Care Home: 28 Southdown Road

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What the care home does well The home has informative Statement of Purpose and Service User guide, this would give prospective residents and or their families/representatives a good guide as to whether they would choose to use this home. Care plans are individual to each resident, and give detailed information in regard to family history, physical condition, personal, physical and social needs. Good detail can be found in each care plan as to what body language, sounds and facial expressions communications mean. There are also good guidelines for staff as to how they could spot a potential epileptic episode. Risk assessments are kept separately from the care plans as are the daily diaries for each individual resident. There was evidence of good multi disciplinary working with the manager and staff in the home. Residents lead full and varied social lives, depending on their choices, and interests. The home has recently been extended to provide two new bedrooms with ensuite wet rooms. Five bedrooms and communal bathrooms have ceiling hoists and there is a variety of equipment available within the home to assist both residents and staff with moving and handling. The home has a welcoming and homely atmosphere. All furnishing are domestic in style and the home is well maintained. The back garden has access via ramps to a lawn area and is safe and secure for the residents to use. There have been no complaints or adult protection issues since the last key inspection. The inspector was able to view compliments received from residents` families. Staffing levels are good in the home, all residents need one to one care and support. On the afternoon of this key inspection staff took residents out on a one to one basis, to carry out activities of their choice or just for a social trip out. Staff are well qualified, and have access to specialist training as and when required. The majority of staff have also undertaken mandatory training in health and safety issues. All new staff are required to have an in depth induction including an introductory induction within the first few days of their employment. Recruitment procedures are stringent, and all staff have the appropriate checks carried out prior to being employed by Southdown Housing Association. The manager is highly thought of within the home, and has the qualifications and experience to ensure that staff work as a team, and meet the differing needs of the residents. What has improved since the last inspection? There is more detail provided in the care plans in regard to individual epilepsy guidelines, communication, and health and welfare needs. Care plans are regularly reviewed. All medication is properly administered, and all Monthly Administered Dosage charts are completed correctly. All medication in the home is in date. What the care home could do better: One requirement was made in regard to staff ensuring that medication brought into the home by a new resident or prescribed by a Dr. mid cycle, should be correctly signed in on the Monthly Administered Dosage chart, with the date, quantity and initials of the member of staff receiving the medication into the home.Risk assessments could provide more guidelines to staff in the form of procedures to ensure that staff are able to keep recognised risks to a minimum. CARE HOME ADULTS 18-65 28 Southdown Road Seaford East Sussex BN25 4PG Lead Inspector June Davies Unannounced Inspection 17th March 2008 09:30 28 Southdown Road DS0000021001.V359106.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 28 Southdown Road DS0000021001.V359106.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. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 28 Southdown Road Address Seaford East Sussex BN25 4PG 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) 01323 897877 southdownrd@southdownhousing.org Southdown Housing Association Ltd Ms Marion Love Care Home 7 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either M/F Whose primary care needs on admission to the home are within the following categories: Learning Disabilities (LD) 2. Physical Disability (PD) The maximum number of service users to be accommodated is 7. Date of last inspection 16th January 2007 Brief Description of the Service: 28 Southdown Road is a care home, which provides personal care and accommodation for up to seven residents with physical and learning disabilities. It was opened in 1997. The home is owned and run by Southdown Housing Association who are a large voluntary organisation that have been providing services to people with learning disabilities across East Sussex for over 16 years. The home is a large purpose built bungalow situated in a quiet residential area of Seaford. It is close to the town centre and public transport facilities, although the home does have access to two wheelchair-friendly vehicles. All rooms are for single occupancy with hand washing facilities in addition to two large assisted bathrooms. There is a large lounge, spacious kitchen/dining room and a well-maintained, secure garden to the rear of the property. The home is well decorated and maintained throughout and has a friendly and homely atmosphere. The home provides personal care and support to residents, five funded by Social Services and one funded by the Health Authority. The home’s fees as of 17th March 2008 are £1750.00 per person per week. Additional costs are charged for hairdressing (£6-8), hydrotherapy (£variable), some toiletries (£variable) and holidays (£variable). Prospective residents and their relatives are provided with written information 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 5 regarding the services and facilities provided at the home prior to admission. A copy of the home’s most recent inspection report is available on request from the home. