Inspection on 17/11/06 for The Farmhouse

This inspection was carried out on 17th 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Farmhouse 20/09/07

The Farmhouse 07/12/05

The Farmhouse 14/07/05

The Farmhouse 20/10/04

The Farmhouse 12/05/04

The Farmhouse 10/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Farmhouse Hundred Elms Farm Off Elms Lane Sudbury Middlesex HA0 2NP Lead Inspector Julie Schofield Key Unannounced Inspection 17th November 2006 08:00 DS0000017504.V320090.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 DS0000017504.V320090.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. DS0000017504.V320090.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Farmhouse Address Hundred Elms Farm Off Elms Lane Sudbury Middlesex HA0 2NP 020 8904 8282 020 8903 9860 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) Residential Care Services Ltd DR FRANK ERIBO Mr Tohoully Hughes Gibert Seri Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000017504.V320090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: The Farmhouse is a care home providing personal care to 6 adults with learning disabilities. At the time of the inspection there were no vacancies. The house is a Grade II listed building and is in a quiet residential part of Wembley but close the Harrow Road and Watford Road. There are bus routes along both of these roads and the nearest underground station is Sudbury Town. The property is detached and has a garden at the front and at the rear/side of the property. It is situated at the end of a short passageway (wide enough for access by car) and there is parking for approximately 4 vehicles outside the front gates of the home. There is also parking on the main road. The house consists of two floors, ground and first floor. The ground floor consists of an open plan lounge and dining area, a kitchen, bathroom (with toilet) and three service users bedrooms (two with ensuite toilet and one with ensuite toilet and shower). On the first floor there are three service users bedrooms (all with ensuite toilet and shower), the office, the laundry room and a quiet room (with ensuite toilet) that is used at night by a member of staff sleeping in. Since the last inspection the previous manager, Dr Lynda Eribo, who is also one of the joint proprietors, resigned and Gilbert Seri-Tohoully, a manager from another of the company’s care homes transferred to the Farmhouse. Details of fees may be obtained, on request, from the company’s head office, the telephone number of which is available from the care home. DS0000017504.V320090.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on the 17th November and two visits were made to the home on that day. The first visit started at 8 am and finished at 11 am. The second visit started at 4 pm and finished at 6 pm. During the two visits to the home an examination of records took place. A site inspection was undertaken, observation of a meal took place and there were discussions with the manager, staff and residents. As staff records, including training records, are held at the company’s head office in Forty Lane, a visit was made there on the 24th November. This visit started at 12.45 pm and finished at 2.30pm. The Inspector would like to thank everyone who assisted with the inspection. What the service does well: Two of the residents said that the staff were good and one said that his key worker “was easy to talk to”. They were satisfied with the service provided. They liked their rooms, the food served in the home and both had enjoyed the annual holiday. Residents have a comprehensive day care programme, which includes attending day centres, college courses and clubs held in the evenings. At the weekends they are able to take it easy or to take part in activities. Residents seem at home in the Farmhouse and move around the house, as they wish. Residents enjoy their rooms, which they have personalised and they use their rooms to relax in, listen to music or watch television. A resident was proud of the new items, which he had chosen and purchased for his room. The company’s training programme for staff provides a package of training that includes NVQ training, training in areas specific to the client group and training in safe working practices. The training needs of individual members of staff are identified and recorded in personal development plans. Members of staff said that they are also supported by management through individual supervision sessions and regular staff meetings. DS0000017504.V320090.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. DS0000017504.V320090.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 DS0000017504.V320090.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): 2, 4 Overall quality in this outcome area is good. An assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A trial visit to the home gives the prospective resident an opportunity to sample life in the home and to decide whether the service provided is suitable. However, recordings of these visits lacked detail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a resident from another of the company’s care homes has transferred to the Farmhouse. The letter sent to the placing authority requesting permission for this move stated the reasons why the move would be in the best interests of the resident. The request was made approximately 8 weeks after the placing authority had carried out a review of the care plan and placement and they agreed to this. A transition period was involved, which lasted 2 months. DS0000017504.V320090.R01.S.doc Version 5.2 Page 9 The case file was examined and a letter referred to a transition plan. The file did not contain a copy of this plan. The manager said that the plan might be at head office. On the second visit to the home the manager gave the Inspector a copy of the transition plan that had been delivered from Head Office. It listed a number of visits to the home, including having meals in the home and having an overnight stay and a weekend stay. It was noted that within the comments and observations section that entries were brief, lacked significant details and had no signature or date. Each one consisted of “Everything went well”. DS0000017504.V320090.