Inspection on 15/05/07 for The Padova

This inspection was carried out on 15th May 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 Padova 11/05/09

The Padova 27/02/06

The Padova 25/10/05

The Padova 25/02/05

The Padova 15/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Padova 88 Bristol Road Quedgeley Gloucester Glos GL2 4NA Lead Inspector Mrs Helen James Key Unannounced Inspection 15th May 2007 09:30 The Padova DS0000016627.V335758.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 Padova DS0000016627.V335758.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 Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Padova Address 88 Bristol Road Quedgeley Gloucester Glos GL2 4NA 01452 883764 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) Miss Deborah Bayliss Miss Claire Jayne Thomas Care Home 9 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2) of places The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 27th February 2006 Brief Description of the Service: The Padova is an extended detached house in Quedgeley near Gloucester that provides accommodation for up to nine adults with Learning Disabilities. The older part of the house has a ground and first floor. The new extension is single storey and meets current environmental standards with all rooms having en-suite facilities. On each floor is an assisted bathroom and toilet facility. On the ground floor is a lounge/dining room and a quiet room, kitchen, office and laundry room. The home is staffed twenty-four hours a day and the Registered Manager is in day-to-day charge of the home. The Manager has completed their National Vocational Qualification level four Managers qualification. To the front of the property is car parking for several cars and to the rear is a large well-maintained garden with sensory garden area and a patio area. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection took place over seven and a half hours on one day in May 2007 and was completed by one inspector. Thirty Care Standards for Adults (18-65) including all twenty-two Key standards were assessed on this occasion. Of these fourteen exceeded the standard and fifteen met the standard and one almost met the standard. Time during the inspection was spent speaking with the Registered Manager Miss Claire Thomas, Provider Miss Deborah Bayliss, staff and the four of the people living at the home. Four people living at the home were seen during the inspection, two were able to converse with the inspector fairly well but the other two people had limited speech. Therefore information was gained via observation and listening to interactions with care staff and the manager at the home. The inspector spent time cross-referencing information about the care and welfare gained from talking to and observing people with the persons’ individual care record. A range of records were examined to include care plans, medication records, staff files, training records and health and safety systems. A tour of the environment was also made. A pre-inspection record was provided prior to the visit. Three relatives/visitors of people living at the home returned comment cards, as did the GP. Five surveys were returned from staff. Only one person living at the home was able to complete a comment card with assistance from a relative. Time was spent observing the care being provided to people and talking to the four people at home during the inspection about the service they receive. There were no visitors to the home during the inspection. What the service does well: The home appears to run like an extended family home, which contributes to its ‘success’. Staff interactions with individuals were appropriate, dealing with people respectfully and in a kind, polite and considerate manner. The health needs of people living at the home are well met with evidence of good multidisciplinary working taking place. Two people were able to speak to the inspector during the inspection and were complimentary about the care that was given and the pleasant friendly manner of the staff employed at the home. Stating that “they were approachable and helpful and that they give you good support and assistance when you need it”, “dignity was respected and they were treated as individuals”. “There was the freedom to do what you wanted and no–one ever told you what to do. You could choose to participate in your activity diary or not.” “Staff and the Manager were always available to spend time talking and helping with things”. “You have your own daily routine.” People living at the home indicated that The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 6 they enjoy the activities and outings on offer and that the staff focus on people’s interests and things they enjoy doing. Comments from relatives reported how ‘happy they were with the staff, care and lifestyles that people had at the home’, ‘couldn’t have found a better place’ stated one.” “ The staff are very welcoming”. Management records relating to health and safety issues and regular checks were in place and evidence was available that if any action had been necessary it had been completed. The Manager has an array of documented auditing tools in place to examine quality and effectiveness of systems in the home, which contribute to the Quality Assurance of the home. 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 Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that people who use the service are fully assessed prior to admission and on admission, to ensure that all their specific care needs can be met by the Home. The statement of terms and conditions and contract provides people with information about the service they will receive from the home. EVIDENCE: All prospective new people would be encouraged to visit the home with their relative/social worker/ friends prior to admission, this familiarises them with the home, its facilities and the staff. All people planning to live at the home have their care requirements fully assessed before they are admitted to ensure that the Home is able to meet their needs. Advice is also taken from other people who have been involved in the care at home. There have been no admissions to the home since the last inspection. People had contracts (a sample were seen) but it is the relative/representative or Social Services who deal with this and not the person, due to the fact that many are unable to deal with this themselves. The contract contained all the required details and was compliant with Office of Fair Trading Standards. People spoken with confirmed that they were ‘happy at the home and they liked the carers’. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are treated with respect and dignity and facilitated and supported by staff to live as fulfilling and independent a life as possible within their own limitations. The care planning system involves the individual and their families and ensures that all members of staff have a clear understanding of the person centred care each person requires. EVIDENCE: Individuals’ records are accurate, secure and confidential. Comprehensive information is maintained for people living at the home. These are being constantly monitored, reviewed and updated monthly or more frequently if required. Two care records were examined for two people living at the home, both were observed during the inspection and spoken with albeit they could give limited responses. The care records contained all the required documentation and were very clear in how the individuals were to be managed regarding their The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 10 care. Care plans and activity plans are discussed with each individual person and where possible signatory evidence on care plans is being sought to demonstrate individual’s / relatives involvement in the preparation of these plans and their agreement. It was evident from the daily records and observation that staff adhere to care plans, activity plans and risk assessments and facilitate the choice of individuals. Any restrictions to choice or freedom are recorded on people’s files. Although one restriction noted of a chair safety belt needs to be included in one persons care plan. Through discussion with the manager and observations at the home it was evident that personal autonomy and choice are promoted as fully as possible at the Padova. People living at the home were spoken too and addressed properly and interactions were appropriate. Staff confirmed that they are involved in the annual reviews of individuals. A full range of risk assessments are in place for a variety of activities both inside and outside the home and several of these were examined and demonstrated enablement within a risk framework. These are signed and regularly reviewed. People living at the home have choice about their daily routine and are consulted about all aspects of life at the home, where possible, using a variety of communication tools and monthly house/client minuted meetings. People living at the home have opportunities to help with the day-to-day running of the home by assisting in preparation of meals, washing up, clearing up, cleaning their room, dusting and shopping to list a few. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living at the home participate in age, peer and culturally appropriate activities through engagement in social and recreational activities of their choice and liking within the local community. EVIDENCE: People living at the home have individualised programmes of daytime activities during the week. The ‘Personal Diaries’ where entries are made about the activities they have participated in and with whom, give a valuable insight into the diversity of activities that the people engage in. This demonstrates that not everyone is doing the same thing at the same time, although they may do things with friends within the home. It also demonstrates that they are part of the wider Community and gives an insight into their ‘adventures’. People are encouraged to eat a healthy balanced diet and education about the importance of a healthy eating is ongoing. This is done through involvement of The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 12 individuals in shopping and preparation of the meals. Weight monitoring for loss and gain is undertaken monthly and recorded and is included in the care plan. Appropriate action is taken to address any issues raised that may impact on the health of the individual. One person requires assistance with eating and everyone else just requires supervision at meal times. Breakfast is eaten as people are up and ready for their breakfast so is flexible, lunch tends to be sandwiches when they go out or if they are at home a choice of food. The main meal of the day is usually in the evening everybody eats together with the staff in the dining room and discuss the day’s events and what they would like to do for the evening. There are a variety of evening entertainments on offer, from external clubs to watching a DVD at home to having a foot massage in the sensory room. All the required checks are in place in the kitchen and staff maintain comprehensive records in line with ‘Safer Food, Safer Business’ guidelines and a recent Environmental Health inspection awarded a ‘scores on the doors’ 5 star rating. Training records were seen for all staff for food safety and food hygiene. Menus were supplied prior to the inspection. The Manager audits the catering provision monthly. People living at the home are given choice in everything they do and are consulted about what they want to do within the restrictions of their ability and safety. Assistance and supervision for all activities is available at all times and where extra staff is needed this is made available. The Padova has set up with the Providers’ other home a weekly themed Music Therapy afternoon for people living at the homes; this is well attended and acts as a social function as well as having therapeutic benefits. People living at the home have also invested in a small greenhouse and have planted flowers and vegetables which they are nurturing before they plant them in the garden and they are all thoroughly enjoying the gardening. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal needs of people living at the home are met and they are based on the principles of respect, dignity and privacy. Healthcare need are met through good multi disciplinary working and People are protected by the home’s policies and procedures for dealing with medicines; although some refinements are needed to make them more specific to support and inform practice within the home. EVIDENCE: People in the home appear to have the freedom of choice around their daily activities within their own limitations and this takes into consideration any individual risk assessment or assistance they may require, as seen in care records. Of the two care files examined it was very clearly identified how the individuals were supported in their care plans and personal profiles. There appears to be flexibility in routines dictated by the individual needs, choice and disposition. Staff were seen to be patient, respectful and polite engaging with individuals and responding to them appropriately. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 14 Several people living at the home have communication difficulties and the fact that there is small reliable team of staff who are very familiar with individual behaviour and communication ensures that individuals’ needs are met. The staff know through behaviour/ gestures etc when individuals require assistance or need something. This was observed during the interactions seen during the inspection. There is a total Communication Approach in the home and a variety of tools are used, objects of reference, pictures, photographs, symbols, gestures etc. Other people at the home are able to communicate their needs and wishes and conversations were had with these individuals relating to choice, staff and lifestyle; they responded positively to their life at the home and were very happy with the staff. All medical and healthcare visits and checks are clearly recorded and comply with the health checks required by the individual. All equipment needed for peoples’ health care is supplied appropriately by the Community Nursing services or the GP. People are referred to the Community Learning Disabilities Team and to the appropriate health and welfare professionals at their request or when it is necessary. Issues relating to life and death wishes are discussed in full and documented and signed by the person and/or their next of kin and these are reviewed yearly. The homes medication system was checked. The Manager explained the procedure for medication into/out of the home through the weekly nomad system, re-ordering and administration of medication • Policies and procedures relating to medication were in place but need to be made more specific to support and inform practice at the home. The Manager/provider undertakes regular audits of the medication and excellent stock control procedures are in place. All the staff who dispense medication have received accredited training and are updated regularly. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The Commission has received no complaints. People spoken to and from comment cards say that if they have any concerns they would speak to the manager, owner or staff. Relatives/advocates said they are aware of the complaints procedure and would speak directly to the manager if they have concerns or worries. There are monthly client meetings that provide another forum for people to express their concerns. These are well attended and minutes of these meetings are displayed in the home. The complaints policy and procedure is displayed in the home. The manager should consider how to produce the complaint procedure in a format appropriate to the needs of people who are unable to read, for instance using symbol or photographs. A complaint, concern, compliments record is kept in the home. All comment cards returned from staff indicated that they are aware of adult protection procedures. There was evidence that staff attend training in Abuse The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 16 Awareness and that further training will be arranged when the new safeguarding adults policy and procedure are introduced in Gloucestershire. Staff who have completed their NVQ Awards will also have completed a unit on abuse. A copy of the ‘alerter’s guide’ and the Local Adults at Risk information produced by the local adult protection team should be displayed in the home. The manager is aware of the implications of the Mental Capacity Act and will arrange training for staff in due course. Information about how to access IMCA’S will be made available to people. Recruitment practices within the home are good and comply with Regulation 19. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 17 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, 25,29 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical environment provides for the individual requirements of people living at the home. The home is appropriate for the lifestyle and needs of individuals and is homely, clean, safe and comfortable and complies with infection control standards. EVIDENCE: The standard of the environment in this home is good with people having a pleasant, clean and well-maintained environment to live in. A walk around the environment was conducted and some bedrooms were seen. Maintenance and redecoration issues are addressed as and when needed. The maintenance book needs reimplementing to evidence when and how things are dealt and provide evidence for audit trail purposes. The home has a lived in feel with evidence of lots of personalised touches – pictures, photographs, jigsaws, magazines, books, CD’s and videos in the communal area. There was evidence in rooms seen that individuals had The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 18 brought their own furniture and possessions with them and had been involved in the colour scheme, decoration etc in their rooms. One room is used as a sensory room and some peoples’ own rooms have sensory equipment for creating a stimulating environment using bright colours, lights and mobiles. Likewise thought has been given to people with special needs ensuring that any equipment they need is provided. There was evidence that staff are provided with personal protective equipment that is accessible throughout the home. The laundry is clean and well ordered with washable walls and floor surfaces and hand washing facilities. All staff have a responsibility for overseeing the laundry and good practices were observed to be in place. There is one staff member who cleans and care staff also have to do some cleaning. There are records for auditing the cleaning schedules. Hazardous products are locked away and data sheets/risk assessments are kept in a file in the home. There is a colour-coded system in place for cleaning equipment green for the kitchen and red for the rest of the home. The home meets infection control standards and staff seen confirmed they had received infection control training, records confirmed this. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 19 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 & 36 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. A competent staff team deliver a person centred approach to people’s care. They have access to training programmes to ensure they have the knowledge and skills necessary to provide care for the diverse needs of people living at the home. People are protected by the thorough recruitment practice at the home. EVIDENCE: Pre-inspection information demonstrated that during the day from 7am until 930pm there are at least two members of staff on duty. At night 9-30pm until 7-30am there is one waking staff on duty and the manager is on–call at all times. Rotas demonstrate sufficient staff on duty at all times to meet people’s needs. There are always more hours available so it is imperative that management hours and additional hours worked are included on these rotas to demonstrate the extra support hours available in the home. Pre-inspection information indicated that six care staff and the Manager work at the home. Three staff have been appointed since the home was last inspected. Recruitment and selection processes are on the whole satisfactory The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 20 with evidence that at least two or more written references are being obtained as well as proof of identity, an occupational health check and a full employment history. The Manager verifies gaps in employment history and evidence was seen of this on one new persons file. Recruitment practice met Regulation 19 but it was noted that staff started work following POVA First checks, records demonstrated that the full CRB was not received back until after the staff member had started