Care Home: 12 Shenfield Way

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What the care home does well Residents are supported by a committed team of staff who communicate effectively with each other by daily handovers and regular staff meetings to ensure that care is delivered in the most effective and consistent way. It is evident that staff and management are flexible in their approach and make the most of the resources available to them.Residents have access to a range of social, educational and cultural activities. Activities are planned and facilitated across a twenty-four hour period, seven days each week. Residents are supported to maintain contact with their families and friends and one individual is assisted to attend church each week. The home has systems in place to ensure that residents` care needs are met and that they have access to a range of appropriate professional practitioners. Medication is managed well. What has improved since the last inspection? Action has been taken to comply with some the requirements of the last inspection. As such the previous heavy reliance on agency staff has reduced and residents are now being supported by a more consistent team of people. Redecoration and refurbishment of the internal environment has continued, with some bedrooms and communal areas being upgraded. The refurbishment of the lounge, replacement of the flooring on the ground floor and expansion of external space have all had positive effects on the overall presentation of the environment. The review of restrictive practices within the home and in particular, the removal of the safety bars across the kitchen have, allowed 12 Shenfield Way to become more like a home. Staff have all undertaken training in the safeguarding of vulnerable adults and have become much more proactive in recognising and reporting incidents and behaviours that could affect resident wellbeing. What the care home could do better: In order to move the service further forward, the care planning system needs to be developed with a more accessible and person led approach. A particular emphasis should be on the strategic setting and monitoring of meaningful goals that enable residents to attain both short and long term objectives. The ongoing maintenance and refurbishment of the home must also continue, with immediate attention being paid to those areas identified that could potentially compromise health and safety. Access to staff training must improve to ensure that residents are always supported by a team of people who have the necessary skills and training to fulfil their roles. Despite recognising the good outcomes for the people who live at 12 Shenfield Way, we have asked the service to submit an improvement plan which identifies how the outstanding requirements will be met. The RegisteredPerson must also confirm in writing that requirements have been met within the timescales, otherwise the Commission will have to consider undertaking another inspection to re-assess the impact of these shortfalls. CARE HOME ADULTS 18-65 12 Shenfield Way Brighton East Sussex BN1 7EY Lead Inspector Lucy Green Unannounced Inspection 28 July & 28 August 2008 10:00 th th 12 Shenfield Way DS0000060274.V366919.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 12 Shenfield Way DS0000060274.V366919.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. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Shenfield Way Address Brighton East Sussex BN1 7EY 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) 01273 296364 01273 296367 www.fosteringinbrightonandhove.org.uk Brighton & Hove City Council Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is 3. Service users should be aged between 18 and 65 years on admission. Only adults with a Learning Disability who have been assessed as requiring residential care are to be accommodated. 18th January 2007 Date of last inspection Brief Description of the Service: 12 Shenfield Way provides residential care for up to three younger adults with learning disabilities. The building is owned and maintained by Kelsey Housing Association with the services and staffing are supplied by Brighton and Hove City Council. This service provides long term placements with day care largely provided by the home. The home was opened in 2002. 12 Shenfield Way is a detached, two-storey building, that is situated in an elevated residential area on the outskirts of Brighton. There is access to local amenities, including a food shops, pubs and cafe. The location of this service is such that it is only suitable for those who are physically mobile. All bedrooms are single occupancy and each have their own dedicated bathroom and toilet facilities. Communal areas comprise of a lounge/dining room and kitchen. A garden and patio area are located to the rear of the home. Street parking is available at the front of the house. More detailed information about the services provided at 12 Shenfield Way, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents, along with the latest CSCI inspection reports are on available on request from the home. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 12 Shenfield Way are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, a review of the home’s Annual Quality Assurance Assessment (AQAA) and a site visit which lasted for a total of four hours. The inspection was conducted across three days, with the Inspector attempting to visit the service unannounced on the first occasion. At the time of the first two visits the routines of the residents meant that the everyone was scheduled to be out of the home within thirty minutes of the Inspectors arrival. Following the second attempt to inspect, the Inspector contacted the Service Improvement Manager and provided two days notice of this inspection. The site visit included a tour of the premises and an examination of some medication, care and staffing records. Throughout the inspection process, the Inspector met with all three of the people living