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Overall quality in this outcome area is good. Reviewing the care plan and the placement on a regular basis ensures that changes in the needs of residents are identified and can be addressed. Daily recordings made before events have happened do not reflect the individual lifestyles of residents. The residents’ right to exercise choice in their daily lives is promoted and respected. Staff support residents to take responsible risks so that residents can enjoy an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. Each contained an assessment for a care plan, which covered areas including general health, personal care, social/family contact, leisure and behavioural problems. It was noted that an assessment DS0000017504.V320090.R01.S.doc Version 5.2 Page 11 for a care plan completed for an Asian resident specified how their gender, religious, cultural and dietary needs would be met. There was also a copy of the care plan on each file. This included long term and short term goals. Within each section strategies for improvement and levels of assistance required were recorded. The care plan identified needs in respect of medication, communication, religion, diet and practical living skills etc. Documents were signed by residents (or their relatives), where appropriate. Minutes of review meetings of the care plan and meetings to review the placement were on file. There was evidence that the placing authorities, representative from the day centre and relatives attended review meetings. The daily recording books were examined and it was noted that they had been completed before the end of the shift and before an event had happened e.g. before the resident had had their breakfast. On some shifts the recordings were identical for each resident. It was noted that residents had opportunities to make choices in their daily lives. Before the meal was prepared a resident confirmed that the member of staff had discussed the menu with them and asked whether they wanted something different to eat. On their return from day centre and before the evening meal residents chose whether to spend time in the lounge area or in their room. They are able to choose what clothes they want to wear and when they want to have a shower or bath. It was noted that when residents made choices these were respected. One of the residents has enrolled on a selfadvocacy course (“Speaking Up for Yourself”). Financial records relating to 4 of the residents were examined. Family members support the other 2 residents. Records were up to date and included details of items of expenditure and a balance after each transaction. All residents had a savings account. The manager said that the company’s accountant audits records. Case files contained risk assessments, which varied according to the needs of the residents. There were risk assessments in respect of throwing cutlery, angry behaviour, crossing roads, eating quickly etc. Risk assessments identified the risks, evaluated their likelihood and impact and included risk management strategies and a plan of action. There was evidence that they were subject of review. A missing persons policy is included in the manual of policies and procedures. DS0000017504.V320090.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, 14, 15, 16, 17 Overall quality in this outcome area is good. Taking part in activities, developing new skills and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. By maintaining contact with their family and friends the resident’s need for company and fellowship is met. Residents are encouraged to become more independent by making decisions and by having their wishes respected. Menus respect the religious, cultural and dietary needs of residents although vegetables, particularly green vegetables or salad, are needed to maintain a healthy balance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a weekly activities plan, which includes attendance at day centre on five days per week, Mondays to Fridays. On the day of the DS0000017504.V320090.R01.S.doc Version 5.2 Page 13 inspection 4 of the 6 residents left to attend a day centre, as part of their weekly day care programme. Two residents did not attend day centre because 1 resident had an early medical appointment and the other resident had an appointment in the home with a health care professional, later in the morning. Two residents said that they enjoyed going to the day centre. Residents have access to college courses organised by BACES through their day centres (adult independent living skills and “Speaking up for Yourself”) and one resident does horticulture. One of the residents prefers to stay at home on occasions and the manager said that on these occasions the resident’s wishes are respected. There is evidence that residents use community resources and these include the shops, the local sports centre for swimming, local restaurants for meals that meet their religious/cultural/dietary needs and cinemas. A resident said that he went shopping at the weekends. The home has the use of a mini van to transport residents or they can use public transport or taxis. There was evidence that each residents’ name was entered on the electoral roll, apart from the resident that had recently transferred to the home. Each resident had an