Inspection on 19/02/07 for The Pembury

This inspection was carried out on 19th February 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pembury 12/02/09

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 Pembury The Pembury 9 Pembury Road Gloucester Glos GL4 6UE Lead Inspector Mrs Helen James Key Unannounced Inspection 19th February 2007 09:30 The Pembury DS0000068038.V328348.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 Pembury DS0000068038.V328348.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 Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Pembury Address The Pembury 9 Pembury Road Gloucester Glos GL4 6UE 01452 521856 01452 303418 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 Deborah Bayliss Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection First Inspection following registration in August 2006. Brief Description of the Service: The Pembury is a converted guesthouse in the St Barnabas area of Gloucester. It is a detached house that provides accommodation for up to eight adults of either sex with Learning Disabilities from eighteen to sixty-five. The house has accommodation on the ground and first floor. All bedrooms have en-suite accommodation and four are located on the ground floor. On each floor there is an assisted bathroom and toilet facility. On the ground floor there is also a large communal lounge, separate dining room with quiet /computer area, kitchen, sensory room and laundry. The Managers office is on the first floor. All the accommodation meets the current environmental standards. To the front, back and side of the property is garden area screened by a fence with a patio are at the rear, all of which is well maintained. There is a car park for several cars to the rear of the property with on–road parking at the front of the home. 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 the National Vocational Qualification level four Managers qualification. The Pembury DS0000068038.V328348.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 is the first inspection for this service since it was registered in August 2006. The inspection took place over eight and a half hours on one day in February 2007 and was completed by one inspector. Thirty-three Care Standards for Adults (18-65) including all the twenty-two Key standards were assessed on this occasion. Of these nine exceeded the standard and twenty-one met the standard and three almost met the standard. Time during the inspection was spent speaking with the Registered Manager Miss Deborah Bayliss, staff and the two of the three people living at the home. Two of the three people living at the home were seen during the inspection, both had limited speech and most of the information was gained via observation about the home 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 including care plans, medication records, staff files and training information as well as health and safety systems and the environment. A pre-inspection record was provided prior to the visit. Four relatives/visitors of people living at the home returned comment cards, as did the GP, two Social Workers and one Community Nurse. Five surveys were returned from staff. Two people living at the home completed comments cards with assistance. Time was spent observing the care being provided to people and talking to them about the service they receive. One visitor shared their views 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 multi disciplinary working taking place. The Manager is keen to adhere to guidance and always improve practice to ensure that individual needs and lifestyles are fully met and that people living at the home have an excellent quality of life. The small staff team appear committed to ensuring that people living at the home engage in a range of social and recreational activities that are age appropriate, improve their quality of life and integrate them in the local community. The team is supported well by the Manager, team meetings, supervision and training/developmental opportunities. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 6 People living at the home indicate that 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 indicate, “a high level of care and attention is provided from a very professional team”. “ The Pembury is a very welcoming home” and “provides a safe environment that is pleasantly decorated and furnished to care for the people living there”. Management records relating to health and safety issues and regular checks were in place. There was evidence that if any action had been necessary that 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 Pembury DS0000068038.V328348.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 Pembury DS0000068038.V328348.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): 1,2, 3,4 & 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 each prospective resident is fully assessed prior to admission and on admission, to ensure that all their specific care needs can be met by the Home. EVIDENCE: The statement of purpose and the service users guide are on display in the foyer of the home as well as general information, this is given to individuals on enquiry/admission. Individuals are assessed prior to and on admission and sometimes on a number of occasions, documentation seen confirmed this. Copies of the admission assessments are in the persons care documentation; these provide specific details of care needs, next of kin and general information. The assessments tend to be done in conjunction with the Community Learning Disabilities Team (CLDT), Social Workers and the families with input from individuals who are to be cared for where this is possible. There have been three admissions to the home since the home was registered. Only one of these people was able to have a limited conversation with the The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 9 inspector. So much of the evidence here was gained from observation and discussion with those caring for the individuals. All the current people living at the home came to view the home with their relatives and stayed for short