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on Monday 17th March 2008 over a period of 6 hours. During the course of this inspection the inspector spoke with staff. Observed residents at breakfast. Introduced herself to the residents. Viewed all documentation relating to the standards inspected and carried out a tour of the home. The registered manager facilitated the inspector throughout the inspection. None of the residents are able to communicate verbally, and none are able to use sign language. Staff have learnt to communicate via body language, facial expression and the sounds that the residents make. Therefore the inspector was unable to gain the views of the residents in the home. The Annual Quality Assurance Assessment (AQAA) returned to the Commission in September 2007 was used as part of the preparation for this inspection. The reader should aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the term ‘service user’ to describe those living in care home settings. However for the purposes of this report those living at 28 Southdown Road will be referred to as ‘residents’. What the service does well: The home has informative Statement of Purpose and Service User guide, this would give prospective residents and or their families/representatives a good guide as to whether they would choose to use this home. Care plans are individual to each resident, and give detailed information in regard to family history, physical condition, personal, physical and social needs. Good detail can be found in each care plan as to what body language, sounds and facial expressions communications mean. There are also good guidelines for staff as to how they could spot a potential epileptic episode. Risk assessments are kept separately from the care plans as are the daily diaries for each individual resident. There was evidence of good multi disciplinary working with the manager and staff in the home. Residents lead full and varied social lives, depending on their choices, and interests. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 7 The home has recently been extended to provide two new bedrooms with ensuite wet rooms. Five bedrooms and communal bathrooms have ceiling hoists and there is a variety of equipment available within the home to assist both residents and staff with moving and handling. The home has a welcoming and homely atmosphere. All furnishing are domestic in style and the home is well maintained. The back garden has access via ramps to a lawn area and is safe and secure for the residents to use. There have been no complaints or adult protection issues since the last key inspection. The inspector was able to view compliments received from residents’ families. Staffing levels are good in the home, all residents need one to one care and support. On the afternoon of this key inspection staff took residents out on a one to one basis, to carry out activities of their choice or just for a social trip out. Staff are well qualified, and have access to specialist training as and when required. The majority of staff have also undertaken mandatory training in health and safety issues. All new staff are required to have an in depth induction including an introductory induction within the first few days of their employment. Recruitment procedures are stringent, and all staff have the appropriate checks carried out prior to being employed by Southdown Housing Association. The manager is highly thought of within the home, and has the qualifications and experience to ensure that staff work as a team, and meet the differing needs of the residents. What has improved since the last inspection? What they could do better: One requirement was made in regard to staff ensuring that medication brought into the home by a new resident or prescribed by a Dr. mid cycle, should be correctly signed in on the Monthly Administered Dosage chart, with the date, quantity and initials of the member of staff receiving the medication into the home. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 8 Risk assessments could provide more guidelines to staff in the form of procedures to ensure that staff are able to keep recognised risks to a minimum. 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. 28 Southdown Road DS0000021001.V359106.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 28 Southdown Road DS0000021001.V359106.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): Standards 1 and 2 People using this service experience good outcomes in this area. The homes Statement of Purpose and Service User guide provide residents and prospective residents with the information they need to make a decision about moving into the home. Residents move into the home knowing that their needs can be met and that their independence will be maximised and promoted. Residents know that their goals and aspirations will be supported by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Statement of Purpose and Service User Guide are updated annually and reflect the purpose, philosophy, facilities and level of care offered by 28 Southdown Road. The Service User Guide is presented in an easy to read and understandable format that uses symbols and pictures. Three pre-admission assessments showed that the registered manager obtains comprehensive and detailed information regarding the prospective resident to ensure the home and staff can meet that resident’s needs prior to moving into 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 11 the home. Residents are mainly referred by local authorities, who also provide an overview assessment of the prospective residents needs. These preadmission assessments then form the basis for a care plan. Prospective residents and their relatives visit the home prior to moving in, to enable them to meet with residents and staff and to ensure that they will integrate into the home. 28 Southdown Road DS0000021001.V359106.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): Standards 6, 7 and 9 People using this service experience good outcomes in this area. The care planning system in place is consistent and provides staff with easily accessible information they need to meet the residents’ needs. Residents are able to participate in the running of the home as far as their disabilities will enable them. Residents know that their personal goals are reflected in their individual plans and that potential risks are managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are initially based on the prospective residents pre-admission assessments carried out by the home’s registered manager and the local authority, care manager and others multi-disciplinary workers. These care 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 13 plans contain detailed information relating to the residents, and are built on throughout the residents stay in the home. One specific care plan viewed from a new resident into the home, showed that this had been reviewed regularly to reflect, all aspects of the resident’s care needs, and their likes and dislikes as well as the progress they had made since moving into the home. Through discussion with the registered manager it was pointed out that when these changes are made it would be useful to have them dated, as this shows that the manager and her staff are regularly reviewing the changing needs of the residents. None of the residents are able to communicate in language, but use sounds and gestures to communicate with staff, these sounds and gestures are recorded in each individuals care plan and inform staff of how they are able to ascertain whether the resident is happy or unhappy, what their likes and dislikes are. The care plan is drawn up with the