individual weekly programme of activities. There is evidence in the daily recordings and in financial records that residents attend the Apple and Gateway clubs and the leisure club run by the company. Outings have taken place to Margate, Brent Cross, the British Museum and the Air force Museum. Five residents went on an annual holiday to Minehead in July, although one resident said that they had been to Bognor Regis. He said that it was a change and that he had enjoyed himself. He liked where they had stayed. The sixth resident will be going abroad on holiday, with their family. Within the home it was noted that residents like to do colouring, watch TV, listen to music and read the paper. The entries in the visitors’ book confirmed that residents received regular visits from members of their family. A resident confirmed that visitors are made welcome when they come to the home and that visits can take place in the lounge areas or in the privacy of the resident’s room. The manager said that family members are also invited to attend birthday celebrations in the home and the end of year party. Some relatives take the resident out to attend an event taking place in the community or to spend time in the relative’s home. One of the residents said that they liked to help with the preparation of the meals by cutting up the vegetables. It was noted during the inspection that residents take turns to help in the kitchen. Residents are able to choose whether they want to take part in any activities or whether they want to socialise with other residents. Residents’ privacy is respected and it was noted that residents were able to choose to spend time alone in their rooms, if they wished. It was noted that residents are encouraged to take part in the domestic routines in the home and they help to clear their plates away and to do their laundry, under supervision. DS0000017504.V320090.R01.S.doc Version 5.2 Page 14 Training attendance certificates were available to confirm that staff have undertaken food hygiene training. Each week there are 2 menus for the home as there is a menu for the African-Caribbean residents and another menu for the Asian residents, who are both vegetarian. An Asian resident gave examples of the food served in the home, which met their religious, cultural and dietary needs. The member of staff who was preparing the evening meal said that he had checked with the residents whether they wanted to have an alternative to the meal but no one had requested any changes. The meal prepared for the African-Caribbean residents was not the one recorded on the menu. It was tuna in a tomato sauce with potatoes. There were no green vegetables or salad. Fruit is available for residents to help themselves from. Residents dine together in the dining room. Between meals hot drinks and snacks are available. DS0000017504.V320090.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 good. Residents receive assistance with or prompting with personal care in a manner, which respects their dignity and privacy. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was noted that the assessment for the care plan document included a section on personal care and this specified what assistance, if any, would be required e.g. prompting. Where there was a need for a carer of the same sex to provide assistance this was noted. All of the current residents are male and there is always at least 1 male carer on duty on each shift. At present there is only 1 Asian member of staff and so it is not possible to provide this support DS0000017504.V320090.R01.S.doc Version 5.2 Page 16 on each shift to the 2 Asian residents. Other residents are African-Caribbean and there are African Caribbean and African staff working in the home. All residents are able to speak or to understand English and all staff are able to speak English. Within the case files are summaries for staff on how to support residents so that the resident’s likes and dislikes are respected in the daily routines. Case files contained evidence of access to health care services in the community. There was a record of outpatient appointments at the hospital. These included appointments with the psychiatrist, the ENT clinic, the urology department etc. There was a record of medication reviews having taken place. Residents had appointments with the GP, optician and with the dentist. The chiropodist visits the home. The speech and language therapist had carried out assessments. Referrals had been made to the continence advisor. Residents also had access to routine health screening e.g. blood tests and to preventative medicine e.g. flu jabs. The storage of medication was inspected. It is kept in a locked facility. The pharmacist supplies weekly dosette boxes. These are identified by the residents’ names. The empty compartments in the boxes were appropriate for the time of day and for the day of the week on which the inspection visit took place. Records of the administration of medication were inspected. They were up to date and complete. The training plan records that each person working in the home has completed medication training and members of staff on duty during the inspection confirmed this. DS0000017504.V320090.R01.S.doc Version 5.2 Page 17 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. Residents are aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure was available in the home. The simple procedure included timescales for each stage of the procedure and referred complainants to the directors of the company, if the home’s manager could not resolve matters. Information regarding access to other agencies e.g. the CSCI was included, with the address and telephone number of the local office. A suggestions box was in the home. The manager said that no complaints have been