Inspection on 08/08/06 for The Old Quarries

This inspection was carried out on 8th August 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Quarries 30/01/06

The Old Quarries 16/08/05

The Old Quarries 26/01/05

The Old Quarries 19/10/04

The Old Quarries 12/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Old Quarries Rectory Lane Avening Nr Tetbury Glos GL8 8NJ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 8th August 2006 09:00 The Old Quarries DS0000016623.V303581.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 Old Quarries DS0000016623.V303581.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 Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Quarries Address Rectory Lane Avening Nr Tetbury Glos GL8 8NJ 01453 832201 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.hft.org.uk Home Farm Trust Mrs Janet June Newbould Care Home 33 Category(ies) of Learning disability (33), Physical disability (3) registration, with number of places The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 33 LD includes 3 LD residents who are also under PD Date of last inspection 30th January 2006 Brief Description of the Service: The Old Quarries is an old Vicarage House with a number of accommodation facilities within the house or grounds. The home is situated near Tetbury and Nailsworth in Gloucestershire and service users have access to transport that is provided by the Organisation. The service users use the local facilities, supported by staff where appropriate. The site is staffed 24 hours a day, seven days a week. Family and friends are welcome to visit the Old Quarries at any time and service users can meet them in private if they wish to. The service users at the site use a number of Day Services, most service users attend the Day Services that are available on site provided by the Home Farm Trust. Gloucestershire Social Services and local Colleges provide other Day Services. The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was completed on a day in July and the registered manager was on site during the inspection. The inspector visited each unit across the site and spoke to people whenever the opportunity arose. People living at the home were asked about their care packages, staffing and what it was like to live at the home. In each of the units across the site the inspector case-tracked a person’s care examining their assessments, care plans, risk assessments and any other significant documents relating to their care. Whilst visiting each unit the inspector looked at the quality of the accommodation. Where possible the inspector took the opportunity to speak to staff about working at the home and their input in supporting people to meet their goals. When feeding back the findings of the site visit it was agreed with the manager that the best approach for certain sections of this report was to identify each of the units. The inspector would like to take this opportunity to thank the people living at the home and the staff for their time during the day of the site visit. On the day of the site visit the inspector left a number of surveys to be completed by people in their own time if they wished. In addition to this the inspector has sent a number of surveys to relatives and other professionals involved in the care of people living in the home. At the time of this reports publication a number of these surveys remained outstanding. Any comments received from these surveys will be taken into account at any future inspections. The surveys returned to the CSCI were really positive about the service. What the service does well: The home provides people with a safe environment to live and develop their skills. People are supported to identify their goals and needs and develop Person Centred Plans using technology such as computers and videos if they wish. Risks are identified and minimised by staff allowing people to take calculated risks that will improve their lifestyles. People clearly expressed how much they enjoyed the activities they are involved in on and off site. Surveys returned to the inspector also confirmed this information. The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 6 The organisation has a robust recruitment procedure that ensures people are not put at risk. Although two shortfalls were identified the inspector felt that the procedure still minimises risks. When staff have been employed they complete a comprehensive induction training programme that is followed by regular training in topics relating to the needs of the people they support. The management team have re-assessed a number of peoples needs in relation to the hours they receive. This has enabled additional funding for hours providing people with one to one staffing at different times. The organisation have provided a couple with brand new, needs led accommodation that enables them to live as independently as possible, but with the appropriate support to maintain their safety. 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 Old Quarries DS0000016623.V303581.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 Old Quarries DS0000016623.V303581.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 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. Based on the evidence of the previous inspection. Comprehensive assessments are completed before people are admitted to the home. This minimises the risk of someone being admitted to the home whose needs cannot be met. EVIDENCE: The home has a comprehensive admissions policy. At the previous inspection the inspector examined the process completed by staff for the last person admitted to the home. The previous admission process included an assessment completed by a previous placement and another completed by a social worker employed by HFT. Both assessments were comprehensive and enabled the home to make an informed decision as to whether they would be able to meet the person’s needs. No new admissions have happened since the previous inspection. At the time of this inspection the home were in the process of assessing prospective service users and the inspector will examine this process at the next inspection. The Old Quarries DS0000016623.V303581.