Inspection on 21/05/07 for The Old Vicarage

This is the latest available inspection report for this service, carried out on 21st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Vicarage 21/06/05

The Old Vicarage 09/01/05

The Old Vicarage 11/08/04

The Old Vicarage 13/11/03

The Old Vicarage 03/06/03

The Old Vicarage 28/01/03

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

CARE HOME ADULTS 18-65 The Old Vicarage Parsonage Lane Hungerford Berkshire RG17 0JB Lead Inspector Stephen Webb Unannounced Inspection 21st May 2007 10:00 DS0000011143.V331568.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 DS0000011143.V331568.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. DS0000011143.V331568.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Parsonage Lane Hungerford Berkshire RG17 0JB 01488 683634 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) Cornerstone Housing Mr Gary Devlin Care Home 11 Category(ies) of Learning disability (11) registration, with number of places DS0000011143.V331568.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: The Old Vicarage is a care home providing personal care and accommodation for up to 11 adults with learning difficulties. The providers are Mr and Mrs Childs, operating as Cornerstone Housing. The home is situated near the Parish Church of Hungerford and is a short walk from the main shopping area of the town. Access to bus and train services is close by. The home consists of a large house with seven bedrooms, known as The Old Vicarage, and three individual, attached annexes. The annexe buildings are called The Lodge, Coach House, and Parsonage Cottage and each accommodates one resident in a fully equipped flat. All of the residents receive support from the same staff team throughout the day, though a staff member works specifically one-to-one, with the resident in one of the annexe units, each day, and there is also a staff member sleeping in each night within this annexe building, in addition to the sleep-in staff in the main house. Current fee levels ranged from ££870 to £2500 per week at the time of inspection. DS0000011143.V331568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.00am until 4.00pm on 21st of May 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with staff members on duty, and briefly with the manager. Most of the residents present during the inspection were able to communicate verbally with the inspector, and several did so to varying degrees. Some time was also spent observing the interactions between residents and staff at various points during the inspection. Written feedback was obtained from seven residents, two of whom completed the form themselves, and five with facilitation from staff members recording their responses. Questionnaires were also received from three residents’ relatives, and two healthcare professionals. Feedback from residents, relatives and external professionals about the service was very positive. The inspector also toured the premises, and ate lunch with the residents. What the service does well: Prospective residents and their families receive appropriate information to help them to make an informed choice about moving to the unit, and prospective residents are appropriately assessed prior to admission. Residents are effectively involved in their care planning and they are consulted regarding any risk assessments undertaken. The care plans reflect residents’ needs, and also identify their strengths and areas of self-caring ability. Residents are actively involved in planning their daily lives and making decisions, with support where necessary, from the staff. Appropriate risk assessments are in place, which are written so as to minimise their impact on residents’ freedom and rights and maximise their quality of life. Residents can access various in-house activities as well as community based events and activities. Four of the group are able to access the community independently of staff support. Although local authority funded day services have been cut, the unit advocated with families to retain some day service provision for half of the residents, and DS0000011143.V331568.R01.S.doc Version 5.2 Page 6 the staff have worked to ensure that all of the residents continue to have appropriate opportunities, within the unit’s own funding constraints. The home maintains good relationships with residents’ families, and alternative advocacy arrangements are in place where family contact is not available. The residents are actively encouraged to take responsibility for their care and be involved in the day-to-day routines of the house, and are involved in menu planning, shopping and meal preparation. They are provided with a healthy and varied diet, and the staff maintain an overview of healthy eating issues. Residents are supported with their day-to-day care where necessary within an enabling culture and are consulted about how any required support is offered. Their physical and emotional health needs are met, and medication is managed effectively on their behalf. Residents who expressed a view, felt that their views were listened to and that any complaints they had would be addressed. Three relatives also confirmed they were aware of the complaints procedure. Systems are in place to protect residents from abuse and the staff receive training on the protection of vulnerable adults from accredited trainers. The home provides a very homely, comfortable and well-maintained environment for residents, including the provision of separate self-contained accommodation to meet the specific needs of three individuals. Two vehicles are also provided to support community access where necessary. Residents live in a well run home and are supported by competent, trained and approachable staff, and are protected by the home’s recruitment and vetting system. The health, safety and welfare of residents are promoted by the home. What has improved since the last inspection? The unit provides a stable and consistent home for a settled resident group, and has worked hard to minimise the impact of cuts in local authority funded day services. Previously identified remedial works to the premises had been addressed. Care plans and other records are now updated and reviewed more regularly. DS0000011143.V331568.