Inspection on 09/05/06 for The Pines

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Pines 10/07/07

The Pines 01/11/05

The Pines 25/05/05

The Pines 15/11/04

The Pines 22/06/04

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 Pines (The) 39 Portchester Road Charminster Bournemouth Dorset BH8 8JU Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 9th May 2006 09:15 DS0000003994.V294246.R01.S.doc Version 5.1 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 DS0000003994.V294246.R01.S.doc Version 5.1 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. DS0000003994.V294246.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pines (The) Address 39 Portchester Road Charminster Bournemouth Dorset BH8 8JU 01202 555048 01202 567682 Helenluckystar@ad.com 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) Sandbourne House Ltd Mrs Sarah Alison Dixon Care Home 13 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (13), Physical disability (1) of places DS0000003994.V294246.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A service may be provided to people in the category of PD in the respite room only. The Manager must complete the Registered Managers Award by 31.12.05. A job description must be in place clarifying the roles and responsibilities of the Manager. 1st November 2005 Date of last inspection Brief Description of the Service: The Pines accommodates 13 adults, with the purpose of providing care and support to residents who have a learning disability. The home was first registered in 1986, and in February 2002 a new provider, Sandbourne House Ltd took over the service. The provider completed a pre inspection questionnaire on the 15th May 2006 providing the commission with current information about the service including the current weekly fees, which are between £340 and £750. Additional charges are made for hairdressing, toiletries, chiropody, clubs, magazines/papers, transport and holidays. The Pines is a large converted family house. It is a detached property and occupies a corner plot in a residential area of Charminster. Bournemouth town centre, local shops and various community amenities are within easy reach of the home. The home is situated on a bus route. Residents accommodation is provided in two double and eight single bedrooms. Communal facilities comprise a separate lounge and dining room on the ground floor and an activities room in the garden, which is accessed via a walkway from the kitchen. Two bathrooms and WCs are located on the first floor, one shower and WC on the ground and a further WC on the top floor. An internal staircase accesses all floors. There is a large office on the ground floor with staff sleeping in facilities. The registered persons have now converted the previous owners accommodation into a respite room with ensuite facilities. This can be separated from the main accommodation by an internal corridor and its own external access if necessary, which is accessible to wheelchair users. Outside there is a large, well-maintained garden with patio area and a further tarmac area providing car parking facilities. The home is staffed 24 hours of the day and is able to provide a comprehensive range of daytime pursuits for those residents not engaged in activities outside the home. DS0000003994.V294246.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the home carried out as part of the planned inspection programme for care homes undertaken by CSCI. The inspection took place over approximately 7 hours and addressed the requirements and recommendations made at the previous inspection and the all the key standards for care homes for adults. During the inspection the inspector had the opportunity to talk with 6 residents both in privacy and in the communal areas. In addition the inspector also spoke with the manager and 2 members of staff. A tour of the premises was carried out and all the communal rooms were viewed and a sample of 3 service users bedrooms. Various records and documentation were looked at including service users care plans, health and safety records, medication records, financial records, staffing records, rotas and policies and procedures. Information received from the home was also taken into account in this report. This included a pre-inspection questionnaire, service user’s surveys, relative’s surveys, professional’s surveys and reports from monthly monitoring visits by the responsible individual of the home. What the service does well: The Pines is a home that has a number of strengths and produces good outcomes for service users in their daily lives. Service users express a high degree of satisfaction with their care and have plenty of opportunities for social, leisure and educational activities. Service users feel they are able to make decisions and plans in their daily lives and are able to pursue their own interests and hobbies. Service users are regularly involved in the running of the home and take part in shopping, meal planning and preparation, household chores and organising trips and outings. The home has a stable and committed staff team who enjoy their work and have developed excellent relationships with the service users they support. The home demonstrates a commitment to training and staff attend not only the required courses but additional courses that reflect the home’s aims and service users needs. Staff feel well supported by the management team and feel encouraged to contribute ideas towards service development. The Pines is well maintained and provides service users with a comfortable, attractive and homely environment. All bedrooms are individually decorated to reflect the service user’s taste and there is plenty of space for personal possessions. DS0000003994.V294246.R01.S.doc Version 5.1 Page 6 The Pines develops good links with