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 at least once during a 12 month period. 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. PCPs are in place but it was difficult to confirm that people’s needs are being addressed due to poor administration. Guidelines and other documents that staff should complete and review regularly were generally incomplete and out of date. This may put people living at the home at risk. EVIDENCE: Across the site the home is split into smaller units. The inspector visited all of these units and examined one person’s file in each of them. The home has a person centred planning (PCP) approach to meeting peoples’ needs. Peoples’ comments confirmed they were involved in developing their PCP’s and all the people who spent time with the inspector gave accounts of their involvement. Where possible (when people were available) the inspector sat with them while they either explained their PCP or confirmed that their The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 10 goals/needs were being met. In addition to the PCP’s support plans (called ‘my support plan’) are developed, which identify people’s strengths and weaknesses, talents, achievements and dreams, etc. The format of the PCP’s continues to be developed by the registered manager using video, computers and pictures. Examples of these were available and the inspector has seen PCP’s created on a computer and stored on a Cdrom kept by an individual at a previous inspection. Meadow View The person’s file examined by the inspector showed that the last PCP meeting was held in August ’05, just over twelve months ago (relatives and other professionals were involved in this meeting). Staff on duty explained that the person’s key worker had been off sick for a while and this was the reason for a meeting not being organised. Further examination of the PCP goals showed that a meeting should have been arranged for 6 months after the meeting (February ’06) but there was no evidence of this goal being achieved. The inspector sat with the person and asked them about their goals and which ones they had achieved. The person explained that they had had the opportunity to complete the majority of the goals they had highlighted. The person’s PCP was produced in a good paper format making use of pictures, bright colours and plain English. Examination of the person’s file showed a substantial amount of the forms/paperwork used to support the person, identify their needs and record their progress incomplete. Examples of these forms included; information review sheet was blank, a record the person’s progress towards meeting their goals that was blank, personal fact sheet that was incomplete, inventory of personal belongings was blank, last wishes document not complete. The inspector examined the person’s personal file (blue file) as its index stated that it would hold their risk assessments. No risk assessments were present and the staff on duty stated that they may be with the unit manager as all of the files are being reviewed. The Gallery Flat The inspector examined the file for the last person to be admitted to the unit. Notifications of incidents about this person have also been received by the inspector. Again the inspector found a number of forms that were incomplete. Some forms had been completed and evidence of them being reviewed was present. The inspector was concerned that a meeting had taken place with the person and their parents in February 2006 where 7 goals were set and it had been proposed that a meeting was held 2-3 months after as a follow up. There was no evidence that any of the goals have been met, and the meeting has not been held. The manager stated that they were currently working with the family and that they felt it had been inappropriate to been working on the The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 11 service user’s PCP. The inspector recommends that the service user is given the opportunity now to create a PCP with their key worker to enable them to plan meeting their identified goals. Some risk assessments were seen. The organisation use a system called assessnet to assess risks to the service users. This is a computer based system where staff are able to access assessments completed by other staff across the organisation. The Bungalow The file examined by the inspector contained the minutes of an annual contract meeting held in May ’06. This meeting involved other professionals and family members. The minutes seen were comprehensive. Due to the complex needs of the person the home have been making good use of other professionals to meet needs that they are not qualified to. A PCP was present for the person but the inspector was unable to find any goals that the person wished to achieve. This was brought to the attention of the unit manager. A personal profile and support plan were in place but in discussion with the unit manager it appeared that neither document were up to date, therefore not meeting the person’s assessed needs. Chandler House The file examined by the inspector reflected what had been found in the other units across the site with forms being incomplete and evidence of needs being met poor. The manager stated at the feedback session that this may be due in part to the unit testing the new care software package. The inspector accepts that some shortfalls may be due to this, but a number relate to before the new software was implemented. Sunset View The file examined by the inspector contained all the forms listed above as well as other assessments. All of the documents had been reviewed within the past twelve months and evidence was available to confirm the person’s needs were being met. The only shortfall identified in this file was that some documents required dating to enable the reader to judge how