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000011143.V331568.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 DS0000011143.V331568.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): Standards 1 and 2: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate information is made available to support a prospective resident to make an informed choice about moving to the unit, and prospective residents are appropriately assessed prior to admission. EVIDENCE: A detailed preadmission assessment was on file for the most recent admission, together with other relevant documents. Other residents had been at the home for at least three years so their assessment documents were archived. The service user guide had recently been reviewed and updated and each resident had their own copy in their bedroom. Three of the residents were said to be able to understand it in written form, though the document had been gone through with all of them individually, by staff. One of the resident’s copies seen had additional comments written on it where it had been explained to the individual. It was said that the document was being further reviewed to improve its accessibility. Feedback from inspection questionnaires confirmed that parents and residents (responses recorded by staff), felt they had received appropriate information about the service before moving in. DS0000011143.V331568.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are involved in their care planning and consulted regarding any risk assessments undertaken, and whilst care plans reflect their needs, they also identify individual’s strengths and areas of self-caring ability. There is good evidence of the ongoing involvement of residents in planning their daily lives and making decisions, with support where necessary. Appropriate risk assessments are in place, and these are written so as to minimise their impact on residents’ freedom and rights. EVIDENCE: Detailed care plans were on file for the two residents’ whose records were tracked. The files were orderly and relevant family and professional contact details were readily available. DS0000011143.V331568.R01.S.doc Version 5.2 Page 11 The care plans included good evidence of consultation with residents, and of individual preferences, likes and dislikes. Copies of reviews were on file and one resident was due for their next review later in the month of inspection. The care plans also identify goals to be worked towards with the individual. The care plans also had a positive focus on supporting and encouraging selfcare, with regular use of terms like “involve”, “inform” and “support”, and the phrase “no action”, where a resident needed no staff input on particular aspects of their care or daily life. Relevant written guidance was also in place around specific activities, times of day etc. where necessary to maintain a consistent approach. Residents are risk assessed on managing their own personal allowance, and have access to this when needed. Detailed individual balance sheet records are maintained together with receipts to evidence all monies spent. Examination of a sample of balance sheets for the tracked residents indicated appropriate expenditure. Each resident also had an individual bank/building society account and the statements for the account were held on file. Residents pay a contribution from their DLA benefits towards the cost of the transport provided to enable them to access the community. The unit provides two vehicles to facilitate this. A range of risk assessments were in place for each resident and these were focused on achieving minimal impact or restriction on the freedom of the residents to take appropriate risks as part of maximising their quality of life. An individual’s risk assessments are summarised collectively, within a risk area summary sheet, which staff sign to confirm they are aware of them. The documents indicate that the resident and care manager have been consulted regarding each risk assessment. External advocates have also been involved to support some residents. Observations of staff practice during the inspection were consistent with the approach described above, and some of the residents confirmed their involvement in decision-making. One commented that he went out for walks without the staff, and often goes into town, and another told the inspector about her voluntary work at a local store and a new work placement which was about to start. DS0000011143.V331568.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of in-house activities and can also access community based events and activities. Some of them are able to access the community independently, both on a planned and ad hoc basis. Although local authority funded day services have been cut, the unit advocated with families to retain some day service provision for half of the residents, and the staff have worked to ensure that all of the residents continue to have appropriate opportunities, within the unit’s own funding constraints. College and supported work placements are also in place for some. Good relationships are maintained with family, and alternative advocacy arrangements are in place where family contact is not available. Residents are actively encouraged to take responsibility for their care and be involved in the day-to-day routines of the house, and are involved in menu planning, shopping and meal preparation. They are provided with a healthy and varied diet. DS0000011143.V331568.R01.S.doc Version 5.2 Page 13 EVIDENCE: One of the residents has a part-time voluntary work placement and is about to start another similar placement and three attend college