resident, their families, advocates, care manager and members of the multi disciplinary team. Each resident has his or her own key worker. The initial review takes place within 12 weeks of the resident coming to live in the home, then at 6 months, followed by annual reviews unless there are significant changes that warrant a review at an earlier date. From two care plans viewed there was evidence that annual reviews do take place and that the resident, their families, care manager, key worker, and the registered manager are involved in these. Each resident also has their own individual daily diary, and any significant event in this diary that has a bearing on the residents future care is then placed on the care plan. Each diary has a record sheet for epileptic instances, which in turn is then entered in the care plan on a monthly basis. The six service users living in 28 Southdown Road, are severely disabled, and are unable to communicate in verbal form. They are involved as much is possible with the running of the home. The manager is in the process of finding out more about communication passports and these will give staff more understanding of the residents likes and dislikes. Risk assessments are drawn up prior to the residents moving into the home, and further risk assessments are drawn up during their stay at the home, each reflects the degree of risk in accordance with their daily activities such as using the homes vehicles, and their visits to the hydro therapy pool, their daily lives are risk assessed as to how they prefer to mobilise around the home to the use of cot sides on their beds. Risk assessments inform staff as to how the level of risk can be kept to a minimum. 28 Southdown Road DS0000021001.V359106.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): Standards 12, 13, 15, 16 and 17 People who use this service experience good outcomes in this area. Links with the community are good and support and enrich residents’ social and educational opportunities. Both the registered manager and staff ensure that residents maintain links with families and friends. As far as possible residents are able to be involved in the daily routines within the home. The meals in this home are good offering both choice and variety and catering for special diets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 15 While none of the residents at 28 Southdown Road can be employed, they do however participate in appropriate college courses. Tutors from the college hold some of the courses within the home, while others are held on the college campus. College courses comprise of: - ‘Sensory cooking’, ‘Hear and feel the Music’, ‘Pottery’ and ‘Sensory Art’, to name but a few. Staff take residents out on a one to one basis into the local community, to participate in shopping, have a cup of coffee, visit the cinema, visit the pub and to the local hydro therapy pool. The local shopkeepers know the residents, and neighbours stop to speak to the residents when they see them out in the street. Four residents in the home have an interest in exploring the Sussex area and they are taken out each week on a one to one basis, to places of interest. The staff encourage residents to maintain relationships with families and friends, and ensure they write letters for them and send birthday cards. Families and friends are able to visit the home as and when they please, one resident goes out every Sunday for lunch with their mother, and another resident has a friend round each week to watch videos. Residents also attend local clubs where they are able to meet up with their friends. Residents are able to choose what daily routines they wish to be involved in around the home, although each resident is involved with the cleaning of their bedroom. Two residents like to be involved in gardening, another with recycling and one with delivering clean laundry to other residents. Some residents show an interest in helping to prepare meals. The menu is developed on a four-week rotation, and this is changed regularly. All the food is cooked from fresh and provides the residents with a balanced and varied diet. One resident needs to have liquidised meals, at the present time the whole meal is liquidised together, but from discussion with the registered manager, it has been agreed that in future, each food will be liquidised separately to ensure that the meal looks appealing and appetising. Where and when necessary specialised diets can be catered for. The inspector was able to observe residents at breakfast time. Some residents need staff to help them eat and this was being done in a discreet and sensitive manner, with staff using good communication with the residents. Most residents choose to eat in the large kitchen dining room, while another resident sometimes chooses to eat at the table in the communal sitting room. 28 Southdown Road DS0000021001.V359106.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): Standards 18, 19 and 20 People who use this service experience good outcomes in this area. Personal care is offered in a way to protect resident’s privacy and dignity and promote independence. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication in this home is well managed promoting good health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each care plan states the time and level of personal support required by the residents. There was good and detailed guidance for staff in each care plan as to how the personal support was to be carried out, and clearly described where this personal support was to be carried out. All the residents need help and support from staff to carry out their own personal hygiene. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 17 All personal hygiene is carried out in the privacy of the resident’s bedrooms or the communal bathrooms. Staff respect the privacy and dignity of the residents when carrying out personal hygiene, and ensure that doors are locked. Care plans stated what clothes the residents like to wear, and what they feel most comfortable in. Each resident is able to choose their own clothes, by participating in shopping trips with the staff. The residents visit their own hairdresser of their choice and choose how to have their hair cut and styled. The staff rota showed that there was a good gender mix of staff in the home at all times, to meet with the preferences of the residents. All the residents have technical aids and equipment to assist them with their daily living; staff have received the appropriate training in using these aids. One resident needed arm gaiters applied when threatening to self-harm, but since being in the home, staff have found that rather than using these during the day, they are able to distract by other means. In one care plan there was good guidance