Inspection on 19/07/07 for The Paceys

This inspection was carried out on 19th July 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 The Paceys 1 Wakefield Road Swillington Leeds West Yorkshire LS26 8DT Lead Inspector Dawn Navesey Unannounced Inspection 19th July 2007 10:20 The Paceys DS0000069425.V346728.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 Paceys DS0000069425.V346728.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 Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Paceys Address 1 Wakefield Road Swillington Leeds West Yorkshire LS26 8DT 01751 4747 40 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) Wilf Ward Family Trust John Henry Omer Dossey Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7) of places The Paceys DS0000069425.V346728.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: Learning Disability - Code LD and Code LD(E) 2. 3. The maximum number of service users who can be accommodated is: 7 7 places can be used for young persons from the age of 17 years. Date of last inspection Brief Description of the Service: The Paceys is a purpose built, two storey, detached property, providing short term and respite care for young adults who have a learning disability. The service can be booked either weekly or on a flexible basis for a weekend or part week. The accommodation consists of seven bedrooms which all have an en-suite toilet and sink. There are three bathrooms, which cater for the needs of people who want a bath, shower, assisted shower or assisted bath. There is ceiling, tracking hoist to meet the moving and handling needs of people who use the service. There is a well-equipped kitchen, two lounges and a large dining room. There is also a separate laundry room. The home has a passenger lift too. People who use the service are encouraged to make full use of the facilities in the house, garden and patio area, which include sensory equipment, television, DVD player and music systems. The home is situated in east Leeds, near to local shops, public houses and a library. It is on a bus route, with buses going to Leeds and Wakefield. The home also has its own adapted transport. The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 5 The charges at the home are £9 to 14 per night. Additional charges are made for leisure activities. The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector between 10-20am and 5-35pm carried out this unannounced inspection. The purpose of this inspection was to make sure the home was providing a good standard of care for the people using the service. The methods used at this inspection included looking at care records, observing working practices and talking with people who use the service and staff. Information gained from a pre-inspection self-assessment and the home’s service history records were also used. Before the visit, comment cards were sent out to people who use the service, relatives and visiting professionals to the home. Five of these have been returned and used in the preparation of this report. Feedback was given to the manager at the end of the visit. Thank you to everyone for the pre-inspection information, returned comment cards and for the hospitality and assistance on the day of the visit. Requirements made during this visit can be found at the end of the report. What the service does well: The home has a friendly, relaxed and welcoming atmosphere. The manager offers a flexible respite service to people who use the service and tries to accommodate individual’s needs. Information has been produced in an easy read and picture format making it more accessible to people who use the service. Staff have good knowledge of the needs of the people who use the service. Staff interact well with them and treat them as individuals. In a returned survey, a relative said, “They always look after …… well”. In a returned The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 7 questionnaire to the home, a relative said, “My daughter rates the personal care as very good for her needs”. Another said, “I feel so confident when my son is here, I can relax and enjoy myself”. Staff make sure that people who use the service have regular and varied activity that suits them as individuals. In a returned survey, a relative said, “He is always happy when he is there”. In a letter to the home a person who uses the service said, “I had a lovely time, I enjoyed watching the Rhinos at the club”. The home is very homely, well equipped and very clean. Furnishings are of a very good standard, giving people who use the service a good environment to be in. Staff are well supported by the manager of the home. All staff spoken to said the manager was approachable and was a good leader. In telephone conversations with parents, they said they found the manager helpful and open to ideas and suggestions. 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 summary of this inspection report can be made available in other formats on request. The Paceys DS0000069425.V346728.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 Paceys DS0000069425.V346728.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 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have enough information needed to make a choice on whether the home will meet their needs. Pre-admission assessments are completed by parents or carers but do not always show how the home’s staff have been involved in them and therefore whether they can be sure of meeting their needs. EVIDENCE: The home has a comprehensive Statement of Purpose with good information about the service and facilities it aims to provide. There is also a Service User Guide, which is given to each person who uses the service and is also kept in each bedroom at the home. This information has been produced in an easy read format, which includes pictures and symbols. There is also an accessible complaints procedure within it. The cost for the service and what is provided for that is also included in this guide. The manager is in the process of putting this information on the organisation’s web site to make it more widely accessible for people who use the service or are thinking about using the service. This is good practice. The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 10 All people who returned a survey felt they had been given enough information on the service. A person using the service gave a very enthusiastic “Yes” when asked if he liked coming to the home. In telephone calls to parents, they all said they had been given plenty of information about the service and the facilities. Pre-admission assessments are carried out for all people who use the service before they stay at the home. This involves visits to the home, overnight stays and the manager going to visit them in their own home. Parents, carers and the people who use the service are involved in this process. They complete the assessment form and any instructions on medication and nutritional needs. The manager said that he would add information to this assessment and consider whether the home could meet their needs. At the moment, there is no written evidence to show that this has been done, which means some needs could be overlooked. The information is however, reviewed by telephone before each stay at the home. The manager also showed some new documentation that he and others in the organisation have developed. When this is used, there will be a detailed respite support assessment which will be completed by people who use the service, their carers and the home’s staff. This new documentation is person centred and has been produced in an easy read format, using symbols and pictures. This will encourage the involvement of people who use the service. The manager said he plans to have completed these new assessments for all people who use the service within the next six months. Care management, nursing or social work assessments are also obtained prior to people who use the service staying at the home. This means that information is gathered from a variety of sources. The Paceys DS0000069425.V346728.