in the home. Due to the needs of the people living at the home and the importance of not disturbing daily routines, the Inspector’s interaction with the residents was required to be informal and based on more distant observation. The Service Improvement Manager facilitated the main inspection visit and the Inspector also met with four staff members across the three visits. Due to the daily routines of the service it was only possible to speak at some length with one staff member and therefore the Inspector sent surveys to the staff team which were collected by the Commission one week later. Four completed surveys were returned. What the service does well: Residents are supported by a committed team of staff who communicate effectively with each other by daily handovers and regular staff meetings to ensure that care is delivered in the most effective and consistent way. It is evident that staff and management are flexible in their approach and make the most of the resources available to them. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 6 Residents have access to a range of social, educational and cultural activities. Activities are planned and facilitated across a twenty-four hour period, seven days each week. Residents are supported to maintain contact with their families and friends and one individual is assisted to attend church each week. The home has systems in place to ensure that residents’ care needs are met and that they have access to a range of appropriate professional practitioners. Medication is managed well. What has improved since the last inspection? What they could do better: In order to move the service further forward, the care planning system needs to be developed with a more accessible and person led approach. A particular emphasis should be on the strategic setting and monitoring of meaningful goals that enable residents to attain both short and long term objectives. The ongoing maintenance and refurbishment of the home must also continue, with immediate attention being paid to those areas identified that could potentially compromise health and safety. Access to staff training must improve to ensure that residents are always supported by a team of people who have the necessary skills and training to fulfil their roles. Despite recognising the good outcomes for the people who live at 12 Shenfield Way, we have asked the service to submit an improvement plan which identifies how the outstanding requirements will be met. The Registered 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 7 Person must also confirm in writing that requirements have been met within the timescales, otherwise the Commission will have to consider undertaking another inspection to re-assess the impact of these shortfalls. 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. 12 Shenfield Way DS0000060274.V366919.R01.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 12 Shenfield Way DS0000060274.V366919.R01.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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from an admission process that ensures their individual needs and aspirations are appropriately assessed prior to moving into the home. EVIDENCE: The home has not had any admissions since the last inspection and therefore Standard 2 was not re-inspected on this occasion. The last inspection report detailed that the residents at 12 Shenfield Way have all lived there together for a number of years. The Service Improvement Manager reported that should a vacancy occur, the home would use the same admissions procedure that has previously been assessed as good. The home’s admission policy includes giving prospective residents the opportunity to visit the home. The Service Improvement Manager confirmed that compatibility with existing residents would be key in the assessment of any new resident. It was required at the last inspection that the terms and conditions of residency be updated to include details about fees and additional costs and 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 10 that these contracts are agreed with each resident and/or their representative. The previous compliance date for this piece of work was March 2007 and therefore it is of concern that this piece of work has not been completed. The Service Improvement Manager informed the Inspector that reviewing the terms and conditions has formed part of a larger piece of work whereby the Brighton and Hove City Council have been updating the resident information packs to ensure licence agreements, statement of purpose and service user guide are in accessible formats. It was confirmed that this piece of work would be completed by December 2008 and as such the timescale for this requirement has been extended to reflect this date. 12 Shenfield Way DS0000060274.V366919.R01.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 good. This judgement has been made using available evidence including a visit to this service. Care plans include detailed information and guidelines to support individuals, but outcomes would be further improved if they were more strategically reviewed to formulate life goals and develop skills. EVIDENCE: Through discussion with two staff and observation of their practices, it was demonstrated that they have positive relationships with the people they support and a good level of understanding of their needs. The Inspector tracked the care for two residents, which included a partial examination of their care plans, activity timetables and a discussion with the Service Improvement Manager and one staff member. Feedback was also provided by another four staff through surveys. The Inspector met with both of these residents during the course of the inspection visits. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 12 The Service Improvement Manager confirmed that the content and layout of care plans, in particular the way risk assessments are undertaken and updated are in the process of being changed and showed the Inspector a new template that is about to be implemented. The new system of risk assessing will hopefully assist in making care plans more user-friendly and accessible. The previous system involved a raft of assessments that have been updated and amended in so many places that it is difficult for the reader to quickly obtain the key information. It was noted from the documentation that all practices within the service that could be deemed restrictive have been reviewed since the last inspection and many such interventions have now ceased. This is a positive step forward in facilitating resident autonomy and choice. Those restrictive practices that have been assessed as necessary to ensure safety to the individual are now fully documented and kept under review. Both care plans viewed contained detailed support guidelines about daily care routines, behavioural support and communication needs. There was evidence of a person centred approach for one resident in respect of a current review package. There was a body of evidence that indicated that keyworkers have worked hard with their key residents to develop review packs that are meaningful and accessible to them. The review information viewed for one resident contained pictures of the their routines and things that are important to them using their own individual methods of communication. Whilst there was evidence that staff are reviewing the information contained in care plans, the lack of computer facilities available to staff does make the updating process difficult to track. The formal reviews in respect of the two residents whose files were looked at, were also overdue. It was also not clear how the actions discussed at reviews are carried over into the support plans. For one resident, there were no goals identified at their review. The judgement made about care plans is that whilst they contain a lot of very detailed information, the current approach is not entirely person centred and does not sufficiently demonstrate how the home supports residents to strategically formulate life goals and develop their skills and independence. A requirement has therefore been made for the service to move the care planning system forward and ensure that each person has a plan of care that contains up to date information in a format that is easily accessible to the reader. The care plan must also identify both short and long term goals which are linked to skill building and developing independence. In order for this important piece of work to be completed in a meaningful way a requirement has been made with a compliance timescale of six months. It is expected that the Manager will detail the work that has been undertaken in this area in the next Annual Quality Assurance Assessment. 12 Shenfield Way DS0000060274.V366919.R01.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): 11, 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. Residents benefit from the opportunities to access the local community and to participate in educational, social and meaningful activities. Residents are supported to maintain and develop relationships with other people and receive a range of balanced and wholesome food. EVIDENCE: Activity timetables identified that residents have access to a range of social and educational activities that are meaningful to them. The fact that the Inspector visited the service on three occasions in order to find a time when people were at home, is testimony to how active residents at this service are. At the time of the visits, residents were found to be attending day centres, going out for lunch, walks and trips shopping. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 14 The activity timetable viewed for one resident highlighted that they attend a day centre three days each week and house activities include; swimming, pub visits and various outings which are meaningful to them. Another resident is supported by staff to attend church each week. Staffing levels provide 1-1 support for residents and staff surveys confirmed that current levels are sufficient to meet the needs of the people they support. In order to develop excellent outcomes in this area, the home needs to demonstrate how the activities and goal planning are linked to person centred plans of care which support individuals to achieve live goals and achieve maximum independence. The home has a positive approach to enabling residents to maintain contact and relationships with families and friends. There was evidence in the care plans that the home supports residents to meet with and receive visits from their relatives and friends. The Service Improvement Manager and two staff spoken with confirmed that the home understands the importance of good relationships with other stakeholders. Resident reviews include the opportunity for residents’ relatives/representatives to attend if the resident wishes. Meals at 12 Shenfield Way are prepared according to a rotating menu. The menu is drawn up in consultation with residents to reflect the meals they wish to have. The menu is also reflective of individual likes and dislikes. The menu displayed showed that it had been recently updated and included a range of varied and well-balanced meals. 12 Shenfield Way DS0000060274.V366919.R01.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. Residents benefit from the provision of flexible and respectful personal and healthcare support and are protected by the systems in place to manage medication. EVIDENCE: Care plans provided documentary evidence that personal and healthcare needs were being met. It was evident that appropriate referrals are made to external professionals, including GP’s, dentists and opticians. There was evidence for the residents case tracked, that they are regularly weighed and records maintained. Personal support was observed to be being provided in a sensitive and respectful way. The home has introduced health action plans in line with Valuing People, although the Service Improvement Manager advised that the home was moving over to a new system that has been adopted by doctors in the Brighton area. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 16 Medication systems were assessed by way of a review of records, storage and discussion with the Service Improvement Manager. The medication policy was not inspected on this occasion. Both the administration, recording and storage of medication were judged to be satisfactory and guidelines were found to be in place regarding the use of ‘prn’ medication. The Service Improvement Manager reported that the service was in the process of introducing a new more in depth training system in respect of medication. 12 Shenfield Way DS0000060274.V366919.R01.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. Residents benefit from the systems in place to listen to their views and safeguard them from harm. EVIDENCE: The home has a complaints procedure in place, which provides a pictorial version for residents, although the due to the complex needs of the residents they would require support to make a complaint. A complaints book is in place, however neither the CSCI nor the home have received any complaints about 12 Shenfield Way in the last twelve months. The home seeks to operate an open culture where issues are openly discussed and opinions shared. Positive interaction was observed between residents and staff during the inspection. Residents and their representatives are encouraged to express their views about the service. The home has a number of systems in place to protect residents from abuse. New staff are employed subject to the necessary checks being undertaken. There are systems for supporting residents’ with their finances which include monies being checked and signed for. Staff have demonstrated that they are aware of their responsibilities in respect of protecting vulnerable adults and are proactive in safeguarding the people they support. All staff have completed relevant training in this area since the last inspection. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in clean and homely environment with further work needed to ensure that it is well decorated and meets the needs of residents living there. EVIDENCE: The home is located in a residential area in an elevated position overlooking Brighton. To access local amenities and transports links involves some steep inclines. The home is therefore only suitable for those who are independently mobile. The maintenance of the building is undertaken by Kelsey Housing Association. It has been a long standing requirement that the budget holder be identified and that a redecoration programme be developed. The Service Improvement Manager has now confirmed that a service level agreement is currently being discussed between Brighton & Hove City Council and Kelsey Housing Association. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 19 In the interim period, staff have worked hard to improve the decoration and homeliness of the building. As such staff have re-decorated some residents bedrooms themselves and the lounge has also been completely refurbished. Other environmental improvements have included a new flooring throughout the ground floor and authorisation has now been obtained for a new fitted kitchen. One staff member has been resourceful in his bid to expand and improve the outside space and as such should be congratulated for his efforts in successfully upgrading the rear garden. This extra space has also assisted in increasing the amount of communal space available to residents. It is positive to report that the service has made significant improvements since the last inspection in reducing the restrictive practices throughout the home. In particular, the removal of the safety bars across the kitchen has had greatly improved the home. The use of the stable door does not allow free access to this area, however the removal of the bars at least reduces total segregation. Whilst it is recognised that work has been done to promote freedom of movement, there is still further work ad education to be done in this area. The home will need to carefully consider the use of the keypad system and locked doors in respect of the provisions under the Mental Capacity Act 2005 and Deprivation of Liberty safeguards. Ongoing upgrades and maintenance work are continually required and whilst the home has its own record of redecoration plans, this inspection has identified some areas of health and safety that must be addressed. As such, the hand rail on the staircase requires varnishing to reduce the risk of spreading infection and the home must review the location of furniture that was found to be blocking fire escapes. Greater attention must also be paid to the overall cleanliness of the home. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a committed team of staff, although greater protection would be afforded if the training programmes were more rigorously maintained and staff files kept updated. EVIDENCE: At the time of the inspection, the atmosphere was observed to be friendly and busy and the positive relationships between staff and residents were obvious. Residents have active lifestyles and it was evident that maintaining their routines is important to them and staff were seen to manage this well. On each of the three inspection visits, the home was staffed by three carers. The Service Improvement Manager confirmed that three staff is the usual level during the core hours and the rota reflected this. At night, one staff member usually sleeps in, although this has been increased to a waking night duty at times of changing need. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 21 It was a requirement of the last inspection that the service reduce its heavy reliance on agency staff. This requirement is deemed met as the employment of two staff on temporary contracts and the use of regular internal relief staff are currently covering the vacant posts more effectively now. Discussion with the Service Improvement Manager and examination of staff training records identified that there are significant deficits in staff access to training. In particular, the majority of staff require training in infection control and food hygiene. It is of particular concern that such gaps have again been identified as it was a requirement of the last inspection in January 2007 that staff undertake the mandatory and specialist training relevant to their roles. This fact was highlighted to the Service Improvement Manager, who was advised that if significant improvements to this area have not been made within a three month timescale, the Commission would have to consider taking enforcement action. Staff recruitment files for Brighton & Hove City Council are stored centrally and as such the service has commenced obtaining copies of the documentation that is required to be kept in the home. There were still a number of gaps in this information and it is therefore required that this task be completed. The Inspector saw evidence of regular staff meetings being conducted with minutes recorded. Staff also receive supervision on a four-weekly basis. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are now benefiting from the consistency of an appointed Manager who has made some positive changes for their safety and wellbeing. The organisation has systems in place to self-audit and monitor, although greater attention must be paid to ensuring action points do not remain outstanding. EVIDENCE: At the current time, the service does not have a Registered Manager, although a Manager has been appointed who has commenced this process. This individual was on holiday at the time of the inspection and therefore the Inspector did not meet him. The feedback from the staff team was that it was that there needed to be some consistency now to this position as the service has been through several management changes in the last few years. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 23 During the inspection, it was evident that the Manager has made a number of positive changes at 12 Shenfield Way since being in post and in particular reducing the restrictive practices within the service. The Manager is currently working towards the Registered Managers Award and a National Vocational Qualification (NVQ) level 4 in Care. The home has a system of quality monitoring in place with line management conducting regular visits in accordance with Regulation 26. There is also evidence that annual satisfaction surveys are sent out to stakeholders, although at the current time the results of these have not been formally collated and published. It is important that where audits and checks identify issues, that the appropriate remedial action is taken. As such, the fire risk assessment identifies the risk of certain locked doors throughout the home, this action has been repeated over several checks and yet it is not clear what action has been take. The home has various systems in place to ensure the health and safety of the home are maintained. The Inspector sampled some of the records in respect of fire safety, the testing of portable appliances and electrical wiring and as such concluded that the home has satisfactory recording and monitoring systems in place. A comprehensive fire risk assessment has now been devised and it was evident in care plans that each resident has their own personal emergency evacuation plan to be used in the event of a fire. As previously mentioned in the Environment section of this report, the home is required to action in respect of improving infection control standards and clear access to fire escapes. 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 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 X 33 3 34 2 35 2 36 3 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 2 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 25 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 YA5 Regulation 5(1)(b) & (c) Requirement The Registered Person must ensure that the terms and conditions of residency are agreed with each service user and/or their representative and details of fees and additional costs. Previous timescale of 30/03/07 not met. 2 YA6 15(1) & (2) & 13(4) The Registered Person must 01/03/09 ensure that care plans and risk assessments are developed in consultation with service users in a person centred way. These plans must be in a format that are easily accessible and formally reviewed at least every six months. The Registered Person must 01/03/09 ensure that the setting, monitoring, recording and meaningfulness around the goal setting process are improved and include both long and short term goals. The Registered Person must 01/10/08 ensure that the home is kept clean and reasonably decorated. DS0000060274.V366919.R01.S.doc Version 5.2 Page 26 Timescale for action 01/12/08 3 YA11 15(2) 4 YA30 23(2)(d) 12 Shenfield Way 5 YA34 6 YA35 This should include the varnishing of handrails to prevent the spread of infection. 17(2) The Registered Person must ensure that staff recruitment information as detailed in Schedule 4 of the Care Homes Regulations is available in the care home for inspection at all times. 18(1)(c)(i) The Registered Person must ensure that staff receive the training necessary to undertake their roles safely and the specialist training in accordance with the needs of the service users accommodated. Previous timescale of 30/06/07 not met. 01/12/08 01/12/08 7 YA39 19A 8 YA42 23(4)(b) The Registered Person must supply an improvement plan in respect of how the service intends to address the requirements outlined in this inspection report. The Registered Person must ensure that there are appropriate means of escape in the event of a fire. Fire exits must be kept clear and be accessible. 01/12/08 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 12 Shenfield Way DS0000060274.V366919.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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