Care Home: 7 Fairmile Drive

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What the care home does well Before people come to stay for a short-break the management and staff team would have gathered a lot of useful and detailed information about the person and what help and support they need to keep them safe and well. The team spend time with the person, their carers and other relevant health and social care staff to make sure that the home is the right environment and the staff have the right skills.To make sure that staff have the right skills and values they have access to a comprehensive Induction and ongoing training programme that looks at the skills staff members need to be able to support people in the right way. Not only are staff encouraged to participate in the training, they are also assessed to make sure that they are competent and have understood and are putting the skills and values they learnt into practice. The way that the management and staff team have worked with people to find out what help they need can be described as person centred in that they have tried to explain from the person`s point of view what help they need. This was seen most clearly in the way that people need help with their personal care has been recorded. It reads as if the people are telling you themselves how they want to be helped. This is also the level of detail seen in describing how people communicate and how they want to make choices and decisions about their day-to-day lives. Comments we received, mostly from carers, were very positive about the service that people have and the positive attitude of the staff and management. One parent stated that her daughter has settled in really well and can`t wait for her next visit. Knowing that the service can support people and keep them safe is very important to carers. As one carer stated, ` The staff are very caring and I can settle knowing she is well looked after.` What has improved since the last inspection? This was the first key inspection and so the issue of improvements will be addressed at the next key inspection. What the care home could do better: People come to stay for a short-break away from their main carers. This allows people the chance to do something different and this includes taking part in social and leisure activities that people enjoy and may not have tried. The manager and staff team gather a lot of information about what people like to do and what stimulates them. They currently have sufficient staff to be able to provide individual support and help to access activities. Talking to the management of the service and reading the records it was acknowledged that the priority for the service had been to get to know people and to make sure that they could meet their needs. Greater emphasis would now be placed on areas such as people`s social, leisure and stimulation needs. People are helped to look after their personal spending money when they come to stay for a break. The management and staff team do have a safe system forlooking after this money but some improvements could be made to make it even safer. CARE HOME ADULTS 18-65 7 Fairmile Drive 7 Fairmile Drive East Didsbury Manchester M20 5WS Lead Inspector Steve O Connor Unannounced Inspection 29th January 2008 2:00 7 Fairmile Drive DS0000070272.V356255.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 7 Fairmile Drive DS0000070272.V356255.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. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 7 Fairmile Drive Address 7 Fairmile Drive East Didsbury Manchester M20 5WS 0161 434 8895 T/F 0161 434 8895 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) Northern Life Care Limited T/A U.B.U. Catherine Holland Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 7 Fairmile Drive DS0000070272.V356255.R01.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 people 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 people who can be accommodated is: 4 Date of last inspection This was the first key inspection since the service was registered with the Commission. Brief Description of the Service: The care home provides 24-hour care and accommodation supporting people whose primary needs relate to their learning disability but may also have additional physical and/or sensory disabilities. The care home offers a short-break service to young people (16 to 30 years of age) to give them and their main carers a break. The home is a domestic building set in the residential area of East Didsbury in south Manchester and is close to a range of social, leisure and transport facilities. The accommodation comprises of a ground floor mobility adapted en suite bedroom with appropriate furniture and equipment to support people with high mobility needs. Three further bedrooms are upstairs with double beds and television sets provided as standard. There are also communal areas, a kitchen and bathroom facilities. A well-tended garden is at the rear of the house and is fully accessible. 7 Fairmile Drive DS0000070272.V356255.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 inspection report is based on information and evidence we (the commission) gathered since the home was registered in July 2006. Additional information that was taken into account included any incidents notified to us and information provided by other relevant agencies. Before the site visit, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home views the service they provide in the same way that we see the service. Before the site visit people/ their relatives and staff were sent surveys asking them to comment on the service. A number of surveys were returned and the information used to inform the inspection report. The person who was staying at the home at the time of the site visit had little verbal communication and so evidence was gathered through observation of how staff worked with and interacted with them. During the inspection site visit time was spent talking to the manager, deputy manager and staff. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do in the future. What the service does well: Before people come to stay for a short-break the management and staff team would have gathered a lot of useful and detailed information about the person and what help and support they need to keep them safe and well. The team spend time with the person, their carers and other relevant health and social care staff to make sure that the home is the right environment and the staff have the right skills. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 6 To make sure that staff have the right skills and values they have access to a comprehensive Induction and ongoing training programme that looks at the skills staff members need to be able to support people in the right way. Not only are staff encouraged to participate in the training, they are also assessed to make sure that they are competent and have understood and are putting the skills and values they learnt into practice. The way that the management and staff team have worked with people to find out what help they need can be described as person centred in that they have tried to explain from the person’s point of view what help they need. This was seen most clearly in the way that people need help with their personal care has been recorded. It reads as if the people are telling you themselves how they want to be helped. This is also the level of detail seen in describing how people communicate and how they want to make choices and decisions about their day-to-day lives. Comments we received, mostly from carers, were very positive about the service that people have and the positive attitude of the staff and management. One parent stated that her daughter has settled in really well and can’t wait for her next visit. Knowing that the service can support people and keep them safe is very important to carers. As one carer stated, ‘ The staff are very caring and I can settle knowing she is well looked after.’ What has improved since the last inspection? What they could do better: People come to stay for a short-break away from their main carers. This allows people the chance to do something different and this includes taking part in social and leisure activities that people enjoy and may not have tried. The manager and staff team gather a lot of information about what people like to do and what stimulates them. They currently have sufficient staff to be able to provide individual support and help to access activities. Talking to the management of the service and reading the records it was acknowledged that the priority for the service had been to get to know people and to make sure that they could meet their needs. Greater emphasis would now be placed on areas such as people’s social, leisure and stimulation needs. People are helped to look after their personal spending money when they come to stay for a break. The management and staff team do have a safe system for 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 7 looking after this money but some improvements could be made to make it even safer. 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. 7 Fairmile Drive DS0000070272.V356255.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 7 Fairmile Drive DS0000070272.V356255.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Before using the service, people’s support needs were assessed. EVIDENCE: Before a person came to stay for a short-break they would have had the opportunity to visit the home, have a meal and even stay overnight for as many times as was necessary so that they, their family and the home knew that it was the right place for them to spend some time and that the staff at the home could meet their support needs. The manager and/or deputy manager would gather information about people’s needs prior to any visit to the home and would update this information and assessment as they got to know people better. Several examples of these assessments were seen and found to contain a lot of information about people’s needs, their likes, dislikes and other important information. Information from the purchasing local authority would also have to be provided before the person came to stay at the home. Based on the information gathered by the manager from the different sources she would then make the decision as to whether the home and staff team would be able to meet the person’s needs. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 10 The manager and deputy described meetings with people, families and other professionals to discuss people’s needs but these were not always recorded. It is recommended that all information gained through the pre-admission meetings and visits be clearly recorded and used as part of the assessment and care planning process. 7 Fairmile Drive DS0000070272.V356255.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had identified and understood how to support people in the best way that gave them choices and control in a safe environment. EVIDENCE: From the information gathered from people, their family and others the manager and/or deputy then works with the person and their family to develop a care plan that sets out what the person needs and how they want to be supported. The home’s Service User’s Guide describes how care plans will be developed using a person centred planning approach and will reflect what is important to the them and their family. People’s needs and support were clearly identified and changes reflected in their care plans. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 12 Several examples of care plans were looked at and these were found to be very detailed in areas such as personal care, communication and health needs. In particular the way that people’s personal care support and communication is described did reflect a person centred approach in that it was written as if the person was telling staff how they wanted to be helped. As the staff got to know people and to understand their needs then the care plan is reviewed and updated to reflect what the person can do and what support they actually needed. An example was seen where a care plan had been updated to reflect the development of a person’s skills in cooking. People come to stay at the home for short-breaks and before they return the manager and/or deputy contacts the person and their family to find out if there had been any changes in their health or support needs. Members of the staff team were