other professionals and there is evidence of multi-disciplinary working to ensure service users needs are met such as managing medical conditions like diabetes or managing aspects of behaviour. Professional’s surveys indicated that the Pines was well thought of and one care manager described it as “offering a good quality service”. What has improved since the last inspection? What they could do better: At the previous inspection there had been a breach in regulations concerning recruiting members of staff. This related to obtaining POVA first checks on all care workers prior to them commencing employment. The home is now ensuring POVA first checks are carried out but there had been a further breach in regulations as they had failed to obtain written references and evidence of qualifications/experience for a new member of staff. The home must ensure all information and documents are in place for all members of staff as specified in Schedule 2 of the Care Homes Regulations 2001 as failing to follow robust recruitment procedures can potentially place service users at risk. As this was the second breach in recruitment procedures an immediate requirement was issued to address this. The home has subsequently forwarded evidence to the Commission that correct procedures are in place and the required documentation has been obtained. At present approximately 35 of care staff have achieved a level 2 NVQ qualification meaning the home is just under the target of 50 , however, the home is addressing this a further members of staff are being put forward to complete this qualification. The home needs to develop an annual improvement plan. This would provide action points/targets to further improve the quality of service in the home. Service users’ care plans could be improved to provide staff with clearer guidance to service users support needs. Service users could also be given further opportunities to participate in their plans by identifying future goals and aspirations they want to work towards. DS0000003994.V294246.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000003994.V294246.R01.S.doc Version 5.1 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 DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective liaison with care managers and excellent opportunities for service users to ‘test drive’ the service ensures that appropriate assessments are in place to ensure that the home will be able to meet the needs and aspirations of prospective service users. EVIDENCE: This standard has been met at previous inspections of the home. The home has a written admissions policy informing potential residents and commissioners of care about the admission process. The manager informed the inspector there had been no new admissions to the home since the previous inspection. The file of the last service user to be admitted to the home was case tracked as part of the inspection and there was evidence that a full care management assessment and plan had been received prior to admission of the home. The Pines also offers a respite service and service users had been able to utilise this service prior to being admitted to the home. This previous knowledge of the home had ensured they were able to settle in quickly and were confident their needs could be met in the home. DS0000003994.V294246.R01.S.doc Version 5.1 Page 10 The home carries out their own assessments to ensure they are able to meet prospective service user’s needs. All prospective service users are offered an introductory period specific to their individual needs. This could include tea visits, overnight and weekend stays. All new admissions are subject to a trial period and there was evidence that an initial review was held approximately six weeks after the placement began to ensure all parties are happy prior to making the placement permanent. A service user guide has been produced in an accessible format to give service users further information about the services and facilities available. Feedback from placing social workers confirmed the service was “flexible and accommodating for all needs referred to them.” DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have good opportunities to discuss their care needs and staff have an excellent understanding of these. Improvements to the way service user care plans are recorded would provide clearer guidance to staff about service users support needs and provide written evidence of service users goals and aspirations. Service users have opportunities to make decisions about their daily lives and they are supported to make positive choices that promote their well being. The home has a clear policy and procedure for the assessment and management of risk ensuring strategies are in place to enable service users to take responsible risks rather than preventing them from doing so. DS0000003994.V294246.R01.S.doc Version 5.1 Page 12 EVIDENCE: A sample of 3 service user’s individual files was case tracked as part of the inspection. Satisfactory care plans were in place for all 3 residents addressing their daily needs such as personal care needs, mobility and communication. The inspector felt these could be improved by containing more specific information for staff about carrying out individual tasks with service users. The inspector also recommended care plans should contain more evidence of service user participation e.g. indication that they have been consulted about their personal preferences and identifying future goals and aspirations they wanted to work towards. There was evidence that plans were being reviewed regularly and all 3 service user’s plans had been reviewed in January 2006. Residents told the inspector they were consulted about their care and had regular meetings with their keyworkers to discuss their needs. Staff spoken with