Inspection on 29/11/06 for The Old Rectory

This inspection was carried out on 29th November 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 Rectory 04/03/09

The Old Rectory 05/03/08

The Old Rectory 22/11/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Old Rectory Chewton Hill Chewton Mendip Near Bath Somerset BA3 4NQ Lead Inspector David Kidner Unannounced Inspection 29th November 2006 09:45 The Old Rectory DS0000064624.V315641.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 Rectory DS0000064624.V315641.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 Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Chewton Hill Chewton Mendip Near Bath Somerset BA3 4NQ 01761 241620 01761 241497 rectory@hotmail.co.uk 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) Mr Neil Bradbury t/a Bradbury House Organisation Mr Philip John Kilburn Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users who have concurrent mental health needs may be admitted. 22nd November 2005 Date of last inspection Brief Description of the Service: The Old Rectory is registered to provide a service for ten younger adults who have a learning disability. The service aims to support people who have relatively high needs including those who have Autistic Spectrum Disorders. The service is located in a large substantial house in the rural village of Chewton Mendip. The cathedral city of Wells is approximately 6 miles away and the city centres of Bath and Bristol are within travelling distance. There is a village shop across the main road. The home provides accommodation on three floors. The ground floor provides a lounge, dining room and activities/games room. There are two kitchens. The first is the house kitchen, which provides meals for the home. The second kitchen is accessible, with staff supervision, to the people living at the service. This kitchen is used to develop life skills. There is also a downstairs bathroom. In addition to the living accommodation there are a range of staff areas including meeting room, administration office and staff office on the lower floor. The bedrooms are located on the upper floors. All the bedrooms are large and have en-suite facilities. The bedrooms are large enough for them to contain a small sitting area. There are a further three bathrooms, one of which has a spa bath. There is a staff area predominantly used by staff for night supervision. Additionally there is separate self-contained staff accommodation. The service would not be suitable for people with a physical disability who could not access the stairs, as there is no lift to the upper floors. There is an accessible secure garden to the front of the house and a courtyard area to the rear. Bradbury Homes Ltd owns the home. There is a Manager in post and a vacancy for the post of Registered Manager. The Commission for Social Care Inspection is expecting an application for Registered Manager without delay. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a Key Unannounced Inspection and was conducted by two Inspectors. The inspection lasted one day (8hrs). The Inspector met most service users and a number of the care team. The Manager was available throughout the inspection. The Area Manager was present for some part of the inspection and was also present at feedback. As part of the inspection process the inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention, staff recruitment and viewed all areas of the home. The Inspectors spoke to some service users in private and in communal areas and spoke to a total of four care staff. The Inspector would like to thank the service users for making the Inspectors welcome in their home and for their contribution in the inspection process. The Manager and care team were very welcoming. As part of the inspection process the Inspectors sent comment cards to all relatives. One card was returned. The Inspectors sent comment cards to all care managers one was returned. Comment cards were sent to the health care professionals involved with the home. Both cards were returned. On the whole the comments were extremely positive in relation to the care and support provided at The Old Rectory Questionnaires were sent to all the service users living at The Old Rectory. Due to some service users having complex needs only one questionnaire was returned. Some comments received from service users who were also spoken to at the time of inspection include: ‘I am happy here’ ‘I like my bedroom’ ‘I have choices in food and clothes’ As a result of this inspection the home has five requirements and twelve recommendations. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home must review the shift patterns that staff work to ensure that service users and staff are not put at risk. The home must improve on the management of medicines. The home should consider making some parts of the home more homely. The recruitment process must be more robust. Consideration should be given for staff to receive training in mental heath issues and alternative methods of communication. The home must address and number of matters relating to heath and safety as detailed in the main body of this report. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 7 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 Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1245 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a detailed Statement of Purpose. The Service User Guide is presented in an accessible format but requires further information. The home conducts a detailed Pre-admission assessment prior to service users moving to the home. The contracts need further developing. EVIDENCE: The home has a detailed statement of purpose outlying the services that are offered at the home. The service user guide is known as “Where is the Old Rectory” and is presented in an accessible format. It contains symbols and photographs and includes a copy of the complaints procedure and how to contact the Commission for Social Care Inspection, local social services and healthcare authorities. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 10 The Inspectors viewed the pre-admission assessment documentation in relation to the admission of the most recent service user. It is evident that the home conducts a detailed assessment. It was also noted that a number of visits and overnight stays had taken place prior to the service user moving to the home. The contract and service user guide state that a four-week settling in period will be offered. The national minimum standards state that a minimum of twelve weeks trial period should be offered. This was discussed with the Manager and Area Manager. It is recommended that this be reviewed. The Inspectors viewed the format of the contracts. It was noted that the contract did not include the items as listed in Standard 5 of the National minimum standards. This should be addressed. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has detailed care and support plans. Detailed individual risk assessments are conducted and regularly reviewed. The home offers service users as much choice as possible. EVIDENCE: The Inspectors viewed the care and support plans for three service users. The care plans were very detailed and clearly identified the needs of the service users. Guidance to staff on issues such as behavioural triggers and diffusion techniques are identified. The care plans contained behavioural support guidelines. Following discussions, the Inspectors suggested that the home review the need to provide staff with more detailed behaviour support plans other that what is contained in the care plans. These plans could then be more The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 12 accessible to care staff. This is not a negative reflection on the current format. The Manager agreed to give this further consideration. At the end of each shift staff complete a diary sheet documenting the individual activities and significant events. The key workers also complete a monthly summary. The service users are involved as much as possible in the review of the care and support plan. Care and support plans viewed had been regularly reviewed. If restrictions are imposed on service users because of a specialist programme or mental health need, the home takes appropriate steps to address this. This also applies to service users who may be aggressive or self-harm. There is good evidence that the home conducts risk assessments and has regular contact with other professionals. The home has conducted risk assessments in relation to restrictions imposed on service users in order to promote health and safety and to address behaviour management issues. These had been regularly reviewed. The Inspectors discussed some matters in relation to accessibility of all areas of the home by some service users. The Manager and Area Manager confirmed that they would review the use of locks on some communal areas. This will be followed up at the next inspection. Communication systems are still in the process of being developed including PECS (pictorial exchange communication system), signs, symbols and photographs. These developments will need to continue to ensure that all people who live at the service have the opportunity to be involved to the fullest extent in the day to day running of the service. The Inspectors were advised that referrals have been made to Speech and Language Therapists as needed to gain further advice and support on individual communication needs. The home displays a photo board in the main entrance hall of the service users living at the home and the staff on duty. It is recommended that all staff receive training in alternative methods of communication. This is further highlighted in Standard 33 of the National Minimum Standards. The Inspectors spoke to a number of staff that was able to evidence how service users are offered choices. Written documentation was also viewed to support this. Presently there are no service users who can manage their own finances. The home supports service users to develop their budget skills. The home keeps good documentation in relation to service users finances. The Old Rectory DS0000064624.V315641.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11 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 home supports service users to access a variety of personal, social and leisure based activities. Service users are supported to maintain links with family and friends. The home needs to explore other ways in which service can contribute to the planning of menus. EVIDENCE: The home is pro-active in ensuring that if needed service users access professionally valid interventions and therapy. The home will support service users to access church if so wished. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 14 The home is part of the Bradbury Group Ld. The Group owns a large farm that is located approximately two miles from The Old Rectory. This is used as a Day Services facility by the organisation. Service users living at The Old Rectory have access to the farm and its facilities. Access to the farm is dependant on the individual’s needs and requirements. Individuals’ access the sessions, which they would enjoy and gain most from and are supported by the home on a 1:1 basis if needed. Service users spoken to stated that they liked going to the farm and looking after the animals. The farm is affiliated to a local further education college. In addition to attending “the farm” a number of people access a local college to attend a course/s of interest or for personal development. Each service user has an activities timetable. The day-to-day records identify the activities both within the home and external to the home. All service users with the exception of one person need support to access local facilities and the wider community. Documentation viewed confirmed that service users access a variety of social and leisure opportunities. There is a large games room within the home. This area contains such items as a karaoke machine, snooker/table tennis table and is available for arts and crafts. The home encourages contact with family and friends. Records are kept of such visits/contact. There are a number of private areas for people to entertain family and friends. Service users bedrooms are very large and can be used to meet visitors/relatives in private if so wished. The home has