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 Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a clear commitment to assessing residents changing needs. EVIDENCE: “Have your say” surveys were sent to the home in advance of the inspection and six were returned. Three people indicated that they were given enough information to make a decision about living at the home. With the exception of two, the residents at The Elms have been at the home since the property was operated under the NHS. It is unlikely that the current admission process was followed then. Personal Care Plans have identified that three people wish to move into alternative placement. It is anticipated that four people will be assisted to seek alternative placements. Increasing health care needs that cannot be met by the home is the decision for another resident to seek another placement. It was understood from the manager that these vacancies will not be filled. This clearly indicates that the home is committed to assessing residents needs. . The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 9 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. Some residents independence may be compromised as they are not yet fully involved in their care planning. Residents confirmed that they can make decisions about their daily activities. The manager must consider advocacy in line with new legislation. Risk assessments are in place for activities that may involve an element of risk. EVIDENCE: The requirement regarding improving the care planning process will not lapse until the 30/11/06. The progress made with the care planning process was assessed, discussed with the manager and confirmed with the residents during the inspection. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 10 The manager explained that Planning Alternative Tomorrow with Hope (PATH) technique was used because this method focuses on the individual and is based on dreams and aspirations. The individuals wishes, cultural spiritual, beliefs and goals are sought through their PATH, which underpins support plans. There are five already in place and eight to be completed. Residents agreed to give feedback on the standards of care at the home. Residents confirmed that they were involved in discussions about their future with the manager and keyworkers. Two keyworkes with their key residents explained the PATH process and presented copies of their PATH. Members of staff and residents were eager to explain the process and the manner their PATH is to be presented. Support plans describe the need and indicate the person’s agreement, with the actions to be taken by the staff to meet the need. It is anticipated that the action plans will improve each time they are reviewed. Action plans must be clearer about the individuals preferred routine that staff must follow to meet the person needs. Where appropriate strategies and risk assessments are developed from identified risks. Support reducing plans were developed for residents that may exhibit aggressive and violent behaviours. For one person the Community Learning Disabilities (CLD) team was involved in the strategy, as restrictions were imposed on smoking and going into town. The manager explained that eventually these restrictions will be limiting the number of choices to achieve better mental health well being outcomes, for this individual. The manager explained the system that will be introduced to ensure that residents needs are consistently met. Staff must sign progress notes to indicate their awareness of the support plans, which endorses ownership. During supervision the keyworker and coordinator will monitor the support plans monthly to ensure residents changing needs are continuously assessed. Six “Have your Say” surveys were returned on behalf of the residents and four residents indicated that they always make decisions about what they do each day and three said this was usually the case. Residents consulted during the site visit gave examples of the decisions they make about their lifestyle and daily activities. It is clear that systems introduced are empowering residents to make choices. The keyworker of a resident with communication needs described the method used at the home to communicate with the person. Staff use gestures and signs to communicate and the resident will make decisions on the choices shown by the staff. Members of staff are aware of other means of communication and acknowledged that support from specialist should be sought to increase communication with this person. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 11 Running reports were examined during the site visit and indicate that staff record situations when residents make decisions not to follow advise given. For example, refusal of medication. The manager stated that advocates are not currently used at the home. It was further explained that one resident participated in a support group organised by “MIND” and People First can be accessed for advocacy. Advocacy needs to be considered in line with new legislation. A member of staff was designated the task of developing risk assessments and through consultation, the process was explained. It was understood that risks are generally identified by the staff and from incidents that have occurred which then trigger an assessment of the risk. Risk assessments are completed with the resident to gain their agreement with the plan of action and staff are kept informed about the assessments through the communication book. It is anticipated that staff will sign the assessment to ensure their awareness of the action plan. Risk assessments are in place for smoking, crossing the road other assessments for choking, falls and fire safety are also in place. Risk assessments are reviewed six monthly and signed by the resident. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Systems are being developed to increase opportunities for residents to have meaningful activities. Members of staff support residents to be part of the local community. Residents are supported to strengthen links with family and friends. In-house rules must be developed with the residents to promote their independence. EVIDENCE: Planning Alternative Tomorrow with Hope (PATH) is the systems used by the home to seek from residents their wishes and goals. Support plans will then The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 13 assist to achieve their identified wishes and goals. Members of staff confirmed that keyworkers organise action plans for residents to achieve their wishes and goals. Members of staff record pre-arranged 1:1 activities with their residents in the diary and at handovers spontaneous activities with residents are also organised. Staff made additional comments that the current staffing levels can retract from arranging ad-hoc outings with residents. The manager explained that the plans in place ensure that opportunities exist for residents to achieve their wishes and goals. One volunteer and a day care worker were recruited to provide packages of activities based on residents PATH plans. Choices for Learning and WEA were provided with a base within the grounds so that the residents can access the activities. Arts, Independent Living and Gardens are activities organised at the home and facilitated by outside agencies. Residents giving feedback confirmed that 1:1’s with their keyworkers took place and that they are not forced to go out. Another resident stated that they are able to leave the home independently and that concessionary bus passes were obtained on their behalf to travel by pubic transport. There is an activity rota that lists residents daily activities. Four residents are not currently involved in any structured day care and, the other residents attend day centres and colleges. During the site visit residents were observed going out with keyworkers and participating in activities held in the home’s grounds. Members of staff reported that the home’s transport is used for outings and 1:1 to ensure residents can pursue interests and hobbies. Eight residents are able to leave the home without staff support and from the documentation available it is evident that residents visit local shops, pubs and use local facilities. A “Fireworks” display was held at the home and neighbours were invited to promote contact and social inclusion with the residents. The arrangements for visiting the home are detailed in the Statement of Purposes. It states that visiting is open to family and friends and suggests that visits should take place at reasonable times. Three completed relatives comments cards were received before the site visit. Positive comments were made about the manner staff welcome visitors and that visits can take place in private. Two relatives were positive about the home keeping them informed on important matters and the level of consultation about the care to be provided. While one person was not positive about the level of consultation, it was commented that visits to the home are rare. This individual made supplementary comments about the staff’s helpfulness and their satisfaction with the standards of care at the home. A relative at the home agreed to give feedback about their observations of the The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 14 care provided. It was stated that their family member looks on the care service as their home and relatives were invited to social events organised at the home. The Smoking policy states that smoking is restricted to designated areas. One resident said that there is no smoking in bedrooms. The Privacy and Dignity sets the standards for respecting residents as individuals. It commits to providing personal care in private, promoting opportunities for residents to express their needs and preferences, mail will be handed to the person unopened and they will be addressed in their preferred manner. Residents have access to all parts of the building and grounds. It was understood from a member of staff that risk assessments were completed to determine residents safe accesses into the kitchen. Since the completion of the assessment, the kitchen is no longer locked. The action plan of the risk assessment is that for the fridge and knives are kept locked whenever staff are not in this room. Residents feedback about the rules of the home were sought during the site visit. One person stated that smoking was not allowed in bedrooms, another stated that there was an expectation that they undertake household chores and another said that there were no structured times to rise or retire. The manager explained the systems in place for informing residents about the expectations. “Places to Live Agreements” were introduced by the Trust and details the expectations of both parties. It was further explained that residents meetings are used to address house rules for example smoking. The manager with residents must develop the in-house rules to ensure that residents are part of the process that establishes the means by which the aims of the home can be achieved. The kitchen and meals was not inspected on this visit because refurbishment for the area has started. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 15 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. Residents confirmed that staff provide personal care in a sensitive way. Preferred routines must be detailed in residents support plans to further develop a person centred approach to meeting needs. The staff at the home monitor residents health care needs and where appropriate seek specialist advice. There are safe systems of medication. EVIDENCE: Support plans are prepared based on key areas of need, which include personal care needs. The persons abilities and the support to be provided by the staff is described within their support plans. There is a bathing routine schedule for all residents, their preferred routines must be included in the support plans to further develop a person centred approach to meeting residents needs. Residents reported that staff provide personal care in private and ensure their rights to dignity are observed The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 16 The manager explained that one person has mobility needs and walking aids and a walk-in shower was installed to increase independence