periods to allow all involved to gauge whether the individual would be happy at the Pembury. Once a person is placed at the home a six-week review is undertaken with family, social worker and all the agencies involved. The home is to ensure that the placing Authorities review placements yearly and these will be recorded in the care file. People had contracts (a sample were seen) but it is the relative or Social Services who deal with this and not the resident, 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. One person recently admitted spoken with confirmed that they were ‘happy at the home and they liked the carers’. One visitor to the home felt that the care the person they were visiting was receiving was ‘second to none’ and that due to this care and attention, they had progressed socially and were more interactive with people at the home, more than they had been on admission. People were seen given choice during the inspection. All the comments made by relatives/representatives, District Nurse, GP in conversation and via questionnaires were very positive about the home, staff, care, choice, social activities and the food. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care planning system ensures that all members of staff have a clear understanding of the care each person requires and how assistance is to be given. People are assessed and reassessed when their personal needs change. People are treated with respect and dignity and facilitated to live as independent a life as possible within their own limitations. EVIDENCE: Comprehensive information is maintained for people living at the home. This is being regularly monitored, reviewed and updated with the individuals. All three care records of people living at the home were examined. Two people were observed during the inspection. One spoken with could only 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 care. Care plans and activity plans are discussed with each individual person and where possible The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 11 signatory evidence on care plans is being sought to demonstrate individual’s / relatives involvement in the preparation of these plan and their agreement. It was evident from the daily notes and observation that staff adhere to care plans, activity plans and risk assessments. People living at the home were seen spoken too, addressed properly, politely and in a dignified manner, all interactions were appropriate. Staff confirmed that they are involved in the reviews of individuals. Any restrictions to choice or freedom are recorded on people’s files. Through discussion with the manager and observations at the home it was evident that personal autonomy and choice are promoted fully at the Pembury. One person was seen walking and playing about the home, in and out of the communal space with no restrictions placed upon them. 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. The following minor amendments to care record must be implemented: • All written entries must be in black pen, not red or any other colour. • Where a care plan states ‘regularly’, this must state exactly how often. 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 meetings. These are to be recorded (forms being implemented). Individuals’ records are accurate, secure and confidential. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 participate in age, peer and culturally appropriate activities through engagement in social activities of their choice and liking. Individuals are offered a healthy diet and enjoy their meals. 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 residents’ engage in and demonstrates that not everyone is doing the same thing. It also demonstrates that they are part of the wider Community. Outings are arranged that they like and choose to do. This was evidenced in their personal diary. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 13 A daily register is kept of where people are, with whom and when they will return. Individuals are encouraged to eat a healthy balanced diet. Where and if possible individuals are involved in going shopping and preparation of the meals. Weight monitoring for loss and gain is undertaken monthly and recorded and appropriate action is taken to address any issues raised that may impact on the health of the individual. Breakfast is eaten as people are up and ready for their breakfast, lunch tends to be sandwiches when they go out or if they are at home they have what they would like. The main meal of the day is usually in the evening and staff and people at the home eat together in the dining room and discuss the days 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. All the required checks are in place in the kitchen. Training records were seen for all staff for food safety and food hygiene. Menus were supplied prior to the inspection and records of alternative meals served are kept. The Manager audits the catering provision monthly and daily checks are in place. 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 they are made available. Tonight they are going out to a Valentines Disco at the Rainbow club, which all are looking forward to. People at the home are also given the opportunity to go on holiday during the year and are involved in the planning and preparation for this. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 14 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. People receive personal support in the way they prefer and require. The personal needs of people living at the home are met and there was evidence of good multi disciplinary working to ensure all healthcare needs are fully met. People are protected by the home’s policies and procedures for dealing with medicines. 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. The three 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 The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 15 met. The staff know through behaviour/ gestures etc when individuals require assistance or need something. It was observed during the visit that a total Communication Approach is taken with communication using a range of objects of reference, pictures, photographs, symbols, gestures etc. Of the three 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 needs and disposition of the people living at the home. 