for different periods. Residents have appropriate freedom to decide how they wish to spend their day, and four are able to go out without staff support, either to work, college or for walks or shopping in town. There is a schedule of planned activities in place which show some structured periods for each resident, though for some, their activities are planned on a more immediate basis according to their mood or interests on the day. The unit has two vehicles to support community access and six staff out of the team of ten, are able to drive these. New activities are being tried and one resident has been introduced to the possibility of horse riding over a period, firstly by taking him to the stables to watch others riding, then by providing him with a riding hat, and he was due to try riding a horse himself later in the week, for the first time. The level of available local authority-funded day care has been cut, but the unit, together with family support, have successfully advocated for retention of some day-service support in the case of some residents. Two still have parttime day services, for two days per week, and three others receive a part-time service from another local day service provider, which also arranges supported employment placements. Residents have at least an annual holiday or short breaks if more appropriate to their needs. One of the residents talked fondly about their last holiday remembering various anecdotes. This years summer holiday is planned and all of the residents are going to the same place, though in two separate groups. Most of the residents have regular contact with family, through visits being taken out or going to the family home, and telephone and letter contact is also supported. Two residents have no family contact, one of whom has had a longterm advocate, and the other has recently been introduced to a new advocate. The home has a positive and supportive relationship with residents’ families with whom it has contact. This is borne out in the inspection questionnaires returned by three families and verbal feedback received from one parent, who all express very positive opinions about the quality of care and support provided, though two were very concerned about the potential impact of the reductions in local authority funded day-services provision. DS0000011143.V331568.R01.S.doc Version 5.2 Page 14 Residents are expected and encouraged to take part in the day-to-day routines of the home, including cleaning, shopping and cooking though levels of involvement and areas of interest vary between individuals. Some residents confirmed their involvement in the daily routines and household tasks, to the inspector and one was vacuuming his bedroom during the inspection. Residents were also seen making hot drinks and one helped a staff member make the home-made meatballs for that evening’s meal. Menus are planned with residents input, though the staff try to maintain a healthy-eating overview, and a lot of the meals are home-cooked from fresh ingredients. The home-made soup prepared for lunch on the day of inspection was a good example, and was enjoyed by the residents who were in for lunch. DS0000011143.V331568.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported where necessary within an enabling culture and are consulted about how any required support is offered. Their physical and emotional health needs are met, and medication is managed effectively on their behalf. EVIDENCE: Examination of the care plans and risk assessments indicates appropriate consultation with residents, and as already noted, the care plans make reference to the views, preferences and abilities of the resident, rather than focusing solely on areas where support is needed. Residents’ privacy in their bedrooms will be further improved once the planned door locks are fitted, though the manager should ensure they are of a type approved by the fire authority. Where support is needed, the way it should be provided is detailed within the care guidelines. Behaviour management plans are in place regarding specific DS0000011143.V331568.R01.S.doc Version 5.2 Page 16 behaviours for two of the residents and their effectiveness is monitored via the completion of STAR charts. One resident is supported one-to-one by a staff member throughout the waking day and has a dedicated sleep-in staff in a second bedroom in her flat, to provide any necessary night-time support. Observations of the support offered by staff and the interactions between staff and residents, indicated a relaxed and positive relationship and evidence of shared humour. Eight of the residents can verbalise their opinions effectively, one has limited verbal communication but make his needs understood, and one does not speak but staff are familiar with their gestures and facial expressions. Additional support is sought from external healthcare professionals where necessary, including psychologist, psychiatrist, and speech and language therapist support, and indeed, the psychologist visited to see one resident during the inspection. The unit has advocated appropriately for the retention of some day-care provision for a number of the residents. None of the residents currently require any specialist equipment or adaptations to meet their needs. Relevant medical contact details are readily available within individual care files, and each resident has a collective healthcare appointments record as well as separate records regarding individual appointments. The records indicated appropriately recent appointments and gave relevant details. Weight charts were also present where this had been of concern. New “My Health” booklets had been started in consultation with each resident, by their keyworker, though these were still a work in progress. None of the residents is able to manage their own medication, but an appropriate system is in place to do this on their behalf. The records provide a medication audit trail and there were no gaps in administration records. The current medication administration record (MAR) sheets are held in a collective file with typed information about the prescribed medications, a photo of each resident, and other relevant information, for ready access. Completed MAR sheets are filed individually. The staff have received their medication management and administration training from one team member, who has received external medication training. Whilst the training passed on to staff appears thorough, and includes an annual written test and observations/recording of practice in terms of stockchecks and ordering, it is suggested that best practice would be for all staff to be trained directly by a pharmacist or other appropriately qualified external trainer, who will always be up-to-date with any changes relevant to the home. DS0000011143.V331568.