current the information was. This is a minor shortfall that related to a small number of documents and should not detract from what the inspector felt was a really well organised and well maintained file that provided substantial evidence that the service users needs were being met. The majority of the service users case tracked by the inspector are in receipt of additional hours. This has been achieved by the service and registered managers ensuring that needs assessments are completed, then negotiating The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 12 with the relevant funding authorities for the additional funding. This has really benefited the service users with them having more one to one staffing to complete activities (this is described in more detail later in this report). At the end of the site visit the inspector met with the registered manager to discuss the findings across the site. The inspector explained that he had found a number shortfalls relating to evidence of peoples needs being met and documentation being completed as required by the organisation. The manager explained that she had recently completed an audit of three of the units and was aware of these shortfalls. To address this she had instructed the acting unit managers to review all of the files. In respect of the risk assessments seen during the site visit relating to specific risks to people the use of assessnet promotes a consistent approach to risk assessment. But, there must be a consistent approach by all of the units to storage. Either they are all kept on the computer system and a hard copy of each is kept in the persons file, or the assessment is just kept on the computer. It becomes a requirement of this report that the manager ensures that all of the service users’ files are reviewed and are of the same, or better standard than those of Sunset View. The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The wide range of leisure activities and opportunities for people mean they lead active and fulfilling lifestyles. The food provided in the different units was seen to be varied, nutritious and chosen by the people living at the home. EVIDENCE: As mentioned earlier in this report the inspector spoke to a number of people living at the home whilst completing the site visit. During these conversations some were asked what activities they are involved in and whether they enjoyed them. The range of activities people stated they were involved in included: - The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 14 • • • • • • College. Day Services – provided on site. Work placements in the local community as well as one person working in the office on site and another delivering the post across site. Leisure activities – shopping, walking, horse riding, pub visits, cinema and golf. Various holidays People also attend the local Gateway Club regularly. People have friends without learning disabilities and the staff provide support where appropriate with personal relationships. From talking to people across the site the inspector was provided evidence of their rights being respected. A good example of this are the couple now sharing their own flat which has been built to meet their needs and to the specifications that they required. When speaking with them during the building of their flat they spoke about choosing the colours, furniture, style and electrical accessories. People spoken with during the day stated that the food was good and they were involved in choosing and preparing it wherever possible. Menus seen by the inspector confirmed that a good range of healthy, fresh meals were available to everybody. Visiting the different homes across the site showed that snacks are available between meals. The Old Quarries DS0000016623.V303581.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A lot of the forms relating to health and personal care were incomplete and the inspector was unable to confirm whether the peoples needs were being met. The people the inspector met were very positive about the service they receive. On the whole medication is managed correctly minimising the risk of medication errors to people living at the home. EVIDENCE: Meadow View The unit has a form that staff are expected to complete confirming when personal care has been addressed. The person case tracked by the inspector requires some staff support and the form had been completed regularly by the staff confirming that his personal care needs had been attended to. Whilst in Meadow View the inspector examined the medication administration. Records showed that there were no gaps in the administration forms with staff The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 16 signing to confirm that medication had been administered. The medication storage concerned the inspector. Staff had put all of the current medication in paper bag which made it difficult to identify easily and may increase the risk of medication errors. A larger storage cabinet would rectify this problem and the inspector discussed this with the registered manager. The person’s file contained a document to address standard 21 called “when I die” which gives people the opportunity to identify what they wish to happen in the event of them passing away. This document had been partly completed. The Gallery Flat The notes examined by the inspector did not highlight that the person had any personal care needs. Medication administration was seen to be managed correctly. The only shortfall related to ensuring that any topical creams were labelled with the date they were opened. The document to meet standard 21 was not completed. The health action plan was incomplete. The Bungalow The person’s records examined by the inspector provided a copy of a personal profile identifying their personal care needs. Talking to the acting unit manager it became clear that this document was out of date. The acting manager must address this. In addition to this the sheet signed by staff to confirm peoples’ personal