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. All medical and healthcare visits and checks are clearly recorded and comply with the health checks required by the individual. All equipment needed for residents’ health care is supplied appropriately by the Community Nursing services or the GP. District nurses visits on request and when they need to provide care. 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 the home through the weekly nomad system, reordering and administration of medication. All the MAR sheets were examined; two issues were identified: • Allergies were not recorded on the Medication Administration (MAR) sheets. • There were no photos of individuals on the medication file. • The homely Remedies agreement from the GP did not state which over the counter medicines could be given with dosage etc. • Policies and procedures relating to medication were in place but need to be made more specific to the home The home undertakes regular audits of their medication and excellent stock control procedures are in place. All the staff that dispense medication receive medication updating yearly. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 16 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: People spoken to say that if they have any concerns they would speak to the registered manager or co-owner. Relatives said they are aware of the complaints procedure and would speak directly to the manager if they have concerns. The complaints policy and procedure is displayed on notice boards around the home. The manager should consider how she could produce this complaints procedure in a format appropriate to the needs of people who are unable to read for instance using symbol or photograph. The Commission has received one anonymous complaint that was referred to the Providers to respond too. This related to employing an inappropriate member of staff: the Provider/Manager responded appropriately and the complaint was totally unsubstantiated. It was recommended that a complaint, concern, compliments record is kept in the home. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 17 There are quarterly ‘House’ meetings that provide another forum for people to express their concerns. Minutes of these meetings are displayed on a notice board. All comment cards returned from staff indicated that they were aware of adult protection procedures. The registered manager said that staff attend training in the protection of vulnerable adults and that further training would be arranged when the new safeguarding adults policy and procedure were 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’ produced by the local adult protection team is displayed in the home. Staff commented that they deal with challenging behaviour and that they feel they have the skills to do this. The registered manager arranges further training as the need arises. The registered 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 Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 18 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. People live in a home that is safe, clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. The home complies with infection control standards. EVIDENCE: A walk around the environment was conducted and all bedrooms were inspected. There is a handyman who deals with ‘day-to-day’ maintenance issues. The home has a lived in feel with evidence of lots of personalised touches – pictures, photographs, jigsaws, colouring books, CD’s and videos in communal areas. The Manager and staff said that individuals had brought their own furniture and possessions with them and had been involved in the colour schemes etc in their rooms. There is a sensory room and individual rooms have sensory equipment for creating a stimulating environment using The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 19 bright colours, lights and mobiles. Likewise thought has been given to people with special needs ensuring that any equipment they need is provided. People living at the home have access to day centres and recreational activities or they can choose to spend time in their rooms, in the lounge or dining room. A visitor was observed spending time in the lounge and spoken with said that she had seen massive improvements in the individual that she was visiting since they were admitted to the home. An array of hoists and slings are available around the home, which are being regularly serviced. An assisted bath is available on the ground floor that also has a Jacuzzi facility. At the time of the inspection the home was clean and tidy. 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 wall and floor surfaces and hand washing facilities. Washing machines have sluicing facilities. All staff have a responsibility for overseeing the laundry and good practices were observed to be in place. All confirmed that they had received infection control training. There are cleaning staff and there are records for auditing the cleaning schedules for the day and night staff in the home. Hazardous products are locked away and data sheets/risk assessments are kept and displayed 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 Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a training programmes that ensure that staff have knowledge about the diverse needs of people living at the home. EVIDENCE: Pre-inspection information indicated that seven care staff work at the home two have been appointed since the home was registered in August 2006. One started on the 5th February and is on induction for 4 to 6 weeks where she is shadowing a senior member of staff, she has had a POVA first and the Criminal Records Bureau (CRB) has been sent but not arrived back yet. Duty rotas demonstrated that she is working with another carer on each shift. The registered manager is advised to complete a risk assessment to describe the processes she has in place when employing staff with