Inspection on 27/08/08 for Upshire Residential Home

This inspection was carried out on 27th August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 Upshire Residential Home Woodredon House Woodredon Farm Lane Upshire Essex EN9 3SX Lead Inspector A Thompson Unannounced Inspection 27th August 2008 10:00 Upshire Residential Home DS0000071447.V370636.R02.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 Upshire Residential Home DS0000071447.V370636.R02.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. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upshire Residential Home Address Woodredon House Woodredon Farm Lane Upshire Essex EN9 3SX 01992 763922 01992 763922 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) Southwark Park Nursing Home Limited Mrs Teresa Jane Cairns Care Home 29 Category(ies) of Learning disability (29) registration, with number of places Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 29 2. Date of last inspection Brief Description of the Service: Upshire Residential Home (Woodredon House) is a large fully detached property set in approximately five and a half acres of private grounds. There has been a change of owner since the last inspection in 2007. The new owners, Southwark Park Nursing Home Ltd appointed a new registered manager, Mrs Teresa Cairns. Mrs Cairns had previously worked at Upshire for many years as the care manager for the previous owners. Upshire is registered to provide accommodation for up to 29 adults who have a learning disability. Accommodated is provided in seven single and eleven shared bedrooms. Communal space consists of two lounges, one inner hallway/atrium and one dining room, all situated on the ground floor of the home. The grounds surrounding the home are extensive and well maintained. Many rooms benefit from views of the surrounding countryside towards Waltham Abbey to the west and Epping Forest to the south. Access by road is along a single track lane off the nearest main road, where there is a bus stop. This is approximately a ten minute walk from the home. The nearest shopping facilities are in the village of Upshire. Larger towns closest by are Waltham Abbey and Epping, which are a car drive of approximately one and three miles away, respectively. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 5 The home has its own mini bus to ensure service users have full access to the local and wider community. Weekly fees at the time of this inspection were advised as £535.00 . CSCI inspection reports can be obtained from the home, or via the CSCI internet website. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place on Wednesday 27th August 2008. The content of this report reflects the inspector’s findings on the day of the inspection along with information provided by the service and feedback by service users, staff and other parties. The registered manager of the home was present throughout the day. The manager had completed and returned their Annual Quality Assurance Assessment (AQAA) to us prior to the inspection. This document gives homes the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as their future plans for improving the service. Some of the information and detail provided within the AQAA has been included in this report. Discussions were entered into with service users and staff on duty. CSCI survey questionnaires were also provided for service users, staff and stakeholders. We received seventeen completed surveys and reference to feedback from these has been made within this report. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All matters relating to the outcome of the inspection were discussed with the manager of the home, with full opportunity for discussion given and/or clarification where necessary. What the service does well: Good opportunities had been offered to service users to take part in community based activities and pastimes. The communal accommodation and grounds are spacious. The atmosphere in the home was friendly and relaxed. Comments made in surveys received from relatives of service users and other visitors included: ‘the home is always a happy place, I leave (after I visit) knowing my daughter is well cared for and happy’, they ‘provide a caring and personal service responding to individual needs’, ‘they do everything very well and they show great kindness towards all the residents and take great care for their well being’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 7 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. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the home can be confident that the admission processes ensures that the home can meet their needs. EVIDENCE: The home’s Statement of Purpose (SOP) was seen, this included the information needed to help new services users make an informed choice when considering moving into Upshire. The manager confirmed that this document also included the information required in the Service Users Guide (SUG) and undertook ensure that service users were aware that this was a combined SOP & SUG. The majority of service users are placed and funded by local authorities. Records confirmed that these bodies had provided an assessment of needs to the home before admission. In addition to this the manager undertakes a written assessment of needs for all prospective service users (self funded or public funded) prior to admission. An assessment was seen for a service users admitted since the last inspection. Included was information on the individual’s previous lifestyle, likes and dislikes around routines, choices and preferences. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 10 The assessment of need included headings of background information, emotional need, physical health and wellbeing, self care ability and biographical information. Prospective new service users are able to visit the home prior to making any decision on admission. Service users spoken with said they had visited Upshire several times, and had stayed overnight on some of the visits, before they moved in permanently. Information relating to admission provided by the manager in the home’s AQAA includes: ‘Pre-admission assessments completed prior to admission the manager undertakes these at the clients place of residence. Clients are then encouraged to visit the home usually several times for short visits just to look around and have a cup of tea. A day visit usually follows then a two day stay to allow the transition to be as easy and as comfortable as possible for the client’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all service users had a plan of care which included their current needs and not all risk assessments included preventative measures to minimise assessed risks which overall could mean that staff do not provide the right support. EVIDENCE: Three care plans were inspected. The format used was unchanged since the last inspection. Files inspected were seen to include information regarding personal details of the service user with next of kin contact. The name of the service users GP, dentist and optician was also recorded. Assessed needs were detailed under headings of: emotional wellbeing (includes likes, dislikes, preferences), physical care (includes sight, hearing, mouth care, foot care), biographical information, self care ability/needs, personal care Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 12 ability/needs, toilet needs, mobility considerations, lifestyle factors, assessed risks. Each heading should have contained written implications, requirements and resources expected from staff and the service on a day by day basis, to facilitate working towards and meeting the service users individual and overall needs. Unfortunately one care plan seen did not have any objectives recorded and two care plans had no actual daily plan of care recorded. The manager said she would address these shortfalls. Occasional service user meetings are held at the home. Minutes were seen of meetings held in October 2007 & April 2008. Discussion had included activities, complaints, food, laundry and daily choices. Service users spoken with confirmed that they thought staff took account on a day to basis, of their wishes and opinions about choices and routines available. They also said that staff listened to them when they wished to express a view or opinion. Upshire’s assessment format clearly includes questions to the service user on their preferences, likes and dislikes on subjects including lifestyle, food, and activities. Observations and discussion with service users and staff evidenced to us that these preferences are taken account of daily. The manager said that advocacy services are available through a Social Services link, with an independent service called ‘Cornerstone Advocacy’ available to service users. The manager added that at the time of this inspection no service users were accessing this facility, although some had used advocacy services in the past. Risk assessment formats were in place for service users within their individual care plans. However one file seen recorded a perceived ‘risk of falling’ for one service user, but this did not have any actions or preventative measures recorded for staff to follow to minimise this risk. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities within the community mean that service users have various options to participate in social, educational and leisure opportunities. Meals and mealtimes are flexible and meet with the lifestyle of service users living at the home. EVIDENCE: Activity programmes showed that thirteen service users regularly attend a local college. Four also attend a day centre and three are still on a local volunteer register. Discussion with service users, staff, management and examination of records evidenced that college courses attended include drama, dance, computer skills, basic education i.e. maths and english, woodwork, yoga, forestry and cooking. Some service users spoken with were eager to talk about what they did at college and about the items they had made in classes. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 14 One service user still undertakes voluntary work on Sunday afternoons at a local church in the summer months. Service users said they enjoyed attending community based facilities and activities. They did this with staff using the home’s mini bus. The inspector asked service users where they visited, places mentioned were libraries, pubs, cinema, leisure centre, seaside and churches. They also spoke about going regularly to shops, on outings and some on trips home. It was evident from observations, discussions and records seen that staff continue to fully support service users to see and keep in touch with their families and friends. The manager confirmed that the home’s mini bus is still used to take service users for home visits. Staff will also collect relatives from their own homes or nearest main transport link and bring to Upshire to enable regular visits to the home. Staff were seen to knock before entering private rooms. All rooms are lockable and many service users continue to hold their own keys. The grounds were fully accessible to all (some required full staff support for this). During the inspection staff were observed to interact and respond appropriately with service users and not just with other staff. Some were seen assisting service users in the laundry, in the lounges and also dancing with service users in the large atrium lounge area. Service users were asked about the food. All spoken with said they got enough to eat, they