Inspection on 04/12/07 for The Old Vicarage

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Vicarage 02/12/08

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 The Old Vicarage 48 Church Lane Stallingborough Lincolnshire DN41 8AA Lead Inspector Ms Wilma Crawford Key Unannounced Inspection 4th December 2007 09:30 The Old Vicarage DS0000069301.V355375.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 DS0000069301.V355375.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 DS0000069301.V355375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address 48 Church Lane Stallingborough Lincolnshire DN41 8AA 01472 882891 01472 882891 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) Home From Home Care Limited Mrs Janice Neal Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 10 New service Date of last inspection Brief Description of the Service: The Old Vicarage is one of a group of homes owned by Home From Home Care Limited. The home is registered to provide care for 10 adults aged 18-65 who have a learning disability. It is a large country house situated in its own grounds at the end of a gravel driveway. The home is situated in the village of Stallingborough, next to the church and within walking distance of local shops and amenities. It has a large private garden with generous parking facilities to the front and rear of the building. The home has 10 single bedrooms all with en suite bathroom facilities. There is a range of communal rooms and facilities including a lounge, activity room, and dining room with a quiet sitting area, sensory room, and spacious kitchen. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager or staff on the home. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the registration of the home and includes information gathered during a site visit to the home The site visit was unannounced and took place over seven hours. Four people living in the home, and three staff were spoken with during the visit. Two senior members of staff were available to assist the manager throughout the day. The manager was unavailable on the day as they were attending a training course. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of three residents and three staff were inspected. An Annual Quality Assurance Assessment (AQAA) document asking for information about the home was sent out before this visit and information from this was included as part of the inspection process of this service. Twenty-two surveys were sent out to people living in the home and staff, ten of these were completed and returned. Of the surveys returned four were from people living in the home, three from staff, one from a care manager and two from relatives and carers. The comments from these and from discussions during the site visit are also included in the report. The range of fees charged is £1436 — £1500 per week. These fees are based on a standard fee and an additional package of hours based on the individuals needs. This inspection visit was part of a key inspection the unannounced site visit took place over 1 day on 4th December 2007. What the service does well: People living in the home are provided with an excellent environment, which is spacious, decorated to a very high standard and equipped with high quality furnishings. Each bedroom is for single use, is spacious and each has it’s own en suite bathroom. This gives people the opportunity to personalise their room to their own taste, as well as providing them with an area where they can spend private time or receive visitors. The home is spacious and offers a variety of communal rooms for people to use. Service users and their relatives are provided with information that is easy to read so that they know what to make a number of visits and stay overnight to help them to decide if the home will be able to meet their needs or not. Each person living in the home has an extremely detailed individual plan of care to make sure they get the care and support they need. These also include The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 6 information about helping people to keep their independence and learn new skills. Relatives are very involved in the home and are made to feel welcome, making sure that family can keep in contact. The kitchen is spacious and service users are involved in the planning of menus, grocery shopping for the home and assist with the preparation of this. This encourages people in the home to be supported to eat a healthy diet and make choices about what they eat. Each service user now has a health action plan which helps to make sure that their health needs are met. Service users medicines are looked after well and staff assist service users to take their medicines safely. A good recruitment policy is in place so that staff employed are safe to work with the service users and they are protected from harm. The staff are very caring and treat service users with respect and dignity. The staff team have received training which has helped them to develop the skills and understanding of the needs of the people who they are supporting. What has improved since the last inspection? What they could do better: Although the staff team complete the Learning Disability Award Framework in conjunction with their induction, only one has achieved a National Vocational Qualification at level two or above. However, all of the staff team have been registered to complete this award. Information relating to the recruitment of staff, references and checks completed prior to appointment should be made available in the home. One care plan examined had a couple of gaps in the monitoring information recorded, this needs to be brought up to date so that staff have all the necessary information available about the individuals progress or deterioration. During the examination of accident records, information was found that suggested that two safeguarding issues had not been referred to the appropriate authority or regulation 37 notifications sent to the Commission for Social Care and Inspection. This information needs to be reported so that individuals are protected from harm. The duty roster doesn’t identify which staff members are supporting individuals on a 1:1 basis at any time during the day, making it difficult to establish how this support is offered to meet the individuals agreed conditions of contract. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage DS0000069301.V355375.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): 1, 2, 3, 4 & 5 People who use this service experience good quality outcomes in this area. A full needs assessment is carried out and people are given enough information about the home and its facilities before admission, for them to be confident that their needs can be met by the service. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and this details all of the information required by this standard and Schedule 1 of the Care Homes Regulations 2001 for adults 18-65 years. A service user guide is available and this contains all the information required by National Minimum Standard 1.2. These documents are currently available in written format, the home is planning to develop these further into a more user format. The Annual Quality assurance assessment submitted prior to the site visit states that each individual is assessed prior to moving into the home. The assessment includes the identified needs to be met and both the individual and their families are involved in this process. Other information is collated from other sources, such as the family, social care teams and professional bodies e.g. psychologist. The care files of three people living in the home were examined. Each contained a range of assessments carried out by a variety of professionals who hade been involved in the care of the service user in The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 10 previous care settings. The staff team had more than enough information on the assessed needs of the service user and this enabled them to provide an individually tailored service to meet the service users complex needs and ensure their emotional stability. Written information, discussion with people living in the home and staff members evidenced that people living in the home had been offered and had taken up the opportunity of visits and overnight stays prior to making a choice about living at the home. In addition to this there was evidence that the other people in the house had been consulted about the new person moving in and had agreed to it. People have been introduced to the home gradually and the staff numbers increased as each new person has been admitted to the home. This has made it easier for the people living in the home to accept the changes and cause the least disruption possible. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8, and 9 People who use this service experience excellent quality outcomes in this area. People using the service are able to make decisions and everyday choices as part of an independent lifestyle. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care files were examined as part of the inspection process. Each file contained an index page which gave details of each part of the care plan and include: personal details, current care plan, risk assessments, daily support plan, daily records, contact records, health information, report forms analysis information and financial records. The profile of each individual gives details of their medication, it’s use, the persons likes and dislikes, aspects of their behaviour and an explanation of how this manifests itself and the reasons behind this. Each person has a pictorial and written booklet called my hospital passport all about me. This give information about the individual, their communication any aids or adaptations they may need, current medical conditions, allergies, what they might do if they were in pain, how they prefer their medicines to be given, how they would tolerate the nursing staff, what they may do if they were upset and any other information which hospital staff The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 12 may need to ensure that their needs are met during their stay in hospital. Service users also have a health action plan. These documents were identified in the AQAA as an action to be developed within the next twelve months and have been put in place within six. Care plans are comprehensive, very detailed and are based on the individuals assessed needs and give precise information of what support staff need to provide for service users and an element of what skills and ability service users already have in order to build on these and demonstrate progress. This is especially important at The Old Vicarage as the service users that live here have more complex needs and need a lot of staff support. The people living in the home are consulted in the development of their care plan and place their thoughts on the daily record sheet and sign it. Risk assessments and care plans are evaluated and reviewed in line with the individuals changing needs. The risks had been identified, assessed and were being minimised by the production of risk assessments that staff were familiar with and followed and a number of these related to measured risk taking allowing service users to develop and maintain their independence. This was further supported during discussion with people living in the home and staff. In one of the care files examined there was one monitoring form that had not been fully completed for the previous day. Further checks of this care plan and two others showed that this appeared to be the only occasion that this had occurred, all other areas of the care plans were fully complete and up to date. Care plans also documented areas of specific needs and charted the progress or deterioration in these areas. All of the people living in the home whose files were examined had made considerable progress in identified areas of their behaviour. Minutes of reviews showed that multi agency decisions were made and agreed with the individual and that reviews were held regularly in line with the individuals changing needs. In addition to this the service users had benefited from a person planning book which covered all areas of the individual: their previous life, likes/dislikes, hopes and dreams and an individual action plan on how the person could be supported to fulfil these. These records were documented on a daily basis by the individual and their keyworker. Information about any specific conditions that the person had were also available in the care plan for example epilepsy and Cornelia de Lange syndrome. The inspector observed service users being offered opportunities to participate in the day to day running of their own home; assisting with shopping for the home. There are regular residents meetings which minutes are available for. Staff and service users confidential information was observed to be securely kept. Staff were observed to knock on doors and to ask permission to enter bedrooms. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,and 17 People who use this service experience excellent quality outcomes in this area. People using the service have opportunities to access an extensive range of leisure activities, are supported to maintain relationships and have their nutritional needs met. The judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the Old Vicarage have significant needs and all require a moderate level of support from the staff team. Therefore none of the service users have work placements. One person has a college placement. Each individual has their own timetable of planned activities in the home and the community. The timetable is based on vocational, occupational, recreational and educational activities. A sample of a daily programme included cleaning their bedroom, a trip to the seaside, a walk to the post office and then watching a film. During the visit different activities were observed, two people went out with staff to do some shopping at the local supermarket, The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 14 one person had a head massage from an external therapist, another went out into the village, one person was at college, while another was involved in baking. A group of people visited from another home. Each activity was identified in each person’s timetable. In addition to this holidays, day trips , visits to pubs and clubs, bowling, swimming, piano lessons, and horse riding are also offered, details of these are also documented in care plans. In addition to this each person has a ‘Step Matrix’ This is where people are supported by the organisation are engaged in a range of activities in order to eventually pursue a career of their own choice. The manager and staff promote a healthy eating menu. Breakfast is cereals/porridge and toast. Lunch is either provided at the college or is a choice of pasta bakes, homemade burgers and chips or anything the person may request. Options on the menu for dinner included sweet and sour pork stir fry and stew and dumplings. Supper is the service users own choice of snack. Service users spoken with and feedback from their surveys confirmed that they enjoyed the food and they were involved in both the menu planning and shopping for the home. They also commented that staff would prepare anything that they wanted. One person has a special diet which is provided for and in close consultation with the individual. They were able to explain how they were involved in this and how a record of this was kept. It was felt that the balance was right for the service users and ensures their physical well being and ongoing good health. The Old Vicarage DS0000069301.V355375.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): 18,19,20 People who use this service experience excellent quality outcomes in this area. Residents receive appropriate health care and personal support. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Records examined confirmed that service users health needs were met by GP, dentist, chiropody and that they had access to a wide range of other health professionals e.g. psychologist, if and when required. The health action plans are complete and detailed, providing valuable information about individuals health needs, but also further information about the as individuals and how they would demonstrate that they were ill or in pain and their response to medical treatments and how they could be supported to manage this effectively. This would ensure that symptoms are picked up on quickly and the appropriate support offered, so that the individual does not find the process traumatic in any way. Staff and service users spoken with were aware of this process and able to give clear examples of when it had been used successfully. In addition to this the recording of outcomes to health appointments were detailed on a separate sheet to make it easier for staff to follow treatments or appointments, without having to go through all of the The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 16 daily recording sheets over a period of time. These also provided information to show that individual’s health needs are met. Discussion with Service users and staff and observations confirmed that the staff promoted service users dignity, privacy and respect. Staff were observed to promote these in their interactions with service users. A relative commented ‘The staff at The Old vicarage show a lot of respect towards the people who live there.’ A care manager involved in placing an individual in the home commented ‘He was registered with a G.P. within 24 hours of moving into the home. A dentist, podiatry and opticians appointments have also been booked’. Home from Home Care has robust medication policies and procedures that include receipt, storage, administration and disposal of medication. The medication policy, states that people coming into the home can self – medicate if they wish to after a risk assessment has been completed and agreed. No one currently chooses to administer their own medicines. The home currently uses Boots The Chemist blister pack system. The medication system and records were found to be accurate up to date and well managed. Medication is only administered by a senior member of staff who has completed medication training and has been judged competent to do so. The Old Vicarage DS0000069301.V355375.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): 22,23 People who use this service experience good quality outcomes in this area. People using the service feel able to air their concerns without any fear of repercussions. The staff vetting procedure is sufficiently robust to ensure the safety of the service users. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a well-developed complaints procedure. This contained contact details for the CSCI and the ombudsman and gave an assurance that service users and their families would not be victimised for making a complaint. The timescale given for responding to complaints was 21 days. The home is also looking into how a complaints policy could be developed for service users using the picture Exchange Communication System, where pictures are used to describe events. All of the surveys received back from service users indicated that the service users knew who to go to if they had a complaint or concern. All minor issues were dealt with through the house meetings. More serious issues were taken to the manager and a mechanism is in place for responding to these areas of concern and/or complaint. There have been no recorded complaints received by the home or in relation to the home. Feedback from staff, service users and relatives demonstrated that they were aware of the complaints process and who they needed to go to with any concerns of any sort. Service users felt that they would be listened to and were confident that any concerns would be taken seriously. Staff were aware of their role in the complaints process, including supporting service users with The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 18 any concerns or complaints they might have. They were also aware of local advocacy services and how they could be contacted on service users’ behalf. The home has a separate whistle blowing procedure. The manager oversees the recruitment process. An application form, two written references, a Criminal Records Bureau check and a Protection of Vulnerable Adults check are undertaken prior to a person starting employment. On the day of the visit three staff files were examined and although some information was in place in the file. two written references and confirmation of POVA checks being completed were not on file. Discussion with recently appointed staff members indicated that the recruitment process had been fully adhered to and all the necessary checks completed prior to them being given a date to start work in the home. A phone call was made to the manager and the operations manager and copies of the information were made available to the inspector. Since the visit a copy of this information has been placed on the staff files. The risk of harm to people is minimised due to the stringent procedures in place. During a random check of the accident book two incidents where there had been altercations between service users were logged. However details of these had not been sent to the CSCI or the local safeguarding team. This was later discussed with the manager and the operations manager who contacted the local safeguarding team, they felt that neither incident would be followed up as a safeguarding issue but asked for the details to be forwarded to them. This was duly done. The operation manager has requested that further guidance be sent to the home by the safeguarding team so that any further issues can be properly addressed. Despite this appropriate action had been taken by the home for each situation and the individuals’ care plans amended to reduce the risk of further situations occurring. There was also evidence to show that this had been closely monitored following the incidents. Two staff members who had been recruited after the incidents occurred, spoken with, had a good understanding of their role in the protection of service users from harm and were clear on their responsibilities within the POVA procedures. They said that they had completed training in this during their induction and this was supported by information in staff training records and information provided in the AQAA document. There was evidence from the home’s recruitment and selection processes, staff training records, staff understanding of the referral process, complaints log and the use of risk assessments that the manager ensured that service users were protected and safeguarded from abuse. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 19 The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,and 30 People who use this service experience excellent quality outcomes in this area. The residents have been provided with a homely, comfortable environment that is clean and has been decorated to a high standard, with both private and communal space being suitable for their needs. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The Old Vicarage is situated in the village of Stallingborough and is owned by Home from Home Care. The accommodation is provided in a two storey detached building, set in a large private garden with generous parking facilities to the front and rear of the building. The home is close to local transport links, parks and the resort of Cleethorpes. All fixtures/fittings and furniture were of a very high good quality and on the day of inspection the house was extremely clean and tidy and very well presented. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 21 The home has 10 single bedrooms all with en suite bathroom facilities. There is a range of communal rooms and facilities including a lounge, activity room, dining room with a quiet sitting area, sensory room, and spacious kitchen. There is also an office, staff sleeping in room and additional toilet facilities. There is a lift available between the ground and first floor for anyone unable to use the stairs, however there are bedrooms available on the ground floor of the home. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager or staff on the home. People living in the home said that they were proud of their home and were keen to show the inspector their rooms and how they had personalised them. The home is spacious and offers a range of communal facilities for individuals to use. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34 and 35 People who use this service experience good quality outcomes in this area. People living in the home are supported by staff who are supervised and undertake training. The staff vetting procedure is sufficiently robust to ensure the safety of the residents. The judgement has been made using available evidence including a visit to this service. EVIDENCE: There are currently six people living in the home who are supported by the manager and three care staff in the morning and four care staff in the afternoon. There are two waking staff available during the night and one sleeping in staff member available for additional support if required. The staff also provide support with domestic tasks and with cooking. Some of the people living in the home have identified additional support needs and additional staffing hours have been agreed to support with this. However it was not clear from the staffing rota, which staff were working with which individuals to provide this. When staff and people living in the home were spoken with it was clear that this additional support was in place and each staff member was aware of their duties during the shift and which individual or individuals they were responsible for supporting. This ensures that service The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 23 users diverse needs and person centred plan goals can be met and planned for. Observation of staff practices confirmed that they have developed appropriate relationships with service users and treat them in an age appropriate way and with the utmost of dignity and respect whilst offering guidance and support in a firm but sensitive manner. The staff team are supported by a wide range of health professionals e.g. psychologist and audiologist. A care manager commented, ‘the staff work through a person centred care plan. This supports the staff to find out what the person wants to do, their hopes and dreams, likes and dislikes. Giving the service user more control over his life.’ Three new staff members files were examined as part of the site visit and this evidenced that Home from Home Care recruitment policies and procedures are robust and staff have CRB disclosures, POVA checks, all identity as required by regulation and references obtained prior to commencement in employment. Supervision records were examined and were in order and the current staff team are up to date with their mandatory training and have undertaken other specialised training relevant to the needs of the service users, i.e. epilepsy, autism, managing difficult behaviours, health action planning, person centred planning, and introduction to learning disabilities. All new staff members complete the Learning Disability Award Framework training during their induction, providing them with a good knowledge base to understand the needs of the people they are supporting and offer them the appropriate support. Only one staff member has completed a national vocational qualification at level 3, they also have an assessor’s award. The remaining staff are registered to complete this award. The Old Vicarage DS0000069301.V355375.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39, 40 & 42 People who use this service experience good quality outcomes in this area. People using the service overall benefit from a safe and well managed place to live. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Janice Neal is the registered manager at The Old Vicarage. Mrs Neal has a Bachelor of Art’s degree in social science and is completing a Higher National Certificate in social care. She has considerable experience in working with adults with learning disabilities and managing residential care settings. Regular residents meetings that include staff and service users, staff supervision and the key worker system ensure that staff and service users have the opportunity to influence the way the service is delivered. Mrs Neal is considered by staff and people living in the home as being approachable and open to suggestions. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 25 The organisation has a ‘corporate period service review’ in place where every aspect of the service is looked at and certain criteria met. This quality assurance audit demonstrates how the service is performing and what action needs to be taken to improve any areas that need to be further developed. Areas recorded on the AQAA document for improvement in the forthcoming year included to make policy and procedures more accessible to service users’, involve service users more in quality assurance processes and feedback, and to work to establish 50 of the staff group achieving an NVQ qualification As part of the inspection all maintenance records were seen and were up to date and in order ensuring that the service users live in safe environment. This corresponded to the information provided by the home in the AQAA document. Staff spoken with said that they felt well supported by the manager. Information from staff team minutes and discussion with staff indicated that they can attend meetings each month and were able to express their views. During the examination of accident records, which were well documented information was found that suggested that two safeguarding issues had not been referred to the appropriate authority or regulation 37 notifications sent to the Commission for Social Care and Inspection. This information needs to be reported so that individuals are protected from harm. (see standard 23) The Old Vicarage DS0000069301.V355375.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 3 2 4 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 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 3 3 3 3 2 X The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 27 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 YA23 Regulation 37 Requirement Timescale for action 04/12/07 2. YA34 19(b)(i) 4,5 3. YA43 37 The registered person must ensure that all safeguarding issues are immediately reported to the local authority in accordance with their safeguarding procedures. The responsible person must 31/12/07 ensure that information in relation to the recruitment of staff and the checks completed is available in the staff files. The registered person must give 04/12/07 notice to the Commission without delay of all untoward occurrences in accordance with the regulations The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA6 YA32 YA33 Good Practice Recommendations All the information in all service users files should be kept up to date. The registered person must ensure that at least 50 of the care staff are qualified to NVQ level 2. The registered person must ensure that the home has adequate staffing levels available in order to meet the individual needs of service users and to fulfil the terms and conditions of individual contracts that are in place, which specify allocated 1:1 staffing hours. Details of this should be recorded on the staffing roster. The Old Vicarage DS0000069301.V355375.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Vicarage DS0000069301.V355375.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. 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