work. The Manager assured the inspector that all new staff work with another carer on induction for 4 to 6 weeks and longer if the CRB is not back at the end of the induction. The Manager must evidence this explicitly on the duty rotas. The Manager is required to complete a documented risk assessment to describe the processes that are in place when starting staff with only a Povafirst check. Supervision is given throughout the induction period and then starts routinely to comply with the regulations, evidence seen during the inspection. The duty rota identifies the monthly staff meetings and all supervision sessions for the month. Yearly appraisals are done for all staff. On discussion with a new staff member she confirmed that an induction process was completed and that she had received regular supervision and training. The two new staff records seen verified this. The staff member also confirmed that she enjoyed working at the home and that she enjoyed the variety in her working day and enjoyed enabling people to have an enjoyable quality of life. Training records seen confirmed that all staff receive the appropriate mandatory training and that this is ongoing. Training is well supported by regular supervision sessions and yearly appraisals. This is well recorded in the home and demonstrates a proactive approach to staff personal development. There are six members of staff one has National Vocational Training (NVQ) Level 3, one is undertaking NVQ level 3 and three are doing NVQ level 2 at the present time. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 21 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, 38,39,41,42 & 43 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People using the service are safeguarded by good management that actively promotes independence and choice for people. There is good leadership, guidance and direction to staff from the manager, this ensures people receive consistent quality care and results in practice that promotes and safeguards the health, safety and welfare of the people living here. The home needs to develop its quality assurance system by reviewing its performance and writing a quality assurance report to demonstrate continual improvement and development in the service. EVIDENCE: The manager actively pursues her continuing professional development by participation in local training and attending training courses to develop her skills and abilities. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 22 Staff confirm that they get good support and leadership from the Manager and that the ethos for the home is to provide the best quality care and lifestyle for the people living there. The staff team is small and minuted staff meetings take place monthly they look at the improvements that the team can make and what they are doing well. This means that staff are involved in influencing how the home and care is managed and this appears to increase staff commitment to the home. Staff comment cards indicate that the manager is accessible and a good role model working alongside them in the home. Staff are extremely motivated and comment that they enjoy their work as it is so varied. People were observed having positive interactions with the manager and staff during the inspection. The manager described the systems she has in place to assess the standards of care being provided. People take part in an annual quality assurance survey from which changes and developments are made. The Manager needs to produce a report indicating what measures will be taken to address any issues identified. This should then be available in different formats for people living in the home and their relatives/social workers/doctors etc. A range of quality audits are completed for health and safety, cleaning, food hygiene, management and medication. There are good systems in place for people’s personal monies. The Manager described the processes that are in place. Records are audited regularly. Staff confirmed that they have an annual appraisal, copies of which were seen on files. The manager states that she observes staff practice regularly and records confirm that staff receive six supervision sessions each year and the content of these supervisions. In this years review of the Kroner policies and procedures some will need local adaptation to demonstrate homes’ working practices, so that staff have a resource and guidelines to work too. Health and safety systems are in place that are monitored and reviewed. The environmental checks and the maintenance issues need to be recorded to evidence the ongoing checks that are informally in place. Water temperatures are regularly taken for outlets around the home. First aid and COSHH risk assessments are displayed around the home. The pre-inspection questionnaire confirmed that all equipment is regularly serviced and health and safety checks are in place. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 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 4 26 X 27 X 28 X 29 4 30 4 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 4 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 4 4 3 X 3 3 3 The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 24 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. 1. Standard YA20 Regulation 13(2) Requirement Policies and procedures relating to medication need to be made more specific to support and inform practice at the home. The Registered Person must ensure that a ‘Risk assessment’ is documented for staff starting work on a Povafirst check, describing how people are protected from possible harm. The Registered person must produce an annual quality assurance report to evidence the review of the quality systems in the home. This must include stakeholders’ views and future developments in the home. Timescale for action 01/08/07 2. YA34 19 schedule 2(6 01/07/07 3. YA39 24 (1-3) 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The complaint procedure should be made available in a format appropriate to the needs of people unable to read DS0000016627.V335758.R01.S.doc Version 5.2 Page 25 The Padova 2. 3. 4. 5. 6. 7. YA23 YA24 YA33 YA34 YA40 YA42 text. A copy of the ‘alerter’s guide’ and the Local Adults at Risk information produced by the local adult protection team should be available in the home. Manager to re-implement maintenance book to evidence when and how things are dealt with for audit trail purposes. All management hours and additional hours worked should be included on the duty rotas to demonstrate additional hours available to support individuals. The Manager must evidence on the duty rotas where new staff, with only a Povafirst check, are working with another member of staff. Kroner policies and procedures to be adapted locally to demonstrate homes’ working practices. Manager to keep a record of evidence of: • The environmental checks. The Padova DS0000016627.V335758.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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