Inspection on 15/08/06 for The Old Vicarage

This inspection was carried out on 15th 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Vicarage 19/06/07

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Old Vicarage 75 The Greenway Uxbridge Middlesex UB8 2PL Lead Inspector Sarah Middleton Unannounced Inspection 15th August 2006 09:15 The Old Vicarage DS0000061744.V303461.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 Vicarage DS0000061744.V303461.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 Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address 75 The Greenway Uxbridge Middlesex UB8 2PL 01895454710 01895454711 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) Autism Consultants Limited Miss Lorraine Janet Harland Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A Brief Description of the Service: The Old Vicarage is located in a large house that has been adapted to offer the space and homely environment for the service users to live in. It is near to a main road that leads into the local town Uxbridge where there are good transport links into London. The service has its own house car and is located near to the college that some of the service users access. The Old Vicarage is a service that can offer accommodation for adults with Autism and or associated disorders. It is registered for adults with an age range of 18-65 years old. Formerly this service was registered at The St Mary’s Centre. The service users, staff and Registered Manager moved to the Old Vicarage in November 2005. The Registered Provider is Autism Consultants Limited. The Registered Provider provides schools and a college for people with Autism and associated disorders. They also own an agency, which provides staff to various services. The service users living at the Old Vicarage are able to access this college. The staff team consists of a Registered Manager, Deputy Manager and three support workers. Additional regular bank staff also work in the home. At night the home has a sleeping-in member of staff who is available for service users. There is also an on-call person, usually the Registered Manager or the Deputy Manager who is available to offer additional support and advice. Fees vary depending on whether service users receive one to one support, (this is reviewed on a quarterly basis) and whether they attend the college owned by the Registered Provider. The residential fees range from £75-78 thousand per year. This does not include the college or one to one fees. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection took place from 9.15am-4.30pm. The Inspector carried out a tour of the home and inspected service user plans, staff files and maintenance records. Two members of staff and three service users were spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with Autism and associated disorders. The Registered Manager was not present for this inspection. The Deputy Manager assisted with the inspection. The home currently has two service user vacancies. This was The Old Vicarage’s first inspection since registering with the CSCI at this new location. Therefore there were no previous requirements. Four new requirements were made at this inspection. All of the Key Standards were assessed. What the service does well: The home offers service users the opportunity to develop independent skills and to gain confidence in their ability to make informed choices and decisions about everyday life. Members of staff are committed to supporting and encouraging service users and show an understanding of the individual specific needs of each service user. Care plans and risk assessments are detailed and clearly highlight service users health, social and personal care needs. Activities are organised and structured to meet the abilities of each service user. These activities are varied and structured to enable service users to gain skills and different experiences. Service users and parents views of the home are obtained at least annually to ensure the home seeks opinions from those using and visiting the home. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Vicarage DS0000061744.V303461.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 Vicarage DS0000061744.V303461.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&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are assessed prior to the move into the home. This enables the home to make a decision as to whether it is a suitable move for the prospective service user. Prospective service users are encouraged to visit the home, along with their representatives, in order for them to make an informed choice regarding the home. EVIDENCE: The Inspector was informed of a new service user who had recently moved into the home. Reports regarding this service user had been forwarded on to the home. In addition the Inspector viewed an initial enquiries form that is used to take details of the referrer and prospective service user. Application forms are then sent out to the referrer, although these are not always returned to the home. The Registered Manager and Psychologist, from the college then visit the prospective service user and any family members to assess the service prior to a decision being made. The Inspector viewed a report completed by the Registered Manager. This included discussions the Registered Manager had with the service user and their background and any particular needs that the home would need to be aware of. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 9 The home then devises, with the prospective service user, a transitional plan, that includes visits to the home and overnight stays. This plan enables the prospective service user to meet with other service users, members of staff and to see how the home runs on a day-to-day basis. The Inspector asked the newly admitted service user about the move into the home. They commented on how it had taken quite a while to move in, but that they had plenty of opportunities to visit the home and to make a decision. This service user stated they were happy now they had moved into the home, but acknowledged that it was early into their move and they were still adjusting to the new routines and expectations. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the service users had been identified and were being met. Service users are encouraged to make decisions about their lives and are given support and guidance where necessary or when requested. Risks are recorded and addressed within the home. The risk assessments completed do not impinge on the service users progress towards further independence. EVIDENCE: The Inspector viewed a sample of care plans. These were comprehensive and included details on the service user such as their medical and social history, health professionals they have contact with, mobility issues and any mental health and personal care issues. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 11 These care plans are fully reviewed on an annual basis. One care plan viewed was slightly out of date, but steps had been taken to address this and the Inspector was informed that the support worker would be printing off the amendments and alterations by the end of the week. Monthly summaries also take place and include general information, medical and recreational information. A detailed recent Psychology report was also seen by the Inspector and gave an overview of the work that had been occurring with the service user. Daily records were viewed and detailed the events, health and any other relevant information regarding the service user. The home encourages service users to make every day decisions and this was confirmed by some of the service users spoken with. Information and communication is very clear to the service users. This method of working with the service users is particularly important for those who can become anxious if they know too much or too little information about what is occurring in their home and their lives. Those service users asked stated they are able to make important decisions and that staff respect the decisions they have made. Where possible, service users manage their own finances, with staff assisting where needed. Decisions regarding supporting and encouraging service user’s level of choice, independence and ability to make informed decisions are taken on an individual basis. A sample of risk assessments were viewed and assessed. These were comprehensive and clearly demonstrated the service user’s potential risks to themselves or others and approaches were recorded to minimise the identified risks. One service user, who self medicates, had the potential risks in administering their own medication outlined on their risk assessment. These assessments are also updated and reviewed on an annual basis or when there has been a change in the needs of the service user. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities that include leisure activities that suit their individual needs and interests. Community resources are accessed and those service users who feel able to, can go out independently. Service users can have holidays and go on day trips to offer them a different environment and life experiences. Visitors are encouraged and service users are supported to maintain personal relationships. Service users rights are recognised and promoted by the staff team. Mealtimes and meal provision is well managed with choices and individual needs adhered to. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 13 EVIDENCE: Overall most of the service users lead a full and active life. Many attend college, where various classes are held such as cooking and computer studies. Two service users prefer to engage in activities that do not involve attending the college. One service user is studying for a Masters degree in Maths and another is completing a degree in computers. One service user has particular difficulties in engaging in certain activities and tasks and staff have developed a structured week that enables the service user to feel able to take part in tasks without feeling pressured into fully engaging with people all of the time. Those staff spoken with had a clear understanding of the service users abilities and needs regarding how service users wish to spend their time. All service users go out into the community and access the numerous resources available to them. Some service users can go out independently without a member of staff. One service user has friends, who they visit and attend different meetings with them, whilst others visit local places such as the pub; keep fit classes or the cinema. The home has a small room where there is a computer with broadband fitted for service users to access information. In this room there is also a notice board where activities and information is shared. Often at week ends service users can receive one to one support for part of the day, as some service users visit their families during the weekends. The house has its own private transport, but for the most part public transport or walking is encouraged. Service users with interests and hobbies are encouraged to maintain these likes. Service users organise their own holidays, with staff support where needed. One service user was currently on holiday with friends at the time of the inspection. Another service user spoken with informed the Inspector that they had been on a flight alone to meet their parent abroad. Staff recognise that for some service users going on holiday is very stressful and not an enjoyable break, therefore this is respected and not organised by the home. The college is soon to be on a two-week break and staff are planning with service users whether they would like day trips and activities for this break. Those service users with family and /or friends are supported to maintain relationships with them. Service users can choose to visit their families or friends as and when they wish to. Visitors are also welcomed to the home and service users can see them in private or in the communal areas. Service users are supported, where needed, regarding relationships and many of the staff working in the home have attended training regarding working with people and addressing and supporting sexuality and relationship issues that can develop. This subject is particularly important for those who struggle to understand how to manage and display feelings and emotions. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 14 Service users have rights and this is recognised by the staff working in the home. Staff asked stated that service users have choices and their independence is encouraged. All service users have keys to their bedrooms and to the front door. The service users, who showed the Inspector their bedrooms, confirmed they have keys. Staff stated that service users receive their own personal mail. Although the majority of the service users were not present for some of the inspection, interactions were observed between members of staff and service users and these were positive and respectful towards the service users. Staff recognise service users rights to privacy and wanting to be alone. This is monitored by staff, who are aware of those service users who spend a lot of time in their bedrooms. The Inspector viewed the kitchen. This was a large, bright and modern kitchen that was clean at the time of the inspection. Service users have their own food cupboards and some food is locked away, such as crisps, as some service users have difficulties in regulating their food intake. Menus are planned with service users and one service user who has Obsessive Compulsive Disorder, (OCD), has a separate menu planned with staff. Staff prepare and cook these meals separately to the meals prepared for the other service users. This service user also has a small fridge in their room to enable them to make lunch and/or snacks. Staff check with the service user to ensure out of date food is not stored in this fridge. Staff are aware of the cultural and religious needs of one service user and provide Kosher food for them. Another service user likes to cook their own meals each evening and this is acknowledged and respected by staff and other service users. This service user orders their food shopping online using the computer. They informed the Inspector that this is the method they prefer. The menus reflected preferences and variety with the aim to provide a well balanced diet. Fresh fruit and other fresh produce were viewed in the fridge. Food that had been opened had been covered and dated to ensure out of date food is not used. Some service users assist and prepare the main meal for the home each week. Staff have provided two service users with recipes that are easy to read and follow. It is hoped that by having a small selection of recipes the service users can learn to make a main meal, without support from staff. Service users can choose where and when they eat their meals. Fridge and freezer temperatures had been taken on a regular basis and were within an appropriate range. The Old Vicarage DS0000061744.V303461.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive as much personal care support as they need to. Staff are aware to be sensitive and encouraging to those service users who require additional prompts and guidance. Health needs are recorded and met to ensure service users maintain their optimum health. Medication systems are robust and protect the health and welfare of the service users. EVIDENCE: Overall service users are able to carry out their personal care tasks independently. Some service users require promoting and encouragement to bathe and this is continuously assessed and discussed with the service user. Service users living in the home choose their own clothes to wear. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 16 The staff team comprises of a mix of gender and so the service users are able to state a preference if they wish to receive support from a particular member or gender of staff. The female service user stated they do not mind being the only female service user as they can talk with the female members of staff. Service users can receive additional specialist support from professionals such as Physiotherapists. Health needs are noted on service users care plans along with details of the support or encouragement service users might need to meet their health needs. Some service users choose to visit health professionals alone, whilst others require support and an escort by a member of staff. Various health professionals are accessed such as GP, dentist, Chiropodist and Psychiatrist and health appointment forms are completed once a service user has attended an appointment. The home has a Psychotherapist who visits to meet with a service user and they have been requested to work additional hours in order to meet other service users, who might benefit from their specialist input. The Inspector viewed the home’s medication systems. The home uses the blistered medication that is sent from the local Pharmacist. All medication viewed was stored in a safe and secure cupboard in the office. As noted earlier, service users can self medicate. Risk assessments are completed and if there is deemed to be no significant risk and if it can promote further independence, then this task is then promoted by staff. One service user spoken with stated they were happy looking after their own medication and that staff give it to them once a month and they sign to confirm they have received it. The home did not have any controlled drugs stored at the home at the time of the inspection. A letter was seen from the Registered Manager and signed by the GP to confirm the homely remedies that each individual service user can receive. Loose medication that was not in a blister pack was clearly dated for when it would expire. The Inspector viewed a sample of medication administration records and these had been completed correctly. The samples of blister packs viewed were also correct. Staff receive regular training and refresher training from the local Pharmacist and the training packs that staff have to work through and complete were viewed by the Inspector and satisfactorily covered the main areas staff need to be aware of with regards to medication and administration. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 policy and procedure is freely available and service users feel confident they have someone they can complain to and be listened to. Robust protection of vulnerable adults systems are in place to safeguard service users. EVIDENCE: There have been no complaints made at this new home. The complaints policy was viewed and was up to date and detailed how a complaint would be addressed. Those service users asked stated they would discuss any concerns or complaints with the Registered Manager. The Inspector was informed by staff that they felt that the service users living in the home were more than capable of making a complaint and airing their views if they wanted to. Parent questionnaires that asked parents if they had received a copy of the complaints policy stated they all had. The home has a copy of the Department of Health’s No Secrets document and an up to date copy of the Local Authority’s policy and procedures of the protection of vulnerable adults, (POVA). In addition the Inspector viewed a copy of the home’s POVA policy and procedure and this was detailed, outlining the various forms of abuse and who to report any allegation to what action should be taken. The home had investigated, along with the Police, a POVA allegation, that had been made at the previous registered home in 2005 and continued to the new home. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 18 The CSCI and the Local Authority’s safeguarding adults co-ordinator were aware of the allegation. This case was dealt with appropriately by the home and the case is now closed. The Inspector did not assess and view service users individual finances at this inspection. Staff informed the Inspector that some service users manage their own finances whilst others need the support of the home to ensure their finances are safe. Service users personal money goes into their bank accounts and can be accessed by the service users and/or staff. The Old Vicarage DS0000061744.V303461.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, 26 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers service users a comfortable place to live in. It is newly renovated and decorated and is a bright, spacious and modern home. Service users bedrooms offers them the privacy and space they might require to relax in. The home was clean and free from offensive odours. EVIDENCE: The Inspector carried out a tour of the home. The home is bright, modern and was free from offensive odours. The home offers a pleasant environment for those living, working and visiting the home. There are two lounge areas and a separate dining room and a games room in the garden. The home is accessible to service users and meets their individual needs. Smoking is only permitted outside in the garden. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 20 The back garden has some outstanding work to be completed, as part of the area of the back of the garden is to be covered with tarmac in order for service users to be able to play ball games, such as football. All fire doors were closed at the time of the inspection. The Inspector was informed that there is a maintenance person available for the home when work on the home needs to be completed. Two service users showed the Inspector their bedrooms. These were spacious and had en-suite facilities. One service user said they were hoping to move their own furniture into their room as they had just moved in to the home. Overall these bedrooms were personalised and offered service users the items they needed to store personal belongings. As noted earlier, the service users can lock their bedrooms. The laundry facilities were located in a separate room. The infection control policy was on display in this laundry room. Service users have a set day to carry out their laundry tasks and one service user prefers to do their laundry at their parents home. The home was clean and tidy at the time of the inspection. The Old Vicarage DS0000061744.V303461.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, 33, 34, 35 & 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A competent staff team supports Service users. The staff team is well established and offers consistency and support to the service users. Recruitment procedures are robust and safeguard service users. Service users individual needs are met through having an experienced and trained staff team who know how to meet those identified needs. Service users benefit from receiving support from staff who are supported themselves through regular one to one supervision. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Inspector observed the staff team to be committed and enthusiastic in meeting the varied needs of the service users who live in the home. Service users asked commented on the staff being caring and supportive. The staff team have worked for several years with the service users and have a good understanding of the individual needs of the service users and can receive specialist training to ensure staff are up to date with information and knowledge relevant to the service users. The home promotes members of staff to study and complete an NVQ and three members of staff have an NVQ level 3. The Deputy Manager is hoping to study for an NVQ level 4 in the near future. The staff team is well established and there is a core group of regular bank staff that work to cover any shifts needed. Staff members stated that the team works well together and that communication is positive amongst staff members. The Inspector was informed following on from the inspection, that where needed, one to one support is funded to enable service users needs to be met. This arrangement is reviewed on a quarterly basis. Staff meet once a month and all members of staff, including bank staff are encouraged to attend these meetings. The rota was viewed and demonstrated that there are sufficient numbers of staff working at any one time. Staff also confirmed they felt there were sufficient numbers of staff working in the home on each shift. Samples of staff employment files were viewed. These contained photographs, completed application forms, two references, health questionnaires and Criminal Record Bureau Checks. Therefore the Inspector was satisfied that all necessary and legal checks are completed and all information regarding an applicant is gathered prior to their commencement of employment. The Inspector viewed the training that members of staff attend. Training is accessed through a variety of sources such as the Local Authority, the Registered Provider and external organisations. Staff commented on the regular and flexible training offered to them. Staff are able to attend training on specialist subjects relating to working with service users who have Autism and/or associated disorders, as well as the mandatory courses, such as moving and handling and food hygiene. Some staff were booked to attend the Protection of Vulnerable Adults training over the forthcoming months. Overall training was up to date for staff and records were kept of courses attended and those booked. In addition the Inspector viewed the induction process for new members of staff. Staff work through a checklist that is countersigned by their line manager. New members of staff also work through the Skills for Care induction programme. The Deputy Manager confirmed that new members of staff shadow existing members of staff in order to get to know the service users and the routines of the home. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 23 Supervision is offered to staff and those staff asked stated they found the one to one supervision supportive. Staff felt their suggestions and ideas were listened to and a two-way dialogue does take place. Supervision notes were not inspected at this inspection. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected 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 home is well managed with the Registered Manager maintaining a positive and approachable presence in the home. The home needs to develop a report to demonstrate how it is has reviewed and improved the running of the home, in order to show where adjustments and alterations have been made for the benefit of the service users. The shortfalls in the health and safety records need to be addressed in order to protect those living, working and visiting the home. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Deputy Manager informed the Inspector that the Registered Manager had completed the Registered Manager’s Award and they were waiting for the work to be verified. The Registered Manager has been in post, both at the new home and the previous home for several years. Staff commented on how the Registered Manager was approachable and maintained a visible presence in the home. Evidence was seen that the Registered Manager undertakes periodic training to ensure they keep up to date with information, current theories and practices. The home has in place various methods of assessing the home. Parent and service user questionnaires are sent out on an annual basis and the summaries of these findings are then sent to parents. These questionnaires cover areas such as staffing and activities. The Inspector viewed a letter where the Registered Manager had noted some of the parents comments and had outlined how she intended to address the shortfall that had been identified. In addition monthly Regulation 26 visits also take place and these reports are forwarded on to the CSCI. However there was not an overall report or summary of the internal work and improvements and amendments that staff and the Registered Manager had been working on. Discussions took place with the Deputy Manager in relation to this shortfall. The Inspector made a requirement for the home to clearly evidence where they have reviewed how the home operates, where alterations and improvements have been made, for example since being in post the Deputy Manager has reviewed all the policies and procedures in the home and how any shortfalls are to be addressed. This report must be devised and made available for inspection and for service users. Servicing and maintenance records were viewed at random. The Gas Safety record and the servicing of the fire equipment was up to date. At the time of the inspection an external company was checking the fire alarms and smoke detectors. This is carried out on a monthly basis. Samples of environmental risk assessments were viewed, these were up to date and covered areas such as clinical waste, using the kitchen and data protection. Each month the Deputy Manager carries out a monthly check on the home and records where there are any health or safety issues and records action that is to be taken to address these issues. The Inspector was informed that at the previous home water temperatures had been taken but since moving to this new home they had not. A requirement was made for water temperatures to be taken and recorded of all the areas of the home where service users have access, including their en-suites rooms. Staff are able to carry out this task as part of the health and safety checks of the home. The water is thermostatically controlled but the Inspector made this requirement to ensure that should this system fail, service users are still safe and protected as staff regularly monitors temperatures. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 26 The home has a combination boiler and so does not have an organisation that test the home for Legionella. However a requirement was made for there to be a risk assessment developed and completed to evidence that action has been taken to reduce the risk of Legionella being present in areas such as shower heads. Discussions took place with the Deputy Manager regarding devising a way to address this issue so that the home has minimised any potential risk to service users. Finally fire drills/practices were viewed and found to be held on a regular basis. However the records did not record the names of the staff members who had attended since earlier in the year. A requirement was made for the home to record the members of staff who attend the fire drills to ensure they attend sufficient numbers of drills throughout the year and can respond in the event of a fire effectively and safely. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 27 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 3 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 4 25 x 26 4 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 4 34 3 35 3 36 3 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 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 x 2 x x 2 x The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 28 N/A 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 YA39 Regulation 24(2) Requirement Timescale for action 30/11/06 2. YA42 3. YA42 4. YA42 An overall quality assurance report must be available for inspection and service users. This must demonstrate how the home has internally reviewed how the home runs and includes the views of service users and their representatives. 13(4)(a)(c) Risk assessments must be 30/09/06 completed, along with action that is to be taken, to minimise the risk of Legionella being present in the home. 23(4)(e) Fire drills/practices records must 16/08/06 include the names of staff present for these drills/practices to ensure staff attend a sufficient number of times and can respond effectively in the event of a fire. 13(4)(a)(c) Water temperatures must be 31/08/06 taken and recorded in all areas on a regular basis, including washbasins in the en-suite rooms. The Old Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 29 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 Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Vicarage DS0000061744.V303461.R01.S.doc Version 5.2 Page 31 - 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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