were clear about their roles as keyworkers and were able to demonstrate a good understanding of service users’ care needs. Observation throughout the day showed service users were encouraged to make decisions in their daily lives. Examples included service users answering the door, choosing where to eat their meal, making drinks when they liked. Discussion with residents confirmed they felt they were able to make decisions including deciding on social events and activities and meal choices. Where there were some restrictions on choice, this was agreed as part of the residents care plan e.g. supporting residents with their personal hygiene by encouraging them to take regular baths despite one service user being reluctant to do so. Some service users told the inspector they were part of a local service user advocacy group. Completed service user’s surveys provided further evidence that residents felt they were “encouraged to decide what I want to do each day” and “I help to plan what I would like to do”. The home had previously set up a risk assessment file and there is a policy on risk assessment and management. This was examined at a previous inspection of the home and a sample of risk assessments were observed for each resident and these included assessments such as management of money, medication, accessing the community and public transport, road safety, and domestic activities. In addition, guidance was seen on individual files for management of certain behaviours where necessary. Observation during the inspection showed staff had a good understanding of risks relating to each resident e.g. ensuring some residents did not go out unaccompanied, ensuring boundaries were in place to manage the behaviours one resident was presenting. DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users have an appropriate programme of activities and are encouraged to access the local community on a daily basis ensuring service users have a whole range of social, leisure and educational opportunities to meet individual need. The home has good links with family and friends and service users are supported to maintain their personal relationships. The daily routines are flexible promoting independence and freedom of movement. Service users responsibilities for housekeeping tasks in the home are clearly identified and understood by the residents. Service users enjoy a varied and balanced diet and were able to contribute to meal planning, shopping and meal preparation. DS0000003994.V294246.R01.S.doc Version 5.1 Page 14 EVIDENCE: The home has previously met all these standards and there was further evidence at this inspection that these standards were being maintained. All service users had written plans of the weekly activities they were engaged in. These included attendance at day centres, voluntary work, adult education courses and day activities provided by The Pines. Observation during the inspection confirmed service users were engaged in activities e.g. some service users came back later in the day after attending the day centre and other service users were taken out during the day by members of staff. Discussion with residents confirmed they had a variety of daytime activities and regularly accessed the community. For example service users told the inspector they liked going out such as getting the bus into “town” and looking round the shops, going to the library and going for walks. They also were involved with social groups such as the Gateway club and some residents were members of the Bournemouth Forum (a local service user advocacy group). The manager said relatives were welcome to visit the home and service users were encouraged to maintain contact with their families. Relative details were observed to be recorded on individual files. Service users confirmed they were able to have visitors and see them in private and gave examples of visits to and from their families. There is clear guidance in the home about service users responsibilities for daily tasks. Rotas were observed sharing out some of the domestic tasks in the home. Observation during the inspection showed service users taking part in activities such as making drinks, helping with meal preparation, unloading the dishwasher and hoovering the communal areas of the home. Discussions with residents showed that independent skills were promoted and service users were keen to tell the inspector that “I clean my room on my own”. A sample of menus was viewed as part of the inspection. A delegated member of staff is responsible for co-ordinating menus based on residents’ choices and to ensure a balanced and varied diet was offered to facilitate healthy eating. Service users likes and dislikes are also recorded in their files, as well as any health needs such as diabetes. Service users said the food was “very good” and observation on the day showed service users were encouraged to participate in meal preparation. One service user did say that they would like to have cold drinks provided in the dining room in the evening as the kitchen floor is washed and they are unable to get in there. DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in a way that promotes and protects service users’ privacy, dignity and independence and takes into account their personal preferences. The healthcare needs of service users are well met with evidence of good multi disciplinary work taking place on a regular basis. The administration of medication is well managed contributing to the well being of service users health. EVIDENCE: There was evidence in the service users’ files that were case tracked that residents’ personal care and health care needs were recorded in their care plans. The majority of service users living in the home were mainly independent with their personal care with support consisting