recorded since the last inspection. Two residents confirmed that if they had any complaints they could speak to some one in the home and both identified the manager as this person. It was noted during the inspection that residents seemed confident in expressing their likes and dislikes to the staff on duty. The manager said that he uses the residents’ meetings as an opportunity to check with residents whether they are satisfied with the service and to see if they have any concerns or complaints. DS0000017504.V320090.R01.S.doc Version 5.2 Page 18 There is a protection of vulnerable adults policy in place in the home. The home also had copies of each placing authority’s interagency guidelines in the event of abuse. The manager said that no allegations or incidents of abuse have been recorded since the last inspection. Staff on duty confirmed that they had received training in protection of vulnerable adults procedures. However it was noted that the date of the training, recorded on the plan for the home, was 2003 for 2 of the members of staff. Staff demonstrated an awareness of the whistle blowing procedure. Training undertaken by staff includes an understanding of physical and verbal aggression by a resident. The manager said that restraint is not practiced in the home. DS0000017504.V320090.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 Overall quality in this outcome area is good. Residents enjoy a comfortable and “homely” environment with pleasant communal and private facilities in which to relax. Some minor redecoration is needed. Residents live in a home where standards of cleanliness are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are safe and maintained to a good standard. The home is comfortably decorated and furnished and offers residents a “homely” environment. The premises were warm and adequately lit. Residents are able to access all of the communal areas. It was noted that the heavy curtains in the dining/lounge area did not reach the windowsills. The new flooring in the ground floor bathroom was “rippled” and the walls needed repainting. DS0000017504.V320090.R01.S.doc Version 5.2 Page 20 Each resident has their own single room. There are bedrooms on the ground and on the first floors. Two rooms have an ensuite toilet and four rooms have an ensuite toilet and shower. Two residents said that they liked their rooms. Both residents said that their rooms were sufficient in size and one of the residents said that when they prayed in their room staff respected the resident’s privacy. Each bedroom reflected the personality of its occupant and residents had purchased personal items. It was noted that on their return home from day centres most residents liked to spend some time in their rooms relaxing. A site visit took place during the inspection and it was noted that all areas were clean and tidy and free from offensive odours. An infection control policy is included in the manual of policies and procedures. The manager said that all the staff working in the home have undertaken infection control training and the members of staff on duty during the inspection and training attendance certificates confirmed this. Laundry facilities are situated in a room on the first floor and soiled clothing can be taken there without walking through areas where food is stored, prepared or eaten. The new washing machine has a sluicing cycle. It is a larger size machine than the one that it replaced and there is restricted access to the door of the machine, due to the lower shelf on the opposite wall. DS0000017504.V320090.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. NVQ training enhances the general skills and knowledge of carers and contributes towards the quality of service that the residents receive. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents. Residents are supported by staff that have access to a comprehensive range of training courses, enabling them to meet the residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 4 carers’ names on the rota (including both permanent staff and agency staff that work in the home on a regular basis), 2 carers have completed their NVQ level 2 training and 1 carer is currently undertaking level 2 training. Therefore the home has met the target of 50 of the staff team qualified to an NVQ level 2 standard. DS0000017504.V320090.R01.S.doc Version 5.2 Page 22 It was observed during the 2 visits to the home that there were sufficient staff on duty to support the needs of the current service users. The rota was examined. There is a minimum of 2 staff on duty for the morning and 2 for the afternoon although additional staff are included on the rota when residents have appointments or on a Sunday if a resident wants to go to church. At night there are 2 members of staff. One member of staff sleeps in but is on call and the other member of staff is a “partial night” as they have to get up once in the night to assist a resident with changing an incontinence pad. The staff team reflects the gender composition of residents and includes staff that reflect the cultural composition of residents. Information has been provided for staff in respect of Makaton, as 2 of the residents use some Makaton signs to communicate. The manager said that staff would be attending a training course on the use of Makaton signs. Two staff files were examined. One of these files belonged to a member of staff who was supplied by an agency. Both files contained an application form, 2 satisfactory references, enhanced CRB disclosure details and passport details and/or proof of right to work. The file belonging to a permanent member of staff contained a contract. A copy of the training plan for the Farmhouse for the period 2006 to 2007 was available for inspection. The plan listed