in both words and photographs which had been supplied by the Community Learning Disability Team as to how one of the service users should be sitting in their wheelchair, to ensure that they were comfortable and did not experience pain. There was evidence that one resident has annual appointments with a psychiatrist, and this is recorded within their medical history file. All residents have a key worker of their own choosing. Residents likes and dislikes are recorded within each individual care plan and are quite detailed, due to their lack of verbal communication. Residents have access to a doctor of their choice, and attend the health centre for general health check ups or when staff have concerns relating to a residents health. Residents make regular visits to chiropodists, opticians, and dentists of their choosing. Staff give the residents’ one to one support when attending outpatient clinics. When a resident needs to see a health care practitioner they are always escorted by a member of staff who ensures that any instructions from the health care professional are carried out. On the day of the visit the inspector carried out an audit of the residents medication and found that all monthly administration records (MAR’s) had been initialled off appropriately. There were some medications that had not been recorded as being received on the MAR sheets and discussion took place with the manager who said that she would ensure this was rectified in future. The MAR sheet file did not have dividers between each residents MAR sheets, 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 18 but the registered manager said that the pharmacy had only just supplied these, and that she would be putting them to use. The home has good policies and procedures relating to the receipt, administration, storage and disposal of medication. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 19 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): Standards 22 and 23 People using this service experience good outcomes in this area. The home has a satisfactory complaints policy and procedure in place, where residents’ and their relatives know that they will be listened to and the complaint will be acted on. Staff have a good knowledge and understanding of safeguarding vulnerable adults, which protects the residents’ from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a detailed and reviewed complaints policy and procedure in place. The complaints policy describes how a complaint can be made, and to whom it should be made in the first place, and that each complaint will be responded to within 28 days. There have been no complaints made to the home since the last inspection. Four families have sent written compliments to the home, regarding the excellent standard of care that the residents’ are receiving in the home. The home has up to date policies and procedures relating to safeguarding vulnerable adults together with East Sussex County Councils, protocols and guidelines for protecting vulnerable adults. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 20 There have been no safeguarding vulnerable adult issues since the last key inspection. The home’s policies and procedures regarding residents’ monies are about to change. The registered manager will no longer be appointee to five residents in the home but there will be cooperate appointee-ship from within the Southdown Housing Association, who will oversee the residents’ finances. There are also policies and procedures in place in relation to the management of personal finances for the residents, and ensuring that staff do not accept gifts or receive a bequest from a resident. Resident’s personal monies are well managed. Each resident has their own cash box, and Building Society book; these are kept securely under lock and key within the home. Residents have their own cash sheet, which records cash spent, a temporary receipt sheet which staff complete for money they take out on behalf of each resident and this is completed when returning from shopping and the actual expenditure together with receipts is written up onto the cash sheet. These cash sheets and cash boxes are checked on a daily basis for each resident. A passbook transaction sheet also records monies coming in and going out of the residents building society accounts, any monies taken out of these accounts needs two signatures, one must be the signature of the registered manager, these are also checked on a daily basis. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 21 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): Standards 24 and 30 People who use this service experience good outcomes in this area. The standard of the environment within the home is excellent providing residents with an attractive and homely place to live. Staff have a good knowledge of infection control procedures to ensure that residents are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 28 Southdown Road is a purpose built bungalow that has recently had an extension added, to provide carer for up to seven residents with physical and learning disabilities. This home creates homely domestic atmosphere for the residents to live in. Each bedroom has a ceiling hoist. The two communal bathrooms are especially equipped with ceiling hoists, specialised baths and trolleys, with one bathroom having a wet room combined, there are audio 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 22 speakers where staff are able to play music to the residents while having their bath or shower. All toilet facilities have specialised handrails. Some bedrooms have electronically adjustable beds. All bedrooms are personalised and reflect the interests on the residents. The kitchen /dining room is very large so that it is able to accommodate wheelchairs; all working surfaces are situated at wheelchair level. The home has an under floor heating system therefore there are no radiators in any of the rooms, and all hot water outlets have thermostatic control valves fitted. The registered manager has recently acquired a sensory unit, which is being placed unobtrusively in a corner of the very large communal lounge. The whole premises, is maintained to a high standard, and there are no offensive odours. Bedroom and communal rooms are fitted with magnetic door closures which will activate should a fire occur. The garden of the home has ramps to make the garden accessible for wheelchair users. The laundry room is situated away from the kitchen and has two washing machines, one with a sluicing facility, and one industrial tumble drier. The laundry room floor is impermeable to water. Staff are provided with protective clothing, plastic aprons and disposable gloves, these are available in specialised holders in each bathroom. The communal bathrooms have clinical waste bins with the appropriate clinical waste sack in situ. The company has a contract with a clinical waste collection company. The home has a policy and procedure to prevent cross infection. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 23 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): Standards 32, 34. 35 and 36 People using the service experience good outcomes in this area. Staff morale is high resulting in an enthusiastic team that works positively with the residents to improve their whole quality of life. Staff are multi skilled ensuring good quality care and support Recruitment policies ensure that each new member of staff is properly vetted to ensure residents are not placed at risk. The registered manager carries out regular supervision of the staff in the home, to ensure that their understanding of their roles are clear, and that any training needs are documented and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are employed in sufficient numbers to ensure that each resident receives one to one support throughout the day. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 24 Many staff with the exception of two new employees have received work related training, to ensure that they can meet the assessed needs of the residents. Further work related training has been booked within the next few months to further develop support workers skills. Forty five per cent of support workers have a NVQ qualification with further staff in the process of gaining NVQ. Southdown Housing Association head office retains staff employment records, but the manager of each home is required to visit the office and sign a checklist to ensure that new employees are recruited with all the relevant paper work and checks. The registered manager was able to show the inspector checklists for three employees. These showed that each employee had completed an application form (requiring a full employment history), two references had been obtained, CRB check had been carried out prior to the employee being allowed to work in the home, and that at least two forms of identification had been obtained. All new employees receive a structured induction programme, and are required to attend induction training carried out by Southdown Housing Association at the beginning of their employment. During this induction they are introduced to a more detailed induction programme, based on Skills for Care induction, which when completed will lead to a certificate. The majority of staff have received mandatory training in Health and Safety issues, such as Fire Safety, Food Hygiene, Moving and Handling, First Aid, Infection Control and Medication. Further courses are booked for next month, and two new staff working in the home will be expected to attend this training. Each member of staff receives regular supervision and annual appraisals, when they have completed their probationary period of employment. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 25 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): Standards 37, 39 and 42 People using this service experience good outcomes in this area. The manager has a good understanding of what needs to improve in the home. Planning is in place and sets out how these improvements will be resourced and managed. The quality assurance system in the home is good and ensures that residents receive a high quality of care. The manager ensures that all aspects of health and safety are adhered to ensuring that both residents and staff live and work in a safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 26 The registered manager has obtained her NVQ level four, a City and Guilds 3253 in Advanced Management and has worked in the management role for a period of 9 years. The manager works hard to ensure that the home is managed around the needs of the residents. On the day of the inspection there was a pleasant and friendly atmosphere in the home. Staff spoke highly of the registered manager and the support that she gives them. From discussion and observation the inspector found that the registered manager does all she can to support residents in the lifestyles that they wish to have, within the limitations of their disability. The home has a good quality assurance system in place, which seeks the views of the residents informally, and written surveys from residents relatives and external stakeholders. The registered manager has a monthly checklist where she monitors systems used in the home. There is an annual Health and Safety and Fire risk assessments carried out in the home. On an annual basis, the team all get together for a Quality Monitoring Day. On that day the team review and audit what is happening in the home, this generates an action plan showing our goals and targets for the coming year, this is then reviewed after six months to ensure that the team is meeting it goals. The findings of the quality assurance system are then published within the annual Southdown Housing Association business plan. As mentioned previously the majority of staff have completed their mandatory training, and further course have been arranged for this year. All cleaning materials are kept safely locked away in the home. All equipment used in the home has current maintenance certificates. Window restrictors are fitted to all opening windows. Tests are carried out weekly on fire points, emergency lights, Legionella, kitchen hygiene, torch batteries and hot water outlets. Fire drills have been carried out on 28/08/07 and 08/01/08. Policies and procedures relating to health and safety are regularly reviewed by Southdown Housing Association and updated in accordance with legislation. Health and safety and fire risk assessments are carried out on a regular basis. Any accident to either residents or staff are appropriately recorded in the Health and Safety Executive accident book. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 27 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 28 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 Requirement The registered manager must ensure that all medication brought in by new residents or that are prescribed mid cycle must be recorded onto the MAR sheet with the date received, quantity of medication and the initials of the person receiving the medication into the home. Timescale for action 01/05/08 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 YA6 Good Practice Recommendations When care plans are reviewed and entries are made on an ad lib basis, this should be dated and signed. 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 28 Southdown Road DS0000021001.V359106.R01.S.doc Version 5.2 Page 30 - 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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