of monitoring and prompting where necessary. Service users confirmed routines in the home were flexible such as DS0000003994.V294246.R01.S.doc Version 5.1 Page 16 times for getting up/going to bed, meals and other activities. All service users have designated keyworkers and regular sessions were held with service users to discuss their preferences and facilitate continuity of support. There was written guidance for staff about the role of keyworker and staff spoken with were clear about their responsibilities. Observation throughout the day showed that service users were treated with dignity and respect and their personal privacy was promoted. Details of all healthcare appointments were kept including G.P., dentists and nurse. There was further evidence of specialist input e.g. psychiatrist and psychologist and any assessments made by professionals were recorded and acted upon, e.g. managing aggressive behaviour. There was a satisfactory policy and procedure in place for the administration of medication. The home has a locked medicine cupboard in the office and uses a monitored dosage system. MAR sheets are kept with the medicines and these were checked and found to be up-to-date and accurate. Staff receive training in first aid and the administration of medication. The home have also sought specialist advice where necessary, e.g. arranging for a Diabetes nurse to visit and give staff training on managing this condition. DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. An accessible complaints procedure is in place and service users are encouraged to articulate their views about the home in order that issues raised can be dealt with before they develop into problems and formal complaints. The manager and staff have good awareness of local protection procedures. However, they must ensure the homes recruitment procedure is robust and complies with current legislation. EVIDENCE: A complaints procedure is in place, which has been produced using clip art to convey the information in a way that is clear and easy for service users to follow. Service users confirmed they knew how to make a complaint and who they could talk to e.g. their social worker or the inspector. Some service users were members of a local service user led advocacy group. There is an open door policy in the office and service users are encouraged to raise issues so they can be dealt with before they develop into major problems. Observation and discussion with service users provided further evidence that they felt confident in speaking out. The home has policies and procedures in place concerned with the protection of vulnerable adults. These included Awareness and Prevention of Abuse, Aggression towards staff, Bullying, Management of Service Users money and Whistleblowing. The manager confirmed her knowledge of local procedures. Most staff have undertaken training in the Awareness of Abuse. DS0000003994.V294246.R01.S.doc Version 5.1 Page 18 It was noted in the staff records that some of the documentation required by Regulation 19 of the Care Home Regulations 2001 was missing for one member of staff. This is the second time there has been a breach of regulations in recruiting staff and an immediate requirement was issued at the inspection for the home to address this. This affects the overall quality of the outcome for these standards as failing to comply with recruitment procedures potentially places the welfare of service users at risk. DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Pines is well maintained and provides the residents with an attractive, comfortable, homely environment. The home is clean and hygienic with good procedures in place for controlling infection. EVIDENCE: A tour of the premises was carried out as part of the inspection. All communal rooms were seen including the lounge, dining room, kitchen and laundry room and a sample of 4 service users bedrooms. The inspector was also shown the outside garden by two service users. Service users spoke very positively about the home and all service users spoken with told the inspector they liked their rooms. The premises were well maintained and decorated in a comfortable, homely way that was suitable for its stated purpose, i.e. providing care and support to adults with learning disabilities. Service users bedrooms were observed to be DS0000003994.V294246.R01.S.doc Version 5.1 Page 20 personalised to each individuals taste with plenty of space for personal possessions. The premises were found to be clean and hygienic with good procedures in place to prevent the spread of infection, e.g. handwash was available by the door for all visitors to use prior to entering the home. DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users benefit from a stable staff team who have a good knowledge of their needs and are enthusiastic and motivated about working in the home. The home have failed to follow the regulations for recruiting staff for the second time potentially placing service users welfare at risk. The home demonstrates a commitment to providing good quality training to members of staff and although they are not currently meeting the targets for qualified staff in the home, all staff have the opportunity to complete a number of courses that reflect the homes aims and meet service users needs. EVIDENCE: Staff records showed that the home has a stable staff team, with only one member of staff leaving the home since the last inspection. The staff team consists of both male and female workers of a mixed age range and ethnic background. The home does not currently use any agency staff. Analysis of the rota and observation during the inspection indicated there were sufficient staff on duty at all times to meet residents’ needs. DS0000003994.V294246.R01.S.doc Version 5.1 Page 22 Staff records