Inspection on 29/06/06 for The Old Rectory (Trowbridge)

This inspection was carried out on 29th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Rectory (Trowbridge) 04/01/10

The Old Rectory (Trowbridge) 12/09/07

The Old Rectory (Trowbridge) 05/10/05

The Old Rectory (Trowbridge) 06/05/05

The Old Rectory (Trowbridge) 24/09/04

The Old Rectory (Trowbridge) 28/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Old Rectory (The) 27 Stallard Street Trowbridge Wiltshire BA14 9AA Lead Inspector Tim Goadby Unannounced Inspection 29th June 2006 10:15 Old Rectory (The) DS0000028608.V299345.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 Old Rectory (The) DS0000028608.V299345.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. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Rectory (The) Address 27 Stallard Street Trowbridge Wiltshire BA14 9AA 01225 777728 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.craegmoor.co.uk Parkcare Homes (No. 2) Limited Mr Ean Rayton True Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: The Old Rectory provides care and accommodation for up to eight adults with a learning disability. Service users have autistic spectrum disorders. The home is operated by a subsidiary of Craegmoor Healthcare, a private sector organisation with four registered care homes for this client group within Wiltshire. The property is in a residential area of Trowbridge. A range of amenities are available in the town itself. Larger centres, such as Bath and Bristol, are within reasonable travelling distance. The service has been in operation for around ten years, initially under different ownership. A number of service users have lived there from the beginning. The current group is well established. They are all males. All service users have single bedrooms. This includes some on the ground floor. Two bedrooms have en-suite facilities. The others have bathrooms and toilets nearby. Communal areas are situated on the ground floor. There is access to a large enclosed garden. There is also an adjacent building, which is used for daytime activities. Another plot is used to grow vegetables. The fees charged for care and accommodation range between £1123 and £1588 per week. Information about the service is displayed on noticeboards in the home. It has also been circulated to all service users’ relatives recently, in response to a survey which was carried out. CSCI inspection reports are also publicised when they are received. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key inspection took place in June 2006. The evidence gathered included pre-inspection information supplied by the service; five survey forms completed by service users, with support; and eight survey forms completed by staff of the home. An unannounced visit was then carried out. This fieldwork section of the inspection included the following: observation of care practices; sampling of records, with case tracking; discussions with service users, staff and management; sampling activities; sampling a meal; and a tour of the premises. What the service does well: What has improved since the last inspection? There are appropriate arrangements for the management of medication. Requirements identified at the last inspection were addressed immediately, and practice has been maintained at a suitable level since then. Service users Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 6 can be confident that they receive appropriate support in this area of their care. Craegmoor has continued to develop its organisational approach to the management of its specialist autism services, such as the Old Rectory. Teams of senior staff can give input on issues of quality and service development, and on matters relevant to the care of individual service users. A further management reorganisation within the company is ensuring that there is a direct focus on services to people with learning disability. 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. Old Rectory (The) DS0000028608.V299345.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 Old Rectory (The) DS0000028608.V299345.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): Quality in this outcome area was not assessed. Standards relating to admissions to the home were not applicable at this inspection. EVIDENCE: The Old Rectory has not had any new admissions since 2003, so key standard 2 could not be assessed at this inspection. Old Rectory (The) DS0000028608.V299345.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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ needs and goals are reflected in their individual care plans. Service users are supported to exercise choice and control in all aspects of their daily lives. Systems for risk management support the undertaking of social opportunities. EVIDENCE: Two of the home’s eight service users’ files were sampled in depth. Both showed care plans and risk assessments in place for a relevant range of areas. These have been reviewed recently. Issues identified as important to an individual have clear information and support guidelines. This includes showing the ratios of staff to service users that will be needed for different situations. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 10 Further developments are planned in coming months, with progress on the implementation of person centred planning. This will increase the focus on each service user’s input to their own plan, and ensure it is closely based on their own wishes and goals. Issues of choice and autonomy are addressed in service user records. There is a focus on promoting independence. The majority of service users do not have speech. Strategies for enabling them to communicate form an important part of individual plans. There is also an appropriate recognition of the impact of service users’ autism. This is explained clearly within individual records. If restrictions are imposed as part of overall care, there are clearly documented reasons. Service users participate in the day to day running of the home. They contribute to all the practical tasks that are carried out. Craegmoor also has residents’ conferences. This gives some people an opportunity to comment more widely on the organisation’s conduct. Risk assessments show the balance of harms and benefits that may arise from particular activities. Management plans place emphasis on the support needed to enable an opportunity to be undertaken. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 11 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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have frequent opportunities to undertake a range of activities, both at home, and within their local community. Service users are supported to maintain personal and family relationships. Daily lives for service users have an appropriate balance between necessary routine, and individual choice. Arrangements for the provision of meals promote independence, choice and social inclusion. EVIDENCE: The Old Rectory has an adjacent building which offers a range of daytime opportunities. It includes a workshop and a sensory room. Examples of the various activities undertaken by people are on display. The home has been Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 12 successful in getting service users to access this facility, including individuals with a history of not engaging in activities. Some staff commented on the desirability of developing day service opportunities further. The manager agreed with this, and said that the home is anxious to maximise the benefits of having this adjacent facility. Deployment of staff is likely to be reviewed to allocate someone specifically to this area on weekdays. Some service users also attend the local college, supported by staff from the home. It is hoped to access a wider range of college courses in future. Service users are regularly supported to get out and access a range of opportunities. Staffing levels support this. The home also has two vehicles. On the day of this inspection people undertook various activities. These included shopping, going out for lunch, and playing skittles at a nearby social club. Service users are also supported to have days out and holidays. Holidays for 2006 have not yet been finalised, as the plan is to organise these around the building work set to take place at the home. Good links are maintained with service users’ families. Key information is shared, where appropriate. Visitors can come to the Old Rectory. Service users are also enabled to go and stay with family or friends. All but one service user have weekly timetables on display. These are produced in pictorial form, to promote understanding. They show that each individual has a range of planned activities to fill the week, both at home and elsewhere. There is also a daily shift plan to assist staff in achieving all necessary tasks. However, flexibility is built in, especially where needed to reflect an individual’s needs. On the day of this inspection, a variety of things were happening with different service users. Some spent time in their own rooms. Others were in communal parts of the home, interacting with staff. Service users also went out individually or in small groups, with staff support, in both the morning and the afternoon. Service users regularly access local amenities, and are recognised members of the local community. For instance, one service user usually makes a daily trip to a local shop, but hadn’t done so for a few days because of illness. This had been noticed by staff of the shop, who asked after him, and were sending a ‘Get well’ card. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 13 Lunch on the day of the inspection was quiche and salad. Fruit or yogurt was available for dessert. Jacket potatoes with a choice of fillings were due to be served as the evening meal. Five service users ate in the dining room, with others being either unwell, or out for lunch. Support needed by service users was given sensitively. Various service users assisted with relevant tasks, such as clearing tables. One resident is more independent, usually buying and preparing his own meals. A comment from a staff member suggested the need for greater input to service users in the areas of diet and nutrition. The manager responded that the home is looking at individual service user plans in these topics. Input has been requested from staff keyworkers. Menus have been reviewed recently, with a conscious effort to include more healthy options, such as increased use of fresh fruit and vegetables, and fish dishes. Individual care plans also strike a balance between service users’ preferences, and support to advise and encourage about variety. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to address their personal and health care needs effectively. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Service users’ personal care needs are set out in their individual plans. Abilities and needs vary widely amongst the group. Some are fairly independent, and need only advice or prompting from staff. Others are much more dependent, and require direct assistance with all relevant tasks. The level of support given is tailored appropriately, with guidance set out in records. Service users have various health needs, and records show that appropriate steps are taken to respond to these. People are supported to access input from relevant professionals. This includes regular review from a consultant specialising in learning disability and mental health issues. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 15 Health is promoted through a focus on exercise and an active lifestyle. Opportunities such as swimming and walking are offered to each individual, appropriate to their own abilities and needs. The health action plan section of individual care plans is due to be developed further, as part of the forthcoming review of the overall format. No service users are self medicating, so staff take on the responsibility for storage, administration and recording of medication. The home’s procedure sets out all the relevant information about how this is managed. Arrangements for storage are appropriate and secure. Administration is carried out by a senior carer, with another staff member witnessing. All care staff receive training in medication, via the pharmacy which supplies the home. The medication protocol is also used as part of the in-house training programme. Staff sign to indicate that they have read this, and will abide by it. The medication folder contains a section on each service user. This includes their administration record chart; a care plan on how they take medication; information about any reviews or changes of prescription; and individual guidelines for any drug which is prescribed to be taken ‘as required’. Requirements from the previous inspection were addressed as soon as they had been issued. The home also reports any medication errors which occur, and takes appropriate actions in response. Medication is reviewed by appropriate medical professionals. Any advice or changes to prescriptions is recorded, and cross referenced to the administration record chart if necessary. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 16 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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: The complaints procedure is prominently displayed within a public area of the home. Recording systems are in place. The complaints procedure was also recently circulated to all service users’ relatives again, as a result of comments received when a survey was carried out. No complaints have been received since the previous inspection. The Old Rectory has also made referrals to local vulnerable adults procedures, when required. By being open about any incidents that occur, the home has access to support from other agencies. This process has assisted in identifying actions to minimise the risk of service users coming to any harm. All staff receive training in abuse awareness as part of their overall induction. This includes information about how to record and report concerns. Each staff member is issued with a copy of the booklet which summarises the multiagency adult protection process in Wiltshire. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 17 Some service users have complex and challenging needs. These can include issues arising from personal relationships. Relevant professionals such as a behaviour nurse specialist are involved in giving support to these individuals, and in supporting the home to develop suitable approaches for management of difficult situations. All staff are given suitable training, to assist in the effective management of service users who may present challenging behaviour. There is a focus on defusing and de-escalating potentially difficult situations. Some instruction in physical interventions is also given. There are clear parameters around the level to which this may be practised. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 18 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 was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Significant improvements are required to the quality of the living environment for service users. EVIDENCE: Previous inspections have highlighted the need for significant improvements to the Old Rectory premises. It is recognised and acknowledged by Craegmoor as an issue requiring major investment. A large scale programme of works has been authorised, and funds allocated. The whole property is to be refurbished. A project manager is to be appointed to oversee this. An action plan has been produced, although the expected timescale for the work to commence has been delayed. It is now hoped that work should begin in the near future. Issues of planning and building consent may cause some further delays. The Old Rectory is a listed building, which means that all the proposed changes need approval. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 19 Further plans will be needed to define the programme of works, and how the impact on service users is to be minimised. Each service user has a single bedroom. One person has an individual flat, with separate access internally. There are two lounges on the ground floor. The kitchen has been completely refitted within the last year, giving service users and staff much improved facilities in this area. The home appeared clean and hygienic to a reasonable standard in all areas seen. A cleaner is employed for a number of hours each week. Service users and other staff also take part in relevant tasks. Some parts of the home are difficult to keep clean, due to the need for refurbishment. The garden is well maintained, and attractively landscaped. Staff comments included a concern about the external security of the property. However, no problems have been experienced over the past year. This area will be reviewed again as part of the overall refurbishment of the premises. It is likely that perimeter fencing will be improved. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 20 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, 33, 34 & 35 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by suitable numbers of appropriately trained staff. The home is unable to evidence that appropriate recruitment processes are in place, to ensure the protection of service users. EVIDENCE: The home was suitably staffed on the day of the inspection, and cover is maintained at high levels of staff to service users. There are a minimum of four staff on duty during daytime hours, if all residents are at home. The usual aim is to have six staff on a morning shift; and five in the afternoon and evening, up until 22.00. Some residents need one-to-one support for much of the time. This responsibility is shared amongst the staff on duty. Night time cover consists of one waking and one sleeping member of staff. There is a separate team of waking night staff, although other carers may also occasionally cover these shifts. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 21 Staff working at the Old Rectory also take turns to deliver support to service users at the smaller nearby home which is jointly managed. Some activities may be jointly undertaken by service users from the two homes, in which case staff support may be combined. The services have continued to experience staff turnover. Recruitment was taking place again around the time of this inspection. Records for three recently appointed staff were seen. Most of the required evidence of recruitment checks was in place. Nobody had commenced employment until it was verified that their name did not appear on the national list of those judged unsuitable to work with vulnerable people. In two of the three sampled records, written references had not been obtained from previous care employers. This is specifically required within care homes legislation. The reasons for this deficit were discussed during the inspection. In both cases, it was said to be because there was no longer anyone available from the previous employers to give a meaningful reference. But there was no note on the relevant staff files to make this clear. Comments from staff raised concerns about the effectiveness of their induction as new employees, and about how well they were introduced to the needs of service users before they began working with them. These were acknowledged as valid concerns by the manager. The issue has been looked at and discussed, and some changes to practice are now planned. In future, new staff will spend the first two to three days of employment not actually working with service users. Instead, this will be time for them to be introduced to people, and to start getting familiar with key documents, such as care plans and important procedures. Craegmoor has an organisational induction format, linked to national standards for the social care workforce. This is also being revamped. After induction, staff go on to undertake a range of other training relevant to their jobs. Some of this is done via self directed learning, using packs which have been developed by the company. Staff are given time whilst on duty to read through these, and then have to complete a test paper to demonstrate what they have learned. The home’s deputy manager acts as training co-ordinator. Records are maintained for each employee, showing which courses they have attended, and what other training needs have been identified for them. There is also an overall plan of what training is required over coming months. Sessions are often held in the hall next to the Old Rectory, with trainers from Craegmoor or other companies coming in to deliver these. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 22 All support workers are expected to study for National Vocational Qualifications (NVQs) in care. The Old Rectory is well above the 50 minimum target for care staff with this award at Level 2 or higher. Thirteen people have achieved Level 2, and three have completed Level 3. Craegmoor is now setting up its own NVQ centre, so that the company will supply assessors to work with candidates studying for the award. Staff commented on how good the training opportunities are. Old Rectory (The) DS0000028608.V299345.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, 38, 39, 41 & 42 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Service users benefit from the open and supportive ethos of the home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Effective record keeping is maintained, upholding service users’ best interests. Service users’ health and safety are protected by the systems in place. EVIDENCE: Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 24 The home’s registered manager is Mr Ean True. He has worked at the Old Rectory for a number of years, and was previously the deputy manager. He has obtained his Level 4 NVQ in management, and is now enrolled for the Registered Manager Award. Mr True is also the registered manager for a smaller nearby home for three service users, and oversees the staff team in supporting both services. The home’s deputy manager has NVQ Level 3 and is now working towards Level 4. Comments received from staff raised some concerns about teamwork and support from senior staff, with the impact of this on staff morale. Through discussion with management it was clear that there is an awareness of these issues, and that steps are being taken to try and address them. This has included a memo from Mr True to all staff inviting them to raise any issues through appropriate channels, and stressing the importance of effective teamwork in meeting the needs of service users. This issue is to remain in focus over the coming months. Staff concerns about communication were also acknowledged by the manager. Again, plans are in place to address these. For instance, a new team leader handbook has recently been introduced. This is used by the senior person on duty to make notes about any key issues that have arisen each day. Staff coming on duty outside the main shift handover periods, who therefore miss a verbal report about the main things they need to know that day, can use this to update themselves. Craegmoor’s services are extensively audited by the organisation. The manager is required to submit various weekly and monthly reports. There are also visits to the home by senior managers. The purpose of these is to ensure that all establishments achieve a minimum standard of performance, and to promote them to move beyond this to reach a level of excellence. Consultation also takes place as part of the overall approach to quality assurance. A survey of service users’ relatives took place in March 2006, with the feedback received being generally positive. The home also tries to get service user input a couple of times a year, although this is more difficult. The current service development plan has targets for staff development, enhancing the quality assurance process, refurbishment of the premises, and implementing a new care plan package. Records are stored securely. Clear guidance is in place about confidentiality, and the boundaries around sharing of information. Sampled service user records showed that entries are made four times a day, including for the overnight period. There is a clear division between objective and subjective comments. This provides a detailed ongoing record of care. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 25 The standard of presentation of service user records varies. Many are produced on computer, making for ease of updating, and this brings a professional appearance to the documents. Others are still in handwritten form, and appear less finished. The home also has a number of sheets within records with spaces for all staff to sign, which will indicate that they have read certain key documents, and agree to work in accordance with these. In all the cases seen, the majority of staff had not yet signed such sheets, meaning that this system for promoting awareness and accountability is not yet working as intended. Some staff felt that they are not allocated sufficient time for record keeping within their working hours. However, the manager said that specific time is given for this within the planned rota. For instance, an hour’s overlap period between shifts ensures that there are additional staff available, and gives an opportunity for records to be completed before people go off duty. All staff undertake training on a range of health and safety topics. These include infection control, food hygiene, and the control of hazardous substances. The fire log book was viewed. All checks and instructions relating to fire safety were recorded as being carried out, and up to date. The property’s fire risk assessment was completed by a contractor in August 2005. There is also individual information about each service user and their likely response in an emergency situation. An environmental health officer inspected food safety arrangements at the home in May 2006, and found these to be satisfactory. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23-2b Requirement The persons registered must provide a written action plan to the CSCI. This must set out the steps they will take to refurbish the building, and ensure the safety and welfare of service users during the process. Action plan updates must then be provided to the CSCI at intervals of not greater than four weeks, until all required steps have been completed. Recruitment checks must include the required evidence relating to any previous employment working with children or vulnerable adults. Timescale for action 28/07/06 2 YA24 23-2b 25/08/06 3 YA34 7;9;19 Sch2-3,4 29/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations Planned changes to the induction process for new staff should be implemented without delay. DS0000028608.V299345.R01.S.doc Version 5.2 Page 28 Old Rectory (The) 2 3 YA41 YA41 Care should be taken to ensure consistency of presentation of all records relating to service users. All staff should sign the forms used to show their awareness of service user plans and other guidelines. Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Old Rectory (The) DS0000028608.V299345.R01.S.doc Version 5.2 Page 30 - 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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