care needs had not been completed consistently over the two months previous to this inspection. An example of this was that according to the records one person had not brushed their teeth over three days. The medication administration was inspected and no shortfalls were identified. The file examined by the inspector showed that the staff were making good use of other health professionals to meet the specific health needs of one person. A health checks consent form had been signed by the resident. Sunset View The support plan identifying the person’s personal care requirements was seen to be thorough and provided staff with a detailed plan as to how the person’s needs should be met. The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 17 The inspector saw a “when I die” document completed by a person with staff support. Comprehensive health and hospital assessments had been completed with the person. The medication was not examined on this occasion. Chandler House Documents seen by the inspector provided evidence of staff supporting people with their personal care regularly. The medication was not examined on this occasion. A consent to healthcare checks, a summary of a health action plan and a document called “my medication” that identified the person’s medication were all incomplete. The Old Quarries DS0000016623.V303581.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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and protection from abuse procedure, plus staff training minimises the risks of abuse to service users. EVIDENCE: The home has a complaints procedure that makes good use of simple language supported by the use of symbols. Previous inspections have provided evidence that all of the people living at the home have been involved in workshops to explain the new procedure. The consensus of opinion across the site was that if people needed to make a complaint they would be listened to by the staff. The Inspector has examined the policy and procedure regarding protection of vulnerable adults at a previous inspection. It sets the framework for a robust response to any suspicion or evidence of abuse or neglect. The majority of the staff team have completed abuse awareness training recently but the manager must ensure that all staff have. The Old Quarries DS0000016623.V303581.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided across the site meets the current needs of the people living there. The Gate House provides an excellent example of a person centred approach to accommodation provision. The organisation continue to fund improvements to the fabric of the accommodation across the site to meet peoples needs. EVIDENCE: Across the site the units are decorated to a high standard with all communal areas in the units being personalised by the people living in them. All of the units provide a safe environment. The environment across the site continues to improve. During the site visit the inspector was informed that the bungalow accommodation will be decorated throughout including a new kitchen being fitted. In the Gallery flat staff said that it is planned re-paint the main hallway. The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 20 The bedrooms seen during the day of the inspection were decorated to a high standard and personalised by the people that lived in them. People spoken with stated that they liked their bedrooms. The new Gate house accommodation is a credit to the site and organisation providing a fine example a person centred approach to meeting specific accommodation needs. The couple that live in the Gate House are really happy with their accommodation. Some shortfalls were identified across the different units and these are listed below. The Gallery Flat – Hall carpet must be cleaned. The Bungalow – The front room carpet must be cleaned. All of the accommodation visited during the site visit was clean and hygienic. The Old Quarries DS0000016623.V303581.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, 33, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff complete comprehensive training providing them with the necessary skills to meet peoples needs. EVIDENCE: The service and registered managers have been involved in re-assessing peoples needs in relation to the staffing hours they receive. This has meant that a significant number of people now receive additional hours of staffing usually on a “one to one” basis. Rotas seen during the site visit clearly indicated when these hours were used. After completion of their induction further training is available and all staff are expected to complete other mandatory training. The inspector examined the training records for 2005/06. Records showed that courses completed by a substantial number of the staff this year included: Food Hygiene, Fire Safety, Abuse Awareness, infection control, Safe Handling of Medication, Supervisory Development as well as other courses. In addition to this the majority of the staff team have completed, or are completing their NVQ’s. Since the previous inspection the organisation have introduced a document called a “professional passport” that each member of the support staff will be The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 22 issued with. It is intended to ‘provide a focus on for the time and effort HFT spend on recruiting and training staff and to magnify the effect that that has on recruitment and retention’. In addition to this HFT has changed its approach to supervision with the implementation of Personal Development Plans. Training records, examination of peoples’ personal files and from talking various people throughout the site visit clear evidence was seen to confirm that needs are met by appropriately trained staff. Where it is identified that peoples’ needs cannot be met the home make use of other professionals, or provide additional training for the staff. An example of this would be the dementia training that some staff have completed. As part of the site visit the inspector examined