levels. Health care records are kept separately from care plans. Health profiles include communication needs, health checks and weight monitoring charts. Within the profiles the assistance needed with health care professionals is also included in the individuals profile. Staff record observations of the residents health care, with actions taken and their outcomes. The residents accommodated are registered with a GP and residents giving feedback confirmed that they visit their GP with staff support. Comment cards based on seeking GP’s views about the care home were sent to health centres on behalf of the CSCI. A comment card was received from the local GP’s used by the resident. Their comments about communication, staff’s insight into residents needs and the provision of care was positive. The manager explained the arrangements in place for residents to access specialist support from health care professionals. Dieticians, psychologists and the Bristol intensive Response Team (BIRT) are accessed through the Community Learning Disabilities Team (CLDT). For residents with acute mental health care needs the CLDT is accessed directly. Senior House Officer (SHO) visit the home three monthly, to review the needs of nine residents with mental health care needs. Crisis management is provided for one person from the BIRT team. The manager explained the system in place for ensuring that the staff follow the advice from health care professionals. Information is passed during shift changes and, there is a handover folder where details about the shift are recorded for oncoming staff. Communication books are also used to alert staff that instructions about individual’s health care have changed. Where appropriate proactive strategies are in place, which lists the triggers of deteriorating mental health and positive actions to be taken by the staff. A member of staff is designated overall responsibility of the medication system and was present during the assessment of this standard. It was understood from this member of staff that there is an expectation that staff are competent to administer medications. Profiles that list the individuals medication with their purpose, dosage and side effects are in place. Medications are administered through a monitored dosage system by the staff. Administration of medication record sheets were examined and indicate that staff sign the records immediately after administering the medication. Controlled procedures are used for one person that is prescribed benzodiazepines. Homely remedies are administered from a stock supply when required by the resident and accurate recording of the remedies was found. “PRN” protocols are in place and list the known triggers, behaviours The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 17 displayed and proactive strategies, which guide the staff to administer medications appropriately. The Elms DS0000026632.V319526.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. The residents accommodated know the complaints procedure and who to approach with their complaints. Their feedback is sought and concerns taken seriously and acted upon. Staff at the home attend Safeguarding Adults training and are able to recognise forms of abuse and take appropriate action. EVIDENCE: The Trust has a detailed Complaints procedure, which is also available in a simple format and in Makaton. Complaints is a rolling agenda item for residents meetings to ensure accessibility and residents were provided with copies of the procedure. The residents giving feedback confirmed that staff take their concerns seriously and take action to resolve their concerns. “Have your say” surveys returned by residents were positive about who to approach with complaints and their awareness of the complaints procedure. There were twelve complaints received at the home since the last inspection and the nature of the complaint, the actions to be taken and the outcomes of the investigation are recorded. Residents signatures indicate the person’s agreement with the actions taken to resolve the complaint. From the log of complaints, it is evident that one person will bully others and make racist comments to the staff. The Bristol intensive Response Team (BIRT) were informed about the bullying and in their role have assessed the training needs The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 19 of the staff to enable staff to address the bullying. Support plans were introduced for this person and for the people that are targeted. Members of staff were supported to access Black Workers Support groups and all staff must attend anti-discriminatory course. The manager was consulted about their responsibilities towards safeguarding adults from abuse. The manager stated that there was one referral for safeguarding adults planning meeting and agencies are currently involved. There was also an investigation conducted about an allegation of missing items, with an inconclusive outcome. The staff employed at the home have completed Safeguarding Adults training. The Elms DS0000026632.V319526.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. Repairs and refurbishments are taking place to provide residents with a homely environment and improvements continue. The home is generally clean and free from unpleasant smells. EVIDENCE: The Elms is a large period property set in its own grounds within a village environment. It is close to amenities, shops and bus routes. Accommodation is arranged over two floors with shared space on the ground floor and bedrooms on both floors. There was a tour of the premises during the inspection and since the last inspection further steps have been taken to provide a homely environment. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 21 It was understood that although the corridor carpets are dirty, they were recently cleaned and once the kitchen is refurbished, the foyer carpet will be replaced with laminate flooring. Sensor lights were installed in the upstairs corridors to ensure that residents safety at night. There are two lounges, dining room and residents kitchen in the ground floor. Smokers use one of the lounges and ventilation is provided. Since the last inspection, lounge blinds were installed and a new three-piece suite was purchased. The dining room is adequate and offers sufficient seating for all the residents to sit together and have their meals. The kitchen will be refurbished while some residents are on holiday and the residents kitchen will be used for the residents that are at home. Overall residents bedrooms are decorated to a reasonable standard, the combination of the home’s furniture and residents’ belongings, reflect their personalities. The tiles around the sink in one bedroom and the seal around the hand basin in another bedroom need attention. An upstairs toilet was converted into a urinal for male residents and an extra long bath was installed in the adjacent bathroom. The laundry is separate from the kitchen, the walls are painted and the flooring is vinyl for easy cleaning. However, the room requires repainting and the flooring must be repaired or replaced. There are two domestic washing machines that can reach 95 and one tumble dryer. “Have your say” surveys were completed by four residents, which state that the home is always fresh and clean. The Elms DS0000026632.V319526.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): 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff at the home undertake training that ensures they have the skills and techniques to meet residents changing needs. EVIDENCE: Staff personnel files are kept at the Trust office and a separate inspection to examine these records will be undertaken by an inspector. Statutory training, which entails First Aid, Manual Handling and Food Hygiene, is provided by the Trust and the thirteen staff currently employed have completed statutory training. Medication training to NVQ level 3 is provided for the staff because medication administration is part of their role at the home. The manger explained that three staff have already completed the training and five are waiting for their results. Members of staff also attend other courses that are relevant to the changing needs of the residents accommodated. Positive Response training was provided to all the staff to increase insight into the needs of the people that may exhibit aggressive and The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 23 violent behaviours. Mental health and learning disabilities training was provided to the staff to ensure that staff have the skills to meet residents changing needs. One member of staff has attended autism training to gain specific understanding of the needs of people that have autism. In terms of Vocational qualifications, staff are encouraged to undertake further qualifications. Six staff have completed NVQ level 2, two staff are working towards NVQ level 3 and two senior staff have completed NVQ level 3. The Elms DS0000026632.V319526.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 & 39 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is experienced and qualified to manage the care home. Checks and systems in place ensure the environment is safe for residents and staff. A competent person should check the lightning conductor to ensure residents safety. EVIDENCE: The manager had completed the Registered Managers Award (RMA) and is undertaking NVQ level 5, which is based on the management of change. Feedback about the direction of the home was sought from the manager. It The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 25 was understood that the home is working towards the Trusts business plan in line with the 5-year strategy plan in line with Unique Futures. Members of staff were consulted about the conduct of the home. One member of staff said that “Everyday is a new day” and the manager has an honest approach. “The manager will tell the staff the truth, which has not always happened, and things are dealt with straight away”. Staff consulted also felt that the staff team were stronger and more stable. The manager encourages the staff team to make suggestions and to be part of the implantation. Completed “Have your say” surveys were received from residents and their comments indicate that the staff always treat them well and they always act on what they say. The records that relate to fire safety practices and checks were examined. The records indicate that checks and practices are conducted at the stipulated frequencies. Individual and area fire risk assessments are in place to ensure residents safety in the event of a fire. The manager takes steps to comply with associated legislation by the checks of system and appliances. Certificates are in place for the annual checks of the boiler and portable equipment. However, the check for the lighting conductor is out of date. A competent person should check the lightning conductor to ensure residents safety. The Elms DS0000026632.V319526.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 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 2 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x x x x 2 x The Elms DS0000026632.V319526.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. 2. Standard YA7 YA6 Regulation 12(2) 12(3) Requirement Timescale for action 30/04/07 The manager must consider advocacy in line with current legislation a) Residents signatures must be 30/01/07 included in their action plans. b) The individual’s decisionmaking process must be included into their person centred plans (pcp). c) Individual pcp must be developed for the residents accommodated. d) Personal care plans must be developed using a person centred approach. e) A system for monitoring the quality and content of pcp must be developed. (Partially met) In-house rules must be developed with residents Repairs and redecoration must take place as detailed in the body of the report. 30/03/07 30/03/07 3. 4. YA16 YA24 4 23 (2) The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 28 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 YA42 Good Practice Recommendations A competent person should check the lightning conductor annually. The Elms DS0000026632.V319526.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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