two kitchen areas. Service users access one kitchen area with staff support as needed as it is used as a ‘training kitchen’. The other kitchen is where the vast majority of meals are prepared. Service users do not access this kitchen. Risk assessments have been conducted in relation to health and safety matters. The home employs a full time cook who devises the menu and prepares the food for the service users and staff. The cook is very aware of the likes and dislikes of the service users. One service user will look at the planned menu and will make amendments as to the meals they want. This was observed on the day of the inspection. The Inspectors had discussions as to how other service users are involved in menu planning. It is recommended that the home give further consideration as to how service users can be involved in this process. One service user has a specialist diet and the cook is aware of the dietary needs of the individual. The kitchen is well managed and there is a cleaning schedule. Records are kept of the fridge and freezer temperatures and a food probe is used to record food temperatures as needed. Food cupboards were well stocked and the kitchen was clean and hygienic on the day of the inspection. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 15 The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. The care team are aware of service user’s needs in relation to personal care and support. Service users have access to a variety of health care providers. The home needs to improve of the management of medicines. EVIDENCE: There is no set time for getting up and going to bed. Some service users are independent when it comes to support with personal care. All service users have single bedrooms with full en-suite facilities. This further promotes privacy when personal care is being provided. Staff were able to demonstrate how privacy is promoted at the home. Staff commented that bedroom doors are always knocked before entering. There are guidelines and risk assessments in situ for individuals who need support with their personal care. Service users are able to choose their clothes with staff support if needed. Restrictions if imposed, are identified in individual care plans. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 17 As previously stated the Inspectors were advised that referrals have been made to Speech and Language Therapist and Dietician. Presently, no service users require specialist aids or adaptations. The home has policies and procedures in place in relation to the management of medicines. The Inspectors were advised that all staff have been deemed competent to administer medicines. However, formal reviews of competency have not taken place. The Inspectors recommend that such reviews take place. The home’s MAR sheets were viewed. It was noted that two staff signatures did not support some hand transcribed medicines and some medicine quantities had not been entered onto the MAR sheets. It is also recommended that photographs of service users are included in the MAR sheets. Detailed risk assessments have been completed in relation to service users who are able to manage the administration of their own medicines. The Old Rectory DS0000064624.V315641.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 home has clear management policies and procedures in relation to the protection of vulnerable adults. The home keeps good records in relation to the use of physical intervention, behaviour management, risk assessments and the management of service user’s finances. EVIDENCE: The home has a Complaints Policy and Procedure. There are no recorded complaints at the home. The home displays the complaints procedure in a prominent place. This is in an accessible format for service users. The home has policies for the protection of vulnerable adults including policies for adult protection and the management of service user’s finances. Care staff that the Inspector spoke to was aware of the home’s Whistleblowing Policy and how to access the policy. Staff were able to demonstrate the process they would undertake if needed. The vast majority of care staff has received training in Abuse Awareness and all care has undertaken Non-Abusive Psychological and Physical Intervention Training (NAPPI). All staff have an Enhanced CRB clearance. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 19 The home keeps detailed records in relation to the use of physical intervention. The Inspectors were able to view detailed care plans, behaviour management guidelines, risk analysis and risk assessments in relation to the management of behaviours and the use of physical intervention. The Inspectors recommended that the Manager develop as system to audit the use of physical intervention. The Manager agreed to do this. The Inspectors discussed the arrangements for the management of service user’s finances. Service users have individual bank or building society accounts The Company is the appointee for six service users. The home should review that appointees for service users’ finances should not be employed by the service or involved in the management or administration of the company. The Inspectors did not view service users individual finance records in detail but noted that the home keeps individual detailed records of service users finances. The Old Rectory DS0000064624.V315641.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 25 26 27 28 29 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Old Rectory is a spacious home providing comfortable accommodation but some areas do not promote a homely environment. All bedrooms exceed the national minimum standards and have full en-suite facilities. They also reflected individual lifestyles and needs and are furnished and decorated to a high standard. On the day of the inspection the home was clean and hygienic but some action is needed to promote infection control. EVIDENCE: The Old Rectory is a large detached property in the rural village of Chewton Mendip. The home provides accommodation on three floors. The ground floor provides a lounge, dining room and activities/games room. The bedrooms are located on the upper floors. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 21 The Inspectors viewed all areas of the home and viewed some bedrooms with the permission of the service users. The ground floor accommodation did not present a homely environment. It was noted that in some communal areas curtains/blinds were not fitted, padlocks were fixed to storage cupboards in hallways, signs/information aimed at care staff were displayed in service user communal areas and the home was lacking in soft furnishing and ‘homely touches’. The Inspectors acknowledged that at times the environment may be subject to high levels of wear and tear, however it is recommended that the home should consider ways of making the ground floor environment more homely including the type of locking devices used in the home. This was discussed in more detail with the Manager and Area Manager. The home has a maintenance and renewal programme and employs a maintenance person. The bedrooms at The Old Rectory are of an excellent size and have full ensuite facilities and are large enough for them to contain a small lounge area. It was noted that the bedrooms reflected individual lifestyles and preferences. Service users spoken to were very happy with their bedrooms. Staff support the service users in making the bedrooms very individual and ensure that they meet individual needs. One service user has digital TV in their room. Other personal possessions include CD, DVD, TV, pictures of family and friends, items relating to specific interests/hobbies, personal furniture and good quality soft furnishings. As well as full en-suite facilities there is also a ground floor bathroom and a further three bathrooms, one of which has a spa bath. The home has a digital controlled temperature for the hot water supply. The home has ample communal space. There is a large lounge area, dining room and an arts and craft room. The laundry and kitchen facilities are domestic in style. There is an accessible secure garden to the front of the house and a courtyard area to the rear. Staff have appropriate office and meeting room facilities. The home has two waking staff at all times. A facility is provided on the first floor for waking staff. The home currently does not need to provide any specialist aids and adaptations. The service would not be suitable for people with a physical disability who could not access the stairs, as there is no lift to the upper floors. On the day of the inspection the home was clean and hygienic. However, it was noted that disposable paper towels were not provided in communal toilet areas. This must be addressed in order to promote infection control. The Old Rectory DS0000064624.V315641.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): 32 33 34 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff demonstrated their awareness in the support required to meet service user’s individual needs. The Inspectors do not support the pattern of work that care staff undertakes. The hours that care workers are identified to work may put service users and staff at risk. Senior Manager need to review this practice without further delay. The home is pro-active in developing the skill base of the care team. EVIDENCE: Staff that the Inspectors met and spoke to were able to demonstrate their awareness and understanding of the service users needs. All staff have received training in Abuse Awareness and have undertaken NAPPI Training and receive refresher training annually. Following discussions with the care team, Manager and Area Manager, it is recommended that the care team receive training in matters relating to Mental Health issues and alternative methods of communication such as Somerset Total Communication. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 23 The care team are undertaking LDAF (Learning Disability Awards framework) training at induction and foundation level. The Inspectors were advised that there is a difficulty in acquiring NVQ Assessors therefore, it was decided that senior management were to undertake NVQ3 and/or NVQ4 and A1 Assessors Award. The Company has developed a NVQ Target Plan. Once the A1 Assessors Awards have been completed it is expected that a programme for NVQ Level2 in Care will commence early January 2007. This demonstrates the services commitment in providing a wellqualified workforce. The duty rotas were examined. They demonstrated that staffing numbers are provided in numbers according to the needs of the people who live at the home on any given day. Staffing numbers are relatively high due to the complex and occasional challenging needs of the people who live at the home. The Inspectors spoke to a number of staff that confirmed that they feel that they have appropriate staffing levels but at times this is challenged by the unpredictable behaviours that are exhibited at times. The Manager advised that the home is fully staffed with no vacancies. Following detailed discussions with the Manager, Area Manager, care staff and the rotas examined, the Inspectors noted that the majority of staff work between 22-24hr shifts. This confirms that care staff may undertake an afternoon shift then undertake a waking night duty and then undertake a morning duty. The Inspectors do not support this pattern of work as it may put service users and staff at risk. It is required that the home review this practice without further delay and advises the Commission for Social Care Inspection of the outcome. The Inspectors sampled the recruitment files of recently appointed staff. It was noted that the files did not contain the required documentation as listed in Schedule 2 of The Care Homes Regulations 2001. It is also recommended that the home does not accept references written: “ To Whom it may Concern “. All staff have an individual staff training and development plan. Bradbury Homes Organisation has a Training and Development Manager. The home keeps a Training Needs Analysis. It was noted that staff have received training in first aid, autism/aspergers, food hygiene, medication, fire, abuse and NAPPI. As previously stated it is recommended that care staff receive training in mental health and alternative methods of communication. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 24 The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Standard 37 was not fully assessed at this inspection, as there is a vacancy of Registered Manager. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has developed satisfactory quality monitoring systems. Some areas relating to health and safety need addressing. EVIDENCE: There is a vacancy for the post of Registered Manager. The Inspectors were advised that the Manager would be making an application to the Commission for Social Care Inspection. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 26 The home completed an annual quality assurance questionnaire in Sept/Oct 2006. Questionnaires were sent to interested stakeholders. The Inspectors viewed some of the returned questionnaires. There was very positive feedback from a variety of professionals in relation to protection and care planning. Another comment stated that staff should receive training in autism and alternative methods of communication. Another comment was in relation to the appropriate mix of the service user group. Such matters were discussed with the Manager and Area Manager at the time of the inspection. The home notifies the CSCI of reportable incidents. The home has attempted to conduct service users meeting but these have been unproductive due to the complex needs of the service users. The Manager stated that the team seeks the views and opinions of service users on an individual basis. The Inspectors viewed documentation relating to matters of health and safety. Fire Safety: The Inspectors noted that the home conducts regular checks on the fire alarm points, emergency lighting and conducts regular fire drills. Annual Service of the fire alarm system, emergency lighting and fire equipment was evidenced. Staff have received fire training however, questionnaires that staff used as part of their training were not dated. This was bought to the attention of the Manager and Area Manager. Hot Water/ Legionnella: The Manager stated that all hot water outlets have thermostatic valves fitted to ensure that the temperature does not exceed the recommended levels. The hot water system is also digitally controlled. The Inspectors recommend that the home keep records of regular testing of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. The home has not obtained a certificate in relation to compliance with Legionella. This must be addressed. Electrical Hardwiring Certificate: This is dated 12/05/06 and was valid for one year. The home must ensure that an up to date certificate is obtained. Portable Appliance Testing: Annual testing took place on 23/11/05. Accidents: The Manager stated that all records are kept of accidents / incidents. These are audited on a regular basis. COSHH: The home has a policy in relation to this. All products are stored securely. Fridge/Freezer: The home keeps daily records of fridge and freezers and keeps food probe records. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 27 Risk Assessments: The home has a detailed risk management policy. The Inspector viewed a number of individual and environmental risk assessments. The Manager has risk assessed the need for wardrobes to be fixed in bedroom areas. Windows are restricted above ground floor level. First Aid: Staff receive training in first aid. Records viewed confirmed that three care staff needed this training. The Manager is aware of this and it has been noted. The Inspector also suggested that the home obtains the HSE Health and Safety in Care Homes for reference. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 28 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 3 2 3 3 X 4 2 5 2 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 4 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X 3 X X 1 X The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 29 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 2 Standard YA20 YA33 Regulation 13 (2) 18 (1) (a) Requirement The home must ensure that all medicine quantities are entered on the MAR sheets. The home must review the hours that care staff work to ensure that the health and safety of staff and service users are not compromised. The home must ensure that recruitment files contain items as listed in Schedule 2 of The Care Homes Regulations 2001. The home must ensure that a certificate re Legionella has been obtained to ensure prevention of infection at the home. The home must obtain a satisfactory Electrical Hardwiring Certificate. Timescale for action 31/12/06 31/01/07 3 YA34 19 31/12/06 4 YA42 13 (3) 28/02/07 5 YA42 13 (4) 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 30 1 2 3 4 5 6 7 8 9 10 YA4 YA5 YA17 YA20 YA20 YA20 YA23 YA23 YA24 YA32 11 12 YA34 YA42 The home should review the contract to read that a minimum trial period of twelve weeks will be offered. The home should review the contracts to ensure they contain the items as listed in Standard 5 of the National Minimum Standards. The home should explore ways in which service users can contribute to the planning of the menus. The home should ensure that two staff signatures support hand transcribed medicines. The home should formally review the competency of care staff in the administration of medicines. The home should consider inserting photographs of individual service users in the MAR sheets. The home should develop an audit system in relation to the use of physical intervention. The home should review that appointees for service users’ finances should not be employed by the service or involved in the management or administration of the company. The home should consider ways of making some parts of the home more homely in appearance including the use of some locking devices within the home. The home should consider providing the care team with training relating to Mental Health matters and alternative methods of communication such as Somerset Total Communication. The home should not accept references references written: “ To Whom it may Concern “. The home should keep records of regular checks of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Rectory DS0000064624.V315641.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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