the recruitment procedures for the last five people recruited to the staff team. A number of the people living at the home are involved in the recruitment of new staff. All staff have job descriptions and contracts and complete a comprehensive induction when they join the organisation. Staff files examined by the inspector contained the CRB reference numbers but no CRB forms. The staff explained that the service and registered managers sign off CRB forms when they have been seen. The forms are then disposed of. The inspector explained that the CSCI guidance says that CRB disclosures should be held at the home until they have been checked by the CSCI. After this they can be disposed of. In addition to this while the inspector was examining the recruitment records he noted that a person recently employed by the organisation had had a position in care previously (before their previous position) but a reference had not been sought from them. The inspector explained that when a prospective staff member has worked in a care position previously that they must, wherever practicable obtain written confirmation for the reason they left that employment. The Old Quarries DS0000016623.V303581.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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager’s leadership and approach is a factor in the continuing development and improvement of the service provided at the home. The external health and safety audit and the committee that meet regularly go some way to minimising potential risks to people across the site. The manager must ensure that fire equipment tests are completed and recorded appropriately to maintain the safety of the service users. EVIDENCE: The registered manager worked at the home for many years before she became the registered manager and has an extensive knowledge of the service. The inspector saw clear evidence of her good leadership and management approach which continues to improve the quality of the service The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 24 provided for the service users. The manager must be mindful of monitoring her senior staff to ensure that the personal files, care plans and risk assessments are always up to date. Since the previous inspection the organisation have reviewed their policy and procedure for the management of service users’ finance. This new procedure will be implemented by September 30th 2006. Each unit across the site has a COSHH file containing data sheets for the chemicals stored/used in the home. The manager provided the inspector with a copy the Health and Safety audit completed by HFT’s external Health and Safety auditor in April this year. Examination of this audit showed that some areas of concern had been identified, but nothing that may be classified as a major concern. A Health and Safety Committee made up of staff across the site meet regularly to discuss issues and identify health and safety concerns across the site. Hot water outlets are fitted with thermostats and staff monitor the temperatures each month to ensure they are within safe parameters (not to exceed 43°C). The accident/incident books were inspected and showed evidence of thorough recording, auditing and appropriate actions. A qualified engineer has serviced all fire equipment at the appropriate intervals. A major shortfall identified at the two previous inspections related to the fire equipment monitoring. It was a requirement of the previous inspections that the manager review the following areas to ensure a safe environment is maintained for the service users. • • • Testing of alarms each week by staff. Fire drills. Testing of emergency lighting. Examination of these points on this occasion have shown an improvement since the previous inspection but unfortunately not enough to meet the criteria of the regulations. The manager must ensure that all of these areas are correctly addressed across the whole site. Since the previous inspection the majority of the staff team have completed fire safety training. Please follow the link below for further guidance. http:/www.communities.gov.uk/pub/886/ResidentialCarePremisesfullguide_id150188 6.pdf The Old Quarries DS0000016623.V303581.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 3 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 3 34 2 35 3 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 2 2 2 2 3 X 3 X X 2 X The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 17(1)(a) schedule 3 Requirement The manager must ensure that my support plans are kept up to date. The manager must ensure that recruitment procedures meet the criteria of these regulations. The manager must ensure that regulation 26 visits are completed as prescribed by the regulations. The manager must ensure that staff complete and record the fire equipment tests as required by the regulations. Timescale for action 27/10/06 2. 3. YA18 YA34 17(1)(a) schedule 3 19, schedule 2 26 13/10/06 29/09/06 4. YA39 29/09/06 5. YA42 23 c, d, e, v 29/09/06 The Old Quarries DS0000016623.V303581.R01.S.doc 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. 4. 5. Refer to Standard YA9 YA20 YA20 YA21 YA34 Good Practice Recommendations The manager should decide whether risk assessments should be held on the computer alone, or a paper copy should also be available. The manager should consider purchasing a larger medication cupboard for the Meadow view unit. The manager should ensure that all creams are labelled with the dates they are opened. The manager should ensure that all documents relating to this standard are reviewed to ensure they have been completed. The manager should ensure that CRB disclosures are stored securely until the CSCI have had the opportunity to examine them. The Old Quarries DS0000016623.V303581.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. Extracts may not be used or reproduced without the express permission of CSCI The Old Quarries DS0000016623.V303581.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!