the names of the five members of staff working in the Bungalow (both on a permanent and on an agency basis) and there was an up to date record of training courses attended. It included both statutory training and additional courses, which enabled staff to fulfil the aims of the home and to meet the needs of the residents. Staff files contained copies of training attendance certificates and it was noted that staff had attended courses in respect of safe working practices e.g. fire awareness, infection control, food hygiene, medication etc. They had also attended courses to enable them to support residents e.g. autism, challenging behaviour, epilepsy and protection of vulnerable adults. The Inspector was provided with a copy of the new Skills for Care “Common Induction Standards Social Care (Adults)” Progress Log, which the home will use in connection with their induction training programme. A copy of the Personal Development Plan was available. This is used in the appraisal process and includes an identification of training needs. DS0000017504.V320090.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. By establishing good working practices and monitoring the quality of care in the home the registered manager promotes a safe and enjoyable environment for residents. Service satisfaction questionnaires, meetings and individual discussions with residents help to monitor the quality of the service provided to residents and contribute towards the development of the service. The training that staff receive in safe working practice topics enables them to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000017504.V320090.R01.S.doc Version 5.2 Page 24 The new manager successfully completed their RMA training. He has worked as a manager of a care home, for adults with learning disabilities, for approximately 4 years. He has recently undertaken training in appraisal techniques and in fire control. Residents are able to give feedback on the quality of the service during discussions with members of staff, at their review meetings, at meetings with their key workers and at residents’ meetings, which are held on a monthly basis. Family members and representatives of the placing authorities can give verbal feedback during visits to the home and at review meetings. Comments made at review meetings are recorded in the minutes. Residents, members of staff and visitors to the home can use the suggestion box to leave comments. A service satisfaction questionnaire had recently been sent to relatives, stakeholders and to those residents in care homes owned by the company that would be able to complete them (with the support of an independent person, if necessary). A review of response rates to the previous questionnaire had led to its re-design. It was now just 2 sides of paper rather than the previous, lengthier document. The company intends to publish the results of the survey in a newsletter and to include a summary of the results in the annual development plan for the business. Valid certificates for the servicing/checking of the fire extinguishers and for the smoke detectors, emergency lighting etc were available. The Landlords Gas Safety Record and a certificate for the checking of the electrical installation were available for inspection. The record of weekly fire alarm tests and of fire drills was available for inspection and was up to date. Each member of staff had participated in a fire drill within the last 2 months. There was a recent Bacteriological Analysis in respect of the water system. A risk assessment in respect of the environment, including fire safety, and an assessment in respect of food hygiene were available. There is a locked COSHH cupboard in the home. The members of staff on duty confirmed that they had received training in safe working practice topics i.e. fire safety, food hygiene and infection control. DS0000017504.V320090.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 2 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 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000017504.V320090.R01.S.doc Version 5.2 Page 26 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 YA4 Regulation 12.1 Requirement That documents used to record the content of visits made to the home by a prospective resident as part of a transition plan are kept in the home, on the resident’s case file. That the record of each visit made as part of the transition plan includes comprehensive details of the reactions of the other residents, staff observations, what the prospective resident did/what they said/how they reacted/significant changes in behaviour etc and that the record is signed and dated. That daily recordings are made after events happen and not before. That main meals include servings of vegetables (green where possible) or salad. That heavy curtains in the lounge/dining area are of a sufficient length that they reach the windowsill. That the flooring in the bathroom is straightened out and that the walls are painted. DS0000017504.V320090.R01.S.doc Timescale for action 01/01/07 2 YA4 12.3 01/01/07 3 4 5 YA6 12.1 16.2 16.2 08/12/06 01/01/07 01/01/07 YA17 YA24 6 YA24 16.2 01/02/07 Version 5.2 Page 27 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 2 3 Refer to Standard YA6 YA23 YA30 Good Practice Recommendations That the home reviews the content of the daily recordings. That staff repeat the protection of vulnerable adults training on a regular basis. That the lower shelf in the laundry room, on the wall opposite to the washing machine, is either remove or the curved section of the shelf is removed. DS0000017504.V320090.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000017504.V320090.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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