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 the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite the gaps in support planning and risk assessment documentation, staff are, in the main, aware of the individual needs of people who use the service. The lack of support plans and risk management plans could however, lead to the needs of the people who use the service not being properly met. People who use the service are involved in decisions about their lives when staying at the home. EVIDENCE: Some people who use the service have support plans that have been developed from the assessment of their needs. However, some of these support plans have not been dated or reviewed for some time. Some of the information related to the previous respite placement. Some of the plans are detailed and give specific information on care needs. Others are not. Instruction such as “change regularly” and “full support” do not give staff the The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 12 detail on how care tasks are to be carried out. A good support plan should give clear and detailed information on how and when care is given, taking particular notice of the peoples’ preferences and choices. For others, the assessment information is being used as a plan of care. This information is not always detailed enough and no support plans have been drawn up from the information. This could lead to important care needs being overlooked. However, the new documentation that the manager is in the process of introducing should make sure that support plans are developed from initial assessments. The manager has agreed that it will take six months to get this in place for the large numbers of people who use the respite service. A relative who returned a survey said they felt the home could improve by reading individual’s notes on care needs and any other information that is passed on. Staff said that they didn’t feel they always had enough information on specific care needs. They said they would contact carers for more information if the person who uses the service was not able to tell them how they needed to be supported. In a telephone call a parent said, “They communicate well with us, we have mentioned one or two things and they have gone out of their way to put it right.” Risks to people who use the service have been identified through the assessment process. However, for many people, there are no action plans in place to show how risk is managed or minimised. The manager is aware of the need to have this in place and has started some work on risk assessments for some people who use the service. This must be done for all people using the service in order to ensure safety and make sure needs are properly met. Despite the lack of documentation on support planning and risk assessment, staff have good knowledge on the needs of people who use the service. They were able to accurately describe the support needs and were observed to be giving support in the way it was written down in some people’s support plans. Staff said they always read the assessment information on people who use the service prior to them coming to stay at the home. They said they also read the pre-visit telephone call information in order to refresh their knowledge of peoples’ needs. People who use the service are involved in the home as much as they wish to be. Some people like to be involved in the shopping and cleaning in the home. Others do not wish to do this and see their time at the home as a holiday. Staff said they respect this choice. At the start of each visit, people who use the service meet with staff and complete an arrival form which gives them opportunities to say what they would like to be involved in during their stay. Staff said they encourage people to make choices on all aspects of their lives when at the home. For example, when to get up, what to do, what to eat and when to go to bed. Staff use picture cards and some signing to communicate with people who do not use verbal communication. This is good practice. The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers opportunities to people who use the service, for personal development in addition to a range of leisure activities. People who use the service are able to make choices about their lifestyle. They also benefit from a good, healthy and varied diet. EVIDENCE: People who use the service are involved in a variety of activity during their stay at the home. This ranges from shopping, going to the pub, meals out, theatre trips, community events and bowling. Some people choose to continue their lifestyle and attend the day centre they are familiar with. Some people who use the service find it difficult to go on outings, so activity is arranged in the home which specifically meets their needs. Others are also involved in activity within the home such as artwork, games, watching DVD’s, games consoles and takeaway evenings. In a returned survey, a relative said, “He is always happy when he is there”. In a letter to the home a person who The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 14 uses the service said, “I had a lovely time, I enjoyed watching the Rhinos at the club”. In a comment made on the home’s quality audit feedback a parent had said they thought the activity at the home was “Quite adequate” another said they were impressed with the service being provided. On the day of the visit, people who use the service had been to their day centres and were all asked if they wanted to go bowling that evening. This seemed to be a popular activity. One of the people using the service was very excited at the prospect of going and it was clear it was something he had asked to do during his stay. People who use the service are supported to keep in contact with their family while visiting the home if they want to. Some people send letters and cards, others make phone calls to their parents or carers. In a note in the home’s compliments book, a parent had said, “I feel so confident when my son is here, I can relax and enjoy myself”. Some of the people using the service have made contacts in the local community and are known in the local shops, garden centre and pubs. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure people who use the service are as independent as possible. One said, “This gives them their dignity and respect”. Staff were able to give examples of how they support people to be as independent as they are able to be. There is plenty of social interaction between the staff and people who use the service. The atmosphere is calming and relaxed. Menus appear to be well balanced and nutritious. A good variety of food is available and the staff make sure there is a good selection of fresh produce. Menus are drawn up each week in consultation with the people who use the service. People who use the service can help themselves at anytime to snacks and drinks in the fridge or cupboards. Fruit is also readily available. The manager said that a diverse range of diets can be catered for at the home. He said Hal Hal food is bought in when a guest who is Muslim is staying. Also vegetarian or pureed diets are provided. The Paceys DS0000069425.V346728.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 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite the lack of some written documentation, personal and health care support is provided in a way that meets the needs of the people who use the service and makes sure their privacy and dignity is respected. People who use the service are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff supported people who use the service with their personal care needs discreetly and in private. The personal care needs of people using the service are well monitored through the use of written recording and daily notes. Staff have good knowledge of the likes, dislikes and preferences of the people who use the service. In a returned survey, a relative said, “They always look after …… well”. In a returned questionnaire to the home, a relative said, “My daughter rates the personal care as very good for her needs”. Support plans around people’s health needs were not detailed and clear enough. This was particularly relevant to epilepsy support plans. The plans did not contain advice on management of fits or emergency situations with fits. The manager The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 16 agreed that more detail is required in order that care needs do not get overlooked. The manager said that the home could be responsive to the needs of people who use the service as they arise. Any specialist training is sought before people stay at the home, for example, training is given by community nurses and dieticians for a person who is PEG fed (tube fed directly into the stomach) and for people who have swallowing difficulties. Also the organisation provides training from a registered nurse on administration of rectal medications. Staff confirmed they are not able to do this without having received the training. The home is registered with a local GP who provides a temporary service for people who use the service when they are staying at the home. The staff document any contact with health professionals on contact sheets in the person’s file. This information is then passed on to parents or carers. Details of health professionals that people who use the service see are included in their assessment information and staff can contact them if necessary. Medication is well managed in the home. Parents or carers complete a medication information sheet prior to each visit and sign this to say their instructions to staff are correct. Staff then book the medication into the home and draw up a medication administration record (MAR) sheet. This is done in two’s to avoid errors. This is good practice. Staff also administer medication in two’s and sign the MAR sheets as such. Staff were seen to administer medication safely and individually to people. Medication is also checked at each shift change over. This makes sure that any errors are picked up sooner rather than later and can be rectified. All staff receive accredited medication training. The Paceys DS0000069425.V346728.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 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect people who use the service from abuse. EVIDENCE: The home has a comprehensive complaints procedure and an easy read procedure with pictures and symbols. A copy of this is kept in the service user guide which each person who uses the service has a copy of. Any complaints the home has received are documented in the complaints book and the investigation and outcome are documented in the files of people who use the service. Any recent complaints have been responded to promptly and dealt with properly. The home also keeps a book for thank you letters and compliments received about the service. All people who returned a survey said they knew how to complain. In telephone calls to parents, one said, “We know how to complain if needs be, but no complaints at all up to press”. Staff have received training in the protection of vulnerable adults. The manager has completed a training course which means he can deliver this training. Staff said they are aware of the different types of abuse and any signs that might alert them to it. They are also aware of their responsibilities in reporting any allegations or suspicions of abuse. The organisation has a comprehensive adult protection procedure in place. The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 18 There are good systems in place to manage any money held on behalf of people who use the service. Money is checked in on arrival at the home and records of any expenditure are kept. The Paceys DS0000069425.V346728.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): 24, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers an attractive, homely, clean and safe environment for people who use the service. EVIDENCE: The home is attractively and tastefully decorated and well furnished throughout. The use of soft furnishings, ornaments, plants and pictures gives a homely feel. It is warm, clean, fresh smelling, light and airy with a good layout. On the day of the visit, builders were working in the home to make the lift fireproof. This will mean that people using the service who use a wheelchair will be able to access the first floor of the home as the lift will be in service. One part of the home has been separated to form an annexe that can accommodate people who need support in a quieter environment or have behaviours that challenge others. The annexe can also be opened up to the rest of the house for people to socialise if they wish. The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 20 Bedrooms have been decorated and furnished, to a very high standard. They are well equipped with moving and handling equipment such as overhead tracking and are all en-suite. They also have a television and DVD player in each room. There are three bathrooms in the home. One bathroom provides a high low reclining bath, another has a shower and shower trolley and the other has a bath. This gives people who use the service an excellent choice of bathing facilities and should meet the diversity of needs provided for at the home. The kitchen is well equipped but domestic in style. This encourages people who use the service to help themselves to snacks and drinks. There is a large garden and patio area. Staff, people who use the service, their families and volunteers from a local garden centre have recently all worked together on many areas of planting. This makes the garden and front forecourt very attractive. Laundry is well managed in a fully equipped laundry. The clothing of people who use the service is washed separately to try and avoid clothing getting mixed up. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who use the service. Staff have received training in infection control as part of their induction and are able to say what infection control measures are in place. The manager said he would like staff to do an accredited course in infection control and has plans to book this in the near future. The Paceys DS0000069425.V346728.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): 32, 34, 35 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are trained and competent to meet the needs of the people who use the service and are well supervised. People who use the service are protected by the home’s recruitment procedures. EVIDENCE: There are staff on duty throughout the day and night. There are usually four staff on the morning and afternoon shifts. At night there are two waking member of staff and one sleeping in, who can be called upon in emergency. There is also an out of hours on call manager. The manager works some of the time on the rota with some time available for his managerial duties. Staff said there was always enough staff on duty as long as they were fully staffed. In a returned survey, a relative said, “He likes the staff very much” another said, “They all do a great job”. In notes made in the compliments book, comments included, “Staff are very helpful and polite”, “10 out of 10 to the staff team” and “I could not fault them”. In a returned questionnaire to the The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 22 home a relative said, “The hard work and professionalism you and your staff team have shown is greatly appreciated”. The home keeps a pro-forma of staff information to show that recruitment is properly managed. It would be good practice for the manager to sign this to show it has been checked against the original records which are held at the organisation’s head office. Interviews are held; references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. There was evidence in some staff’s files to show that telephone verification checks take place on references. The manager said he would make sure this was in all staff’s files in the future. He said he thought this was an administrative error that the form had not been completed in full for some staff. Staff’s mandatory training is mostly up to date. Records are kept of staff’s training and when their updates are due. The manager assesses this regularly to make sure training doesn’t get missed. Staff spoke highly of their training and the support they get from the manager. Staff said “I am happy with my training it is very thorough”. Another said she felt the training had equipped her well for the job. In addition to mandatory training, the manager makes sure that training is given in any specialist needs of the people who use the service. This includes autism, epilepsy and Makaton sign language training. About 36 of the staff team have achieved an NVQ (National Vocational Qualification) in care at level 2 or above. Other staff are to start on this once they have completed their LDAF, (Learning Disability Award Framework) which forms the basis of their induction training. All staff said they felt they have a good team and the manager is approachable and supportive. Staff said they felt communication and teamwork within the home is good. Staff said they receive supervision from the manager every one or two months. Records also showed this. Regular staff meetings also take place and the manager uses these as an opportunity for coaching and developing the staff team. The Paceys DS0000069425.V346728.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): 37, 38, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of people who use the service are seen as important to the manager and staff and are safeguarded and respected at all times. EVIDENCE: The home has an experienced manager who has successfully completed the NVQ level 4 in care and the Registered Managers Award. He offers good leadership to the staff. Staff said he is approachable and listens to what they have to say and any suggestions they make. The area manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to people who use the service and staff about The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 24 the home. A report of these visits is made showing details of any action to be taken to improve the service. The home has developed a quality assurance system where questionnaires are given to people who use the service and their carers to seek their views on the service. The questionnaire has been produced in an easy read format which includes pictures. The manager analyses the returned questionnaires and will act on anything that has been suggested if he can. Comments received included, “Very good, will listen and act accordingly” and “They are always open to suggestions”. One relative expressed concern at clothing going missing during visits. The system of dealing with laundry has been developed to try and address this. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Maintenance records are well kept. Electrical and gas safety checks are up to date. Environmental risk assessments are completed and reviewed. Accident or incident reports are completed, however there is no space on the form to record any follow up action taken after any accidents or injuries. There are a range of policies and procedures in place to ensure health and safety. The manager makes sure that staff read these and sign them to say they have read and understood them. The Paceys DS0000069425.V346728.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 4 2 2 3 3 4 X 5 3 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X X 3 X The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 14.1 Requirement The manager must make sure that pre-admission assessments show how the home have been involved in this process. This will make sure all the needs of the people who use the service are fully identified. The manager must make sure that all people who use the service have an up to date detailed support plan. This will ensure that they receive person centred support that meets their needs. The manager must make sure that all identified risks for people who use the service have a detailed action plan in place in order to minimise or prevent the risk. Timescale for action 30/12/07 2 YA6 YA19 15.1 30/12/07 3 YA9 13.4 30/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. The Paceys Refer to Good Practice Recommendations DS0000069425.V346728.R01.S.doc Version 5.2 Page 27 Standard The Paceys DS0000069425.V346728.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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