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt that their views were listened to and that any complaints would be addressed. Systems are in place to protect residents from abuse and staff receive training on the protection of vulnerable adults. EVIDENCE: The home has an appropriate complaints procedure, which is also detailed in the service user guide, copies of which, residents have in their room, though this is also in written format. Three of the residents were said to be able to read and understand the procedure for themselves, and staff indicated that it had been explained to each resident individually, and they all knew to bring any concerns to staff or management. This was confirmed verbally by two of the residents, and three relatives also confirmed they were aware of the procedure. The service user guide is under review and it is suggested that residents could be asked to help develop a more accessible version of the complaints procedure for inclusion therein. The complaints log indicated no recorded complaints since march 2005, so it was not possible to assess the system in operation. DS0000011143.V331568.R01.S.doc Version 5.2 Page 18 The manager and deputy are both accredited POVA trainers and deliver the POVA training to the staff team. All but one of the staff had received POVA training according to the latest printout of the collective training profile, though for seven of them, records indicated this had last been updated in late 2005 It is suggested that POVA training updates should be considered annually. Appropriate recording systems are in place to protect residents’ funds and to account for all expenditure of these. Residents’ personal allowance is available to them to decide how it is spent, and each has a names bank/building society account where any surplus is maintained. DS0000011143.V331568.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with a very homely, comfortable well maintained environment within the home, which is located close to the town. Standards of hygiene are high and the home has appropriate laundry facilities. EVIDENCE: The service operates in a very attractive and well-maintained period vicarage building, next to the church and close to local facilities. The large kitchen diner, heated by an Aga, is the hub of the home, which draws residents and staff together throughout the day, not just at mealtimes. The kitchen area is spacious providing room for residents to be involved in cooking and food preparation. There is also a separate large lounge. All of the communal areas are decorated and furnished in a homely fashion. DS0000011143.V331568.R01.S.doc Version 5.2 Page 20 Seven of the bedrooms are in the main house with three others within the three attached but separate self-contained flats. None of the residents requires any specialist adaptations to the unit at present though this will have to be considered in future years. Bathing facilities also are standard and well presented, with a choice of bath or shower, and four have en suite facilities. The bedrooms seen were appropriately individualised, very much reflecting the interests of their occupant, and residents choose the colour scheme. As noted earlier, residents’ privacy is soon to be further improved, with the provision of bedroom door locks, for which residents will have a key. Two of the residents confirmed to the inspector that they were very happy with their bedrooms. Standards of hygiene were seen to be good, and the separate laundry provision meets the current needs. The home has a large enclosed and very secluded rear garden, which was reportedly well-used by the residents, one of whom was seen kicking a football around during the inspection. DS0000011143.V331568.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and approachable staff who have high levels of NVQ attainment. Staff also undertake a satisfactory core training programme, though the frequency of some of the core training updates should be reviewed. Residents are protected by the home’s recruitment and vetting system. EVIDENCE: The interactions observed between residents and staff were relaxed and appropriate, and staff were seen to encourage and support the involvement of residents in the daily tasks such as meal preparation and cleaning, as well as encouraging involvement in activities, and community access. There was evidence of appropriate banter between resident and staff and a sense of fun. Residents who were able spoke about the things they enjoyed and had no criticisms to report. One, in particular, said he was happy and really liked the staff. DS0000011143.V331568.R01.S.doc Version 5.2 Page 22 The staff team is a stable one, with only one staff member having left since the last inspection in November 2005, and the staff were obviously very familiar with the needs and preferences of the individual residents. Levels of NVQ attainment are high, with ten of the team having attained NVQ, at various levels including two staff having level 4 and the Registered Managers Award. The newest staff member is also undertaking NVQ level 3. Standard staffing levels