a Povafirst check. Staff confirmed that they complete an induction pack. One new staff member is seventeen and duty rotas confirm that she is working with another member of staff at all times supervised. She is undertaking The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 21 activities and ‘one to one’ sessions with individuals but not personal care at this time. Recruitment and selection processes are on the whole satisfactory with evidence that at least two written references are being obtained as well as proof of identity, an occupational health check and a full employment history. If there were gaps in the employment history the registered manager confirmed that she would question this during the interview process. Supervision is given throughout the induction 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. During the day from 7am until 2-30pm and 2-30pm until 9-30pm there is one member of staff on duty. At night 9-30pm until 7am 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 the needs of the residents, but 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. Evidence was seen via training records 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 seven members of staff and three staff have National Vocational Training (NVQ) Level 3 and one other member of staff is undertaking this at the present time. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 22 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. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People live in a home which is run in their best interests offering them choice, respecting their wishes and keeping them safe. There is good leadership, guidance and direction to staff from the management team at the home. This ensures residents receive consistent quality care and results in practice that promotes and safeguards the health, safety and welfare of the people living here. 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 Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 23 Staff comment cards indicate that the manager is accessible and a good role model working alongside them in the home. People were observed having positive interactions with the manager during the inspection. The staff team is small and 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 the management of the home and this appears to increase staff commitment to the home and the people living there. Staff appear extremely motivated and appear to enjoy their work and working environment. The registered 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 action is taken. The Manager needs to produce a report indicating what measures will be taken to address any issues identified. This should then be available to people living in the home and their relatives/social workers/doctors etc. Additional quality audits are completed for health and safety, cleaning, food hygiene and management and medication. There are good systems in place for people’s personal monies. The Manager described the processes that are in place. Records for three people were examined. Receipts can be cross-referenced with transactions but it is essential that all entries are signed in/out. The Manager confirmed that they regularly check the balances and there was evidence of this on the financial record. 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. Health and safety systems are in place that are monitored and reviewed. Water temperatures are regularly taken for outlets around the home. The staff maintain comprehensive records in line with ‘Safer Food Safer Business’ guidelines. First aid and COSHH risk assessments are displayed around the home. The pre-inspection questionnaire and service inspection documents confirm that equipment is regularly serviced. The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 24 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 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 4 LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 4 4 3 2 X 3 3 X The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 25 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Policies and procedures relating to medication need to be made more specific to the home. The Registered Person must ensure that medication administration records are amended to contain: • Allergies must be recorded on the Medication Administration (MAR) sheet. • Individual photos must be on the medication file. The homely Remedies agreement from the GP must state which over the counter medicines could be given with dosage etc. The Registered Person must ensure that all new staff have a current Criminal Records Bureau check in place before they start work, protecting people from possible harm. The Registered Person must DS0000068038.V328348.R01.S.doc Timescale for action 30/06/07 2. YA20 13(2) 30/06/07 3. YA34 19 schedule 2(6) 30/06/07 4. YA34 19 30/06/07 Version 5.2 Page 26 The Pembury schedule 2(6) 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. 30/09/07 5. YA39 24 (1-3) 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 YA6 Good Practice Recommendations The Registered Person must ensure that the following amendments to care records are implemented: • Where a care plan states ‘regularly’, this must state exactly how often. The Registered Person must put in place a complaint, concern, compliments record is kept in the home. The complaints procedure should be made available in a format appropriate to the needs of people unable to read text. All management hours and additional hours worked should be included on the duty rotas to demonstrate additional hours available to support residents. When Policies and Procedures are reviewed and updated the date of updating must be put on the bottom of the page. The Registered Person must ensure that all entries ‘in and out’ on the Personal monies record are signed to provide evidence that balances are correct. 2. 3. 4. 5. 6. YA22 YA22 YA33 YA40 YA41 ` The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI The Pembury DS0000068038.V328348.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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