also said they got a choice of menu and most who commented said the food was good to eat. Some service users were seen assisting the chef in the kitchen (by choice). The home’s nutritional records and menus were seen. These evidenced a range of choices provided. The main daily meal is early evening with two choices (and a third available), decided on earlier by service users. Specialist nutritional advice and guidance is accessed from a community-based nutritionist via GP referral. The small kitchen provided on the ground floor of the home is still available as a training facility in domestic and independent living skills, and is used daily by some service users to prepare themselves snacks and drinks. The manager said that supper snacks are available at Upshire and include sandwiches, cereals, buns and toast. Information stated in the AQAA under ‘what the home does well’ on lifestyle includes: ‘Clients have a wide range of activities available to them for both education and pleasure. External entertainers visit the home’. ‘Mealtimes are flexible and clients can eat in the dining room, the lounges or their bedrooms and of course the garden in the summer months’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Upshire can expect to receive healthcare support in an appropriate and dignified way that meets their expectations and needs. EVIDENCE: Service users spoken to said they choose their own clothes and make up, where appropriate/able. Most female service users still use the visiting hairdresser while most males visit a barber in the local town. This variance was still mainly due to cost implications. Rising and retiring times are based on personal choice and vary around daily activities planned. Service users said they could have a lie in at weekends and went to bed when they wanted. All service users have designated key workers and staff spoken with demonstrated an appropriate awareness of individual daily needs and preferences. Service users were relaxed during observed discussions with staff. Care plans contained a section entitled ‘lifestyle choices and preferences’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 16 The manager said that service users are supported by staff in visiting their GP. The optician and dentist are visited in the community but a domiciliary service is also provided for those who require this. A chiropodist also visits the home to provide podiatry services. The manager felt that the home still has a good professional working relationship with GP’s, who undertake regular health monitoring and medication reviews for individual service users at the GP’s surgery. The GP will see service users the day of asking if staff request this. Full staff support, including transport, is provided for service users who attend community clinics and outpatient clinics. Good working relationships continue between staff in the home and the local NHS health provider community team. Regular contact and visits are also received from community psychiatric nurses who provide a referral route to the local consultant psychiatrist. Continence support/guidance is provided by community based services. The medication system in use in the home is a four weekly monitored dosage system (pre-packed by the pharmacist). New supplies are delivered to the home by the pharmacist and are checked in by a trained member of staff. Unused medication is recorded on the medication administration record sheet and returned to the pharmacist. Staff who deal with medication had received training. Certificates of this were seen. The pharmacist had also provided update medication training to staff covering: types of medicines, reasons for use, side effects, potential problems, special precautions and medication handling issues. The homes written policy and procedure on receiving and administering medication is regarded as appropriate for the service provision of Upshire. Medication administration records were inspected with no gaps noted. At the time of the inspection no service users were self medicating. Information stated in the AQAA under ‘what the home does well’ on personal & healthcare support includes: ‘Clients are given choices about what they do, where they go, what leisure activities they are involved in. Clients are supported with health matters all staff trained by the pharmacist re’ medication, administration and side effects’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Practices in the home safeguard service users and ensure that concerns are listened to and addressed. EVIDENCE: The homes complaints procedure offered guidance to prospective complainants on who to complain to along with time scales for responses. Also included was the complainants right to refer the complaint on to the current registration authority. All service users and their relatives are provided with a copy of the procedure, so that they are aware of the complaints process. During discussion with service users they said they would speak to staff or the manager about any issues they were not happy with or were worried about. There had been no recorded complaints since the last inspection, but the manager confirmed that records would be maintained of complaints made with investigations undertaken and outcomes. The manager had introduced a standard template for staff to record concerns or compliments. Upshire’s written whistle-blowing policy was seen and states staff responsibilities on reporting incidents of alleged or suspected abuse. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 18 The homes policy on the protection of vulnerable adults, and procedures for investigating allegations or alleged incidences of abuse includes examples of various forms of abuse. The home also had the new Social Services guidelines on safeguarding vulnerable adults and a copy of the guidelines on POVA (protection of vulnerable adults) issued by the Department of Health, for all staff to refer too. The manager is qualified (certificate seen) to provide training to staff on adult protection issues. Evidence was seen of this training, which was regarded as comprehensive, covering types of abuse, who could be abused and by whom and what to do if abuse is suspected. Comments from the manager in the AQAA under complaints included: ‘There is a complaints policy in place, included in the statement of purpose’. ‘There are adult protection policies (POVA) in place, staff are POVA trained’. There is a whistleblowing policy in place and during staff appraisals staff are made aware of the importance of this’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users could not be confident that all areas of the home provide them with a comfortable, clean and homely environment. EVIDENCE: Generally the ground floor of the premises was considered bright, airy and free from offensive odours, and many rooms throughout the home (communal and private) benefit from views of the surrounding woodland and fields. Since the last inspection (when the home was under different ownership) some premises improvements had continued. These had included recarpeting and redecoration to the 2nd floor corridors. Redecoration to the 2nd floor bathrooms and wcs. Redecoration and new carpets in some bedrooms throughout the home, and new flooring in the kitchen. The dining room had also been repainted. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 20 However further work was needed to ensure a well maintained and hygienic environment for service users. These include: repairing the hole in the floor and fitting new/improved floor covering and ensuring walls and surfaces are clean and impermeable in the laundry. The floor in the food storeroom adjoining the kitchen should be covered and the holes in the concrete in this room and the staff toilet repaired. Although the location of the home should be considered as generally isolated, a local transport link (a bus service) is available approximately ten minutes walk from the home, and daily community access is provided for service users by use of the home’s minibus. Most private bedrooms in Upshire measure in excess of the minimum space recommendation and two shared bedrooms and one single benefit from ensuite facilities. All service users who expressed an opinion said that they were satisfied with the private accommodation provided them and that they were encouraged to have personal possessions and belongings in their rooms. All bedrooms inspected were seen to have wash hand basins and had been personalised to individual taste. Personal possessions seen included DVD players, video recorders, televisions and hi-fi’s. Some service users had their own mobile telephones, others use the homes portable phone, or the phone in the small kitchen for private telephone calls. There were five communal bathrooms in the home, four of which had wc’s, one bathroom had a fixed hoist. There were also seven separate wc’s for service users use around the home. Comments from the manager in the AQAA under environment included: ‘The environment standards of the home are generally satisfactory. Although a planned improvement programme is in place for redecorations and maintenance’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by an experienced staff team who had received training, although some update training would improve staff skills. The recruitment procedure in the home provides the safeguards to ensure that appropriate staff are employed. EVIDENCE: Staff training records were inspected. Training offered to staff had included: medication, infection control, first aid, POVA, managing aggression, food hygiene, dementia, health & safety and fire safety. Information provided in the AQAA states that twelve out of sixteen permanent care staff had achieved or were training for their NVQ level 2 awards. The manager has the Registered Manager award and is a qualified trainer for NVQ 4, dementia awareness, health & safety, food hygiene, moving & handling, POVA and fire safety. This qualified her to train staff in-house on these subjects. The manager advised that staff had been given update training on moving & handling and health & safety, however evidence of this was not available and needs to be in place for inspection in future. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 22 Staffing rotas seen recorded that minimum staffing provided was four carers on duty daytime shifts up to 2000 hours, then minimum three carers on duty until 2100 hours. Nightime staffing is two awake on duty. Separate and additional staff were rostered to undertake cooking, cleaning, maintenance and administrative duties. The home’s policy on recruitment practices and procedures covered the recruitment processes, philosophy of the home, equal opportunities and personnel issues. Recruitment records for staff employed since the last inspection were inspected and evidenced that application forms are completed, two references are obtained, CRB checks had been actioned, proof of identity and photograph were obtained. Staff said they had received induction training, records seen confirmed this but it had not followed all of the Skills for Care standards, an issue that was identified in the last report. The manager said that no new care staff had been employed since the last inspection and so progress on this shortfall will have to be looked again when the home is next inspected. Staff spoken with confirmed that contracts and conditions of service are issued to them and they had police checks when they started working at Upshire. Applicants are invited to the home before interview to meet