are two staff within the main house, and one staff working one-to-one in one of the self-contained flats, throughout the waking day. This is sufficient to meet the current needs of the residents as well as enabling community access, given that four of the residents can go out unaccompanied. At night there is one staff member sleeping in, in the main house and another sleeps in within one of the flats as part of the resident’s one-to-one support. Examination of a sample of staff recruitment and vetting records indicated that an appropriately vigorous system was in place, including retention of copies of identity confirmation, and interview records. Although there were some evident gaps in the core training, some of these were being addressed through training that was already booked later in the year. The manager should, however, review the training needs across the team to ensure that all staff have received the core training together with updates at appropriate frequencies. The service obtains much of its training from the local authority, but this does mean long lead-times for some booked training, and the manager should consider whether in some cases it would be appropriate to source courses which are available sooner, or facilitate in-house training to cover until the later courses take place. The manager and deputy are both accredited POVA trainers so are able to address this area of training in-house, but consideration should be given to ensuring annual POVA training updates for all staff. Medication training has been cascaded by one staff member who has been externally trained. As already noted all staff have received this training as well as written testing, but consideration should be given to sourcing this training for all staff externally from a pharmacist. (Recommendation made under Standard 20). DS0000011143.V331568.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home, with an effective manager and an experienced staff team. The views of residents and relevant others have previously been sought as part of a quality assurance process, though this should be undertaken on an annual basis. The provider visits the unit regularly, though not all copies of the resulting regulation 26 monitoring reports were available in the home. The health, safety and welfare of residents are promoted by the home. EVIDENCE: The unit is managed effectively and the staff are supported by regular staff meetings, supervision and appraisals, and encouraged to take appropriate delegated responsibility. The manager is appropriately experienced and has an DS0000011143.V331568.R01.S.doc Version 5.2 Page 24 NVQ level 4 and Registered Manager’s Award, and is also an internal NVQ assessor. A quality assurance system is in place and a cycle of questionnaires was undertaken in January 2006, including residents, families, care managers and other professionals and staff. A quality assurance summary report was produced and the inspector was shown the well-presented pie charts and data which made up the various elements of the report. The results were discussed in a team meeting and a development plan was devised for the unit. The process was said to be due to be repeated in the near future, and should, in fact, be undertaken annually as part of the cycle of review and development of the service. The home is visited regularly by the provider, as part of their management monitoring, but examination of the regulation 26 monitoring reports indicated that several were absent from the file in the unit. The manager confirmed that the visits had taken place regularly and undertook to seek the missing report copies for the file in the home. A selection of health and safety-related service certification was examined, and indicated an appropriate cycle of servicing for the most part, though the electrical appliance testing was overdue and needs to be pursued. Fire drills are held monthly and involve the residents. A fire risk assessment was in place, which had just been reviewed, and individual fire evacuation plans were being compiled in the event that any resident declines to evacuate in the event of a fire. Examination of a sample of the risk assessments indicates detailed and individual documents written from the point of view of maximising the opportunities for residents to access fulfilling activities, with minimal impact on their freedom. Risk assessment summary sheets were a useful aide-memoire for the staff, and were also signed by them to confirm they were aware of the content. Accident records were on appropriate tear-off sheets and were suitably detailed. Copies were placed on the resident’s case record. Incident recording was also on individual sheets and these were copied to the resident’s file and held collectively for management monitoring purposes. It is suggested that a collective accident record should also be maintained for the same reason. DS0000011143.V331568.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 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 4 4 3 X 3 X 2 X X 3 x DS0000011143.V331568.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA20 YA35 YA39 YA42 Good Practice Recommendations Consideration should be given by the provider, to all staff who administer medication, receiving medication training directly from an appropriately qualified person. The manager should review the training needs across the team to ensure that all staff have received the core training together with updates at appropriate frequencies. The manager should ensure that a quality assurance review takes place annually to ensure that the views of relevant parties are heard regularly. The manager should consider establishing a collective record of accidents to residents to facilitate management monitoring. DS0000011143.V331568.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000011143.V331568.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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