showed that there had been a breach of regulations in employing the most recent member of staff. This is the second time the home has failed to meet this regulation and an immediate requirement was issued at the inspection. The registered person must ensure that all staff are subject to rigorous recruitment procedures and obtain all information and documentation as required by Schedule 2 of the Care Home Regulations 2001. The home has a good training plan and discussion with staff confirmed they had attended a number of training courses including first aid, health and safety, food hygiene, fire training, prevention of abuse, medication, manual handling, principles of care, infection control and risk assessments. It was noted that as well as the required courses ensuring safe working practices the home promotes additional courses that reflect the home’s aims and service users needs. The manager has now developed an initial induction programme and is currently working on implementing the skills for care induction programme in the home. At present approximately 35 of care staff have achieved a level 2 NVQ qualification meaning the home is just under the target of 50 , however, the home is addressing this a further members of staff are being put forward to complete this qualification. The inspector talked to two members of care staff who spoke enthusiastically about working in the home. They said the Pines provided a good working environment and they felt well supported. Residents also spoke positively about the staff team and it was clear from observed practice that staff knew the residents well and positive relationships had been formed. DS0000003994.V294246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is well supported by her senior staff in providing clear leadership throughout the home with staff being clear about their roles and responsibilities. The home encourages feedback about the quality of service from the residents and staff but needs to include this in a formal plan setting out aims and objectives for future service development. Health and safety is generally well managed in the home and service users are encouraged to follow safe working practices. DS0000003994.V294246.R01.S.doc Version 5.1 Page 24 EVIDENCE: Sarah Dixon is the registered manager of the Pines. She has over 12 years experience of working in the care industry and has worked for Sandbourne House Ltd, the registered provider, since 1998. She completed her Registered Managers Award in January 2006 and there was further evidence that she was keeping her knowledge and training up-to-date such as attending moving and handling training, fire training and a skills for care induction information session. She is well supported in her role by the registered provider, Helen Somerville and an assistant and acting assistant manager. Staff described the management team as approachable and said they were encouraged to use their own initiative and make a real contribution to the way the service is delivered. The home has a system in place for monitoring quality in the home. The manager has recently sent out questionnaires to service users, relatives and staff in October 2005 and these were shown to the inspector. The manager now needs to collate the results to form the basis of an annual improvement plan. This would provide action points/targets to further improve the quality of service in the home. The responsible individual is now making regular monthly monitoring visits to the home and a report of these is made available to CSCI. Records showed that the home was meeting the requirements of other agencies such as Dorset Fire and Rescue Service and Environmental Health Department. Certificates were in place demonstrating that equipment and facilities were regularly serviced and maintained. A written health and safety policy for the home has been completed and safety procedures are displayed throughout the home. The manager confirmed her awareness of relevant legislation and certificates were in place showing staff had attended various training courses in safe working practices. Observation of practice demonstrated staff followed correct procedures and encouraged service users to work safely e.g. when helping with meal preparations. DS0000003994.V294246.R01.S.doc Version 5.1 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000003994.V294246.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 18 Requirement The registered provider needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. The registered provider must obtain all information and documentation as specified in Schedule 2 of the Care Homes Regulations 2001 prior to care workers commencing employment in the home. Specifically 2 written references and evidence of qualifications/previous experience. The registered provider must develop an annual development plan based upon the views of service users and other interested parties, to ensure success in achieving the aims and objectives of the home. Timescale for action 31/10/06 2. YA34 19 02/06/06 3. YA39 24 31/08/06 DS0000003994.V294246.R01.S.doc Version 5.1 Page 27 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 It was recommended that service users’ care plans provide clearer guidance to staff about service users support needs and provide written evidence of service users goals and aspirations. It was recommended that a system of annual appraisals be set up to review members of staff performance against their job descriptions and agree career development plans. 2. YA36 DS0000003994.V294246.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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 DS0000003994.V294246.R01.S.doc Version 5.1 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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