Inspection on 16/07/08 for Underhay House

This inspection was carried out on 16th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Underhay House 03/08/07

Underhay House 13/09/06

Underhay House 26/01/06

Underhay House 19/07/05

Underhay House 27/02/05

Underhay House 28/09/04

Underhay House 27/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Underhay House 639-641 Muller Road Eastville Bristol BS5 6XS Lead Inspector Sarah Webb Unannounced Inspection 16th July 2008 09:00 Underhay House DS0000026624.V364013.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 Underhay House DS0000026624.V364013.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. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Underhay House Address 639-641 Muller Road Eastville Bristol BS5 6XS 0117 9519094 01275 372151 underhayhouse@freewaystrust.co.uk 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) Freeways Trust Ltd Mrs Sharon Prowse Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12) of places Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia (Code MD) Learning Disability (Code LD) The maximum number of service users who can be accommodated is 12 3rd August 2007 2. Date of last inspection Brief Description of the Service: Underhay House is a care home registered with the Commission for Social Care Inspection currently providing personal care for up to twelve people with a learning disability. The home is also registered to admit people with a mental disorder but there are no people living at the home at this time with this as their primary care need. The home is operated by the non-profit making organisation Freeways Trust Ltd. There is a satellite home for three people at 224 Glenfrome Road that is close to Underhay House and which is also registered with us. Both homes are managed by the same person Ms Sharon Prowse. Underhay House is situated in a residential suburb of Bristol on a busy road. Public transport is available close to the house and there are local shops opposite as well as a large supermarket within a quarter of a mile. Underhay House is within quarter of a mile of the M32, an urban motorway that links to Britains motorway system. The accommodation is of two terraced houses based over three floors. Access to the upper floors is by means of stairs only. Underhay House has a pet cat. The home aims to ‘provide a physical and emotional environment that is safe and secure, where responsible risk taking is promoted’ and ‘to respond effectively to the diverse needs of all service users.’ The range of fees is from £502.17 to £680.42. Items such as hairdressing, activities, clothing and personal items are not included in this fee. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 5 Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection and was carried out over one day. We case tracked the care and support people using the service receive by looking at various records and documents. These included assessments, care plans, how people are supported in taking risks safely and how they are given their medication. Staff recruitment and training records were also looked at. We were shown around the house and spoke with people, staff, a relative and the manager. We looked at information received since the last inspection. This included an Annual Quality Assurance Assessment (AQAA) and monthly reports of the homes management. The previous manager was transferred to another of Freeways homes in March 2008 due to re-structuring within the organisation. Ms Sharon Prowse was registered as Manager in April 2008. Five surveys were received from people using the service, and five from relatives. Two were also received from staff. All of the surveys have been analysed and form part of this report. There were eleven requirements to follow up from the previous visit with three of them that were outstanding. Ten have been met, and one in the process of being met. One requirement and four recommendations have been made through this visit. Verbal feedback was given at the end of the inspection to the manager. What the service does well: What has improved since the last inspection? Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 7 The Statement of Purpose has been updated and now shows the current practices and services in the home so that people are given full information. An identified persons care plan has been sent to us showing us how their needs are being met. There are now Health Action Plans in place stating how people want to be helped with their personal and health care needs. They also show that people are happy to be helped with their medication. Staff have been trained in communication skills so that they can understand and support people better. Risk assessments have been reviewed and updated showing that people are being helped to take risks safely including those for people who may have specific health problems. Repairs and redecoration in two bathrooms have been carried out to help make the environment more homely and safe. Staff have been involved in regular fire drills so that peoples health and safety is protected. Peoples’ inventories have been updated so that their rights and best interests are kept safe. What they could do better: Since the last inspection there have been further changes in the staffing; the new manager and staff team have started addressing areas that need to be improved. As at the last inspection, a period of stability and consistency will benefit all those involved in the home. A requirement is made for a record to be kept of all medication given to people so that they are protected and kept safe. Recommendations made: The lounge carpet must be cleaned so people can benefit from a clean and homely environment. Staff must be updated in mandatory areas so that they support people consistently and safely. A recommendation is made for the manager to send an updated copy of the homes most recent fire risk assessment to show that people are being kept safe. A recommendation is made for staff to update training in safeguarding to keep staff informed and updated with current practice. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 8 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. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 9 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 Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 10 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, & 5 Quality in this outcome area is good. People who want to use the service are given information to help choose a home that will meet their needs. Peoples’ needs are assessed before moving to the home to help ensure they can be met. Up-to-date contracts help to show people what to expect from the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a requirement has been met for the Statement of Purpose to be updated. The new manager has developed the document that now reflects current practices and services in the home. A service user guide also has information for new people wishing to use the service. This is in an easy read format helping people to understand what the home has to offer. The manager was advised to include our contact details. There are currently three vacancies at the home. One new person who has moved to the home since the last inspection, told us that their Social Worker has met with them to assess their needs and that they have been involved in developing their care plan. Other care files showed that all people using the service had assessments carried out before moving in to help ensure the home can meet their needs. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 11 People are referred for a reassessment of their needs if their needs change and the home is not able to meet them. Since the last inspection, two people have moved to other more suitable placements. Four out of five people stated on their survey that they were asked whether they would like to move to the home and that they had received enough information about the home to make a decision. One person told us they had lived at the home for five and a half years and were very happy. Care files showed that all, except one person, had a ‘service user agreement’ in place. These included the amount of fees paid to Freeways, personal allowance and mobility allowances, and the contribution made by people towards transport provided by the home. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 12 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 good. People are involved in the planning of their care. Care planning shows how people want to be supported with their needs; some areas need to be developed further providing more detailed information. People are involved in making decisions about their lives and in all aspects of living at the home. Risk assessments support people to take risks as part of their lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has encouraged people to make choices about how they want to be involved in the planning of their care. Person Centred Plan meetings are being arranged with a facilitator from outside of the home. These plans are in an easy read format with pictures so that people have a better understanding of how their care is provided. There are no separate care plans developed by the home to inform staff how people should be supported. For new staff to be informed they look at Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 13 information through monthly key worker packs, health action plans, and peoples’ reviews to get information. Staff are also given verbal instruction. The manager said peoples care planning is based on their social services assessment and Freeways assessments. However not all care files had this information in place; the manager has asked people’ social workers for a copy of their most recent assessment. The manager is aware that some areas of peoples care planning needs more detail so that staff can support them with their preferences. Yearly care plan reviews take place where all aspects of peoples’ lifestyles are discussed. The majority of people have either had a review or have one planned. These showed comprehensive and clear information is recorded; how individuals have progressed, and their aims for the future year. Records showed that people are fully involved with this process along with significant people in their lives. The home operates a key working system whereby each person has a named member of staff who plays a key role in helping them to plan the services they want. Records are kept of monthly key worker meetings helping to review and monitor peoples care. These were seen and found that some were more up to date than others. A ‘day file’ records peoples’ activities every day. This helps to provide information for the monthly reviews. People are encouraged to make choices and decisions including activities they want to do and menu planning. This was seen in written minutes from meetings. People are also helped to voice their opinions through organisational forums and working groups involving them in writing policies. A requirement has been met for staff to be trained in communication skills so that they can understand peoples different communication needs better. A requirement for risk assessments has been met. A folder with risk assessments has been set up with an index showing future review dates. Individual risk assessments included how people are supported safely in accessing the community and travelling independently, with their personal care, and activities. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is good. People benefit from taking part in educational, social, and recreational activities. They are helped to keep in contact with family and friends if wanted. People are supported in making choices about their lifestyle and are helped to take responsibility in their daily lives. People benefit from a varied menu, and are able to choose the food they prefer and like. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People using the service were seen going out to various activities, day services, and college placements. It is evident that people are offered meaningful activities. Some people are in paid work. Others are involved in volunteering with an advocacy group and local charity. Two people are involved in dog walking. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 15 People are supported to use community-based facilities. Records showed trips to social clubs, shopping, cinema, and meals out. Evening activities are also held at another home in the organisation such as darts. Holidays are arranged on individual preferences and are supported by the staff team. Two people went to Spain while another person went with a social group external to the home. Six people went to Weymouth. People are supported to maintain close contact with their families and friends. Some people regularly visit their families and visitors are welcomed to the home. This was seen through daily notes of peoples’ activities. People are supported with intimate personal relations and are approached sensitively and appropriately. However the manager was advised to contact a specialist so that people can be referred for support with their sexual awareness. Individual care files showed how people are supported in being actively involved in the running of the home. A household task rota was seen and this is discussed at meetings. A life skills day at home helps people to go to planned appointments, activities and keeping their bedrooms clean. Menus seen showed that a choice of food is offered that is varied, wellbalanced with healthy eating options encouraged. The manager has been involved in a healthy eating project called ‘Food Matters and this has helped to give people an awareness about their food choices. Alternative food is provided if people do not want the main meal. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 16 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 adequate. People are supported in the way they want with their personal care. They benefit from healthcare needs being well met. People are treated in a respectful manner by staff. Medication procedures do not keep people safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said people are able to say who they want to be supported by and the home aims to support people with appropriate gender of staff. Observation of staff showed that they approached people respectfully and included them in conversation. Since the last inspection the home has developed individual Health Actions Plans that show how the majority of people want to be supported with their personal and health care needs. There was one area that needs to provide fuller details of an individual’s specific healthcare needs and the risks associated with their health. A requirement has not been made as relevant information is recorded in their recent care plan review. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 17 The home has responded to peoples bathing needs being safely met. New bath mats have been bought, as there have been some incidents of people slipping when getting out of the bath. Healthcare records confirmed that people have access to health care services both in the home and in the local community. People are registered with a General Practitioner (GP) and go to local dentists, opticians and other community services with support from staff. Peoples’ healthcare needs are monitored by staff. This was seen through monthly keyworker reviews. Medication is kept locked in the dining area. We were told by staff that a complaint is being made to the pharmacy who deliver peoples’ medication as there have been several occasions when the medication has been wrong. Individual medication risk assessments have been completed to include peoples understanding and knowledge of their medication. This helps to see if people can be helped to be independent if self medicating. We also saw how people wanted to take their medication. There is one person who self medicates while another is being supported by staff in self medicate. There are no controlled drugs kept on the premises. Records showed that medication is received monthly and is checked in by staff. This was seen recorded on medication administration records (MAR). An outstanding requirement has been met for a record to be kept of peoples consent to being helped with their medication. During the past year the number of medication errors has decreased showing that generally the home has improved in its medication procedures. . However during the visit we saw that there have been two occasions when medication given has not been recorded and this puts people at risk of harm. The record of an ‘as required’ medication did not correspond with balances on stock control records. A requirement is made for a record to be kept of all medication administered so that people are supported safely. Freeways provide comprehensive training regarding the administration of medication and then the staff member completes a series of competency tests. Staff will be observed until the manager is certain that they are competent. Staff have received a specific epilepsy training given by a local Primary Care Trust (PCT) so that people are supported safely and consistently. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 18 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. The people that live at the home feel confident to approach the staff with concerns. People can expect to be protected from abuse and benefit from staff trained in abuse awareness. Staff would further benefit from being updated in safeguarding training to further ensure people are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Surveys from people using the service showed that they knew who to speak to if they are unhappy, such as the manager, staff or family members. All said they knew how to make a complaint. Three of the surveys from relatives showed that they also knew how to make a complaint while the remainder said they did not know and ‘I cant remember.’ One relatives survey stated ‘I prefer to talk through concerns with the management first.’ This was confirmed by the manager who said some families will speak to her about concerns they may have so that they can be resolved quickly. The complaints log showed there have been 8 complaints since the last inspection. All had been dealt with appropriately with a record of the outcome and action taken. The organisation has a policy and procedure for the protection and safeguarding of people. Staff receive training in understanding abuse through their initial induction. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 19 However not all staff have received updating in this area. This was also shown as an area for improvement in the AQAA. The manager has contacted a senior staff member who is able to train staff in safeguarding to organise updates. A recommendation is made for staff to attend training in safeguarding to keep staff informed and updated with current practice. The majority of staff have received training in working with people who may present challenges. Care files showed reactive strategies in place indicating triggers and indicators that helped staff know when people needed support if unhappy. This helps to ensure there is a consistency in supporting individuals with their different behaviours. A ‘behaviour log’ records significant episodes and action taken. The organisation operates safe financial systems for supporting people with their finances that helps protects them from financial abuse. Financial risk assessments seen included peoples understanding of money and financial management. Two peoples financial records were consistent with the balance of monies held in safekeeping. The home employs a member of staff who is responsible for only book keeping and keeps the finances up to date weekly. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, & 30 Quality in this outcome area is adequate. Although people benefit from living in a clean and homely environment there are still some key areas that are in need of improving in order that the health and safety of both people and staff are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Underhay House is a two terraced house based over three floors and in keeping with the local neighbourhood. The house is on a busy main road in a residential area. There are good public transport links to Bristol city centre and surrounding areas. Amenities are close by including a large supermarket and shopping complex. We were shown around the house by the manager. Not all peoples’ bedrooms were looked at but those seen showed they had been individually decorated and had personal items on show. One person said their room had been decorated as they wanted and they had chosen the colours. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 21 Another person showed a new wash hand basin that had been fitted. They said they were still waiting for a unit to be added to help make the room tidier. The curtains in their room were not hanging properly on the curtain rail and they said they were going shopping soon to buy new curtains. We will be following this up in the near future. A vacant bedroom looked at had an unpleasant odour coming from under the sink. The manager said this was an ongoing issue and is being seen to through the maintenance department. There is a lounge that people use to watch television and socialise in. The carpet was stained in some places and needs to be cleaned. A large conservatory dining area is used more as the ‘hub’ of the house. A computer used by people is in this area and there is seating for people to relax. We were told by people that the computer was not working but that it had been reported for repair. The manager said she has asked for the flooring in this area to be replaced with wooden flooring as the carpeting can get stained easily. A requirement for repairs and decoration to two bathrooms has been met. Another requirement for appropriate and safe bathroom facilities to be provided has not yet been done. The manager said building works on the ground floor bathroom to be made into a walk in shower have been planned for in the next few weeks. There are several areas of improvement in the homes environment that are ‘in the process’ of being done. This will be initially followed up in the near future and more fully at the next inspection. The home was generally clean; a part time cleaner is employed to clean the main shared areas of the home. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, & 35. Quality in this outcome area is good. People benefit from a staff team who have a good understanding of their role and responsibilities and who are trained to meet the individual needs of people. People benefit from recruitment policies and procedures that help to keep them safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has undergone a lot of changes during the past eighteen months and it was evident that the home has begun a period of stability with minimal staff change. Staff spoken with showed that that they had a good understanding of the aims of the home, their role and responsibilities, and a good knowledge of peoples needs. There is a staff team of 13 staff, including regular bank staff covering shifts if needed. There are three staff on duty but this also includes one of the staff supporting the people living at Glenfrome during the evening. This was evidenced through the rota. Two staff cover sleep in duties. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 23 New staff have an induction period that includes completing the Learning Disability Award Framework (LDAF) and are then encouraged to complete a National Vocational Qualification (NVQ). Currently there are six staff with a National Vocational Qualification level 2 or above and six staff working towards this. Recruitment records confirmed that the manager follows the homes recruitment policies and procedures. This was seen through staffing files that had appropriate information such as a completed application form, evidence that a Criminal Records Bureau check had been carried out, and two satisfactory references. The manager said she was in the process of collecting staff photographs for the files. Staffing files showed that staff have attended key training in fire, first aid, food hygiene, manual handling and epilepsy. There were some bank staff and one permanent staff needing updates in some of these areas. The manager has developed a training plan that showed areas of training that need to be addressed such as mental health. Several comments received through relatives’ surveys were mixed in their views. One stated ‘Last year had seen many changes in staffing but that the current team seemed to be very positive’, while another said ‘ Staff vary in their skill levels. We think that those working with our relative at present are less consistently skilful in meeting their needs.’ Generally the majority of the comments were positive such as ‘Various staff have different responses but generally I am impressed.’ Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, & 42 Quality in this outcome area is good. People using the service and staff benefit from a well run home with good outcomes for people. The views of the people who live in the home are sought and acted upon with their rights and best interests kept safe through clear record keeping. People and staff benefit from systems that help to promote and protect their health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Sharon Prowse was registered as manager during April 2008. She is competent and experienced to run the home. The Freeways Trust has employed her for five years, and most of this employment has been in senior roles. She has a National Vocational Qualification level 3 and plans to start the Registered Managers Award (RMA) later in the year. Other training she has Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 25 attended includes mandatory training, working with people who present behaviours that challenge and Aspergers Syndrome Awareness. A new deputy manager has also been employed who has worked with Ms Prowse prior to this post. It is evident that both staff and the people using the service benefit from both the manager and deputy’s leadership and management approach to the running of the home. It was seen to be ‘open’ and proactive. A relative spoken with told us that the new manager had made changes for the better and that they were happy with the management of the home. Peoples are encouraged to speak up and their views are asked for through regular house meetings and completed yearly questionnaires. These were seen through written records of meetings and the last completed questionnaires by both people using the service and their families. The manager has set out a plan in response to the results of the questionnaires to help the home to focus on areas that need improving. This is good practice. The home also gets ‘feedback’ from people through reviews of their care. People were observed during the day and having open discussion with the manager and staff. They were relaxed and confident in their approach. Since the last inspection, the previous manager had begun the process of organising paperwork and documentation regarding peoples’ care files. Ms Prowse has continued with this task and it was evident that the record keeping has improved with records being both developed and maintained. A requirement has been met to update peoples’ inventories. Staff are responsible for monitoring different areas of the home such as health and safety, fire and medication. An outstanding requirement has been met to ensure all staff are involved in regular fire drills. However a fire risk assessment seen was dated 2005. The manager was unable to find the most recent risk assessment and a requirement was made for this to be completed with a copy sent to us. A weekly health and safety check is done and requests for any maintenance are sent to the head office. The home notifies us of any information regarding changes affecting peoples’ welfare. The home receives monthly visits from other managers who monitor people’s care, and health and safety Staff from the organisational personnel department visit to check on staffing files and financial procedures. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 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 2 25 x 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 x 3 3 x Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 27 YES 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 Keep a record of all medication given. Timescale for action 19/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA23 YA42 YA24 YA35 Good Practice Recommendations Update staff in safeguarding procedures. Send a copy of the homes most recent fire risk assessment Clean lounge carpet Update staff in mandatory training. Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Underhay House DS0000026624.V364013.R01.S.doc Version 5.2 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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