with service users, to ensure their views are always considered before offering an interview. Staff supervision records were looked at but did not evidence that regular, recorded, 1-1 support was provided to staff. This is a shortfall. Comments from the manager in the AQAA under staffing included: The recruitment procedure at the home meets the required standards. Staff files include all the relevant information required, including proof of ID and CRB checks’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Upshire can be confident that the day to day management of the home is effective but not that their opinions are central to how the home is run. The environment appeared safe. EVIDENCE: Upshire changed ownership in 2008. Part of this process involved registration of a new manager, who had worked at the home for thirty years under the previous owner/manager as a carer and care manager. The new registered manager is very experienced with the service user group at Upshire and holds the registered managers award and several trainer awards (see comments under staffing for details). Although the manager has this experience is would appear that she is expected to run the service without any regular management support visits from the registered provider, or having a deputy Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 24 manager to delegate tasks too. This may have contributed to some of the shortfalls included in this report. The registered provider, under Regulation 26 of the Care Homes Regulations 2001, must carry out a monthly visit to the service and compile a report from each visit. There was no evidence at the home to show that these visits had taken place. The home’s feedback quality assurance (QA) form was inspected. The format included headings of: food and catering, personal care support, daily living, premises, staff attitudes. Completed QA forms were seen for 2007 but there was no record or summary detailing the responses and of any actions taken. Random samples of records required to be kept were inspected. These included: staff recruitment, nutrition, menus, staffing rotas, care plans, assessments, medication, regulation 26 reports and fire drills. Shortfalls were noted regarding regulation 26 reports and care plans. Staff had received training in first aid, food hygiene, infection control & health & safety, but evidence was needed to confirm that update training had been provided on moving & handling and health & safety. Hot water supply in the home is regulated at a temperature of or near to 43 degrees celsius to reduce the risk of scalding. Manual checks on the hot water temperature had also been been made and records of these was seen. Records confirmed that the electrical installation, fire alarms and equipment had been tested, and there was a premises risk assessment in place. There was no mains gas supply to the home. Portable applicance testing was due in September 2008. Comments from the manager in the AQAA under conduct & management of the home included: ‘The manager had recently been registered under the Care Standards act and is also train the trainer in dementia awareness, health & safety, food hygiene, moving & handling, protection of vulnerable adults and fire safety. Staff receive regular training on all of these subjects’. Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 3 X Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 YA6 Regulation 15 Requirement All service users must have a care plan in place that identifies all their needs and gives staff clear information on how those needs are to be met so that service users are provided the support they need. Service user risk assessments must include details of actions to be taken by staff to minimise the risk of injury to service users. The laundry room needs to be refurbished, including repairing the hole in the floor and fitting new/improved floor covering and ensuring walls and surfaces are clean and impermeable to provide a hygienic and safe environment for staff and service users. All staff must be provided regular recorded 1-1 supervision to ensure they are supported in their roles. Timescale for action 31/10/08 2 YA9 13 31/10/08 3 YA24 YA30 23 31/12/08 4 YA36 18 31/12/08 Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 27 5 YA39 24 The results of the home’s quality assurance system must be collated into a summary of the findings and of any resulting actions and be available for service users and the Commission to see, to evidence that service users views are listened too and acted upon. Regulation 26 visits (registered provider visits) must take place on a monthly basis with reports available for inspection. To evidence the appropriate support is available to the manager from the providers and ensure improvement in the home. 31/01/09 6 YA41 26 31/10/08 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 Refer to Standard YA24 Good Practice Recommendations The floor in the food storeroom adjoining the kitchen should be covered and the holes in the concrete in this room and the staff toilet repaired to ensure a safe and hygienic area for staff to work in. Staff training should include update training on moving and handling good practice and health & safety awareness to ensure they have the skills and knowledge for their roles. New staff need to be given induction training that includes the Skills for Care common induction standards subjects. So that they receive appropriate initial training and know what their roles and responsibilities are. 2 YA32 3 YA35 Upshire Residential Home DS0000071447.V370636.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Upshire Residential Home DS0000071447.V370636.R02.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. 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