invited to multi-agency meetings and reviews especially in relation to the younger people they support. The care plans seen placed a lot of emphasis and contained detailed information about the way that people communicate. In particular, how a person communicates their choices and decisions. Examples were seen where the care plan clearly highlighted the importance of offering a person a choice of clothes, of activity and routine and meals. Situations and behaviours that may cause a person and/or others concerns were identified before a person came to stay for a break. Examples of risk assessments were seen that had been written by the staff that looked at how a person would be supported safely in areas such as taking their medication, personal care, mobility, managing their personal monies, health problems such as epilepsy and behaviours that could be seen as a challenge to staff and other people. It is recommended that staff review those situations where they intervene and offer support to maintain people’s safety and make sure that this is formally recorded through the risk assessment process. 7 Fairmile Drive DS0000070272.V356255.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): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported to maintain the lifestyle and routines that they experience in their family home. EVIDENCE: The majority of people who come to stay already have a routine of activities that would involve attending an education service. The staff continued to support people to attend school and college. Before a person comes to stay the manager or deputy would have visited them at their home and found out about what social and leisure activities they enjoy, their interests, likes and dislikes. Samples of these assessment documents were seen and found that they contained detailed and person centred information about what the person actually likes to do. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 14 People’s care plans did not fully reflect what people enjoyed doing although this information had been gained through the assessment process. For example, the staff team knew that several people enjoyed sensory stimulation but there was no activities/facilities around this. Also, the staff team was sufficient to be able to provide the level of support people need to go into the community and access social and leisure activities. The social and leisure activities that people did during their stay would be recorded and examples were seen where people went walking in the local community, to activities such as the cinema and on day trips. It is recommended that the social and leisure activities that people become involved in both at home and in the community be clearly recorded and evidenced. People’s cultural and religious were discussed with them and their family before coming to stay at the home. Several examples were seen where issues such as nutrition, activities and personal care had been identified as culturally important to the person and their family and the relevant support provided. People come to the service for a short-break from their family carers but family can come and visit at any reasonable time. People’s routines were based on the existing routines that they already had. Activities such as attending school, college and specialist day services were supported by staff. Before and during people’s stay at the home information is gathered by the staff about what people like to eat, their nutritional needs and support. Several people were tube fed and staff had received training in providing this level of support and how to respond to difficult situations. When people come to stay they go shopping with staff support and buy the foods that they like to eat. Where possible people help with cooking their meals. Mealtimes are based on when the person wants to eat and not when convenient for staff or according to fixed routines. 7 Fairmile Drive DS0000070272.V356255.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies, procedures and working practices were in place that meant that people’s personal and healthcare needs were supported. EVIDENCE: Each person who comes to stay at the home has clear and detailed information and guidance on how to provide personal care support in the way that the person wants. Some examples were seen and it was found that they reflected a person centred approach in that the guidance read as though the person was telling a staff member exactly how they wanted to be helped, how to give them choices and how to communicate effectively. People who have additional mobility needs have access to the aids and equipment they need such as tracking and mobile hoists and bathroom/shower aids. The manager/deputy manager carries out a moving and handling assessment for each person and support guidance is developed that explains to staff how the person wants to be helped. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 16 People’s health needs had been identified through the pre-admission assessment. Guidance for supporting health needs such as epilepsy and tube feeding had been developed and health services had been consulted and involved where needed. Each person has a medication profile that records the medication people require and any other medication needs such as for administering medication through a tube feed. Before a person comes to stay the family are contacted to make sure that any changes are recorded in the profile and staff aware of the changes. The medication received and administered was recorded and an audit system was in place to check that people had been given the medication that they need. Staff sign the record to show that medication had been administered but a few examples were found where staff signatures were missing and this had not been picked up by the auditing system. It is recommended that the audit system be reviewed and updated to make sure that errors were being picked up promptly. It is recommended that the recording sheets used for the medication administering and auditing be reviewed to make sure that they reflect the short-break services needs. Staff had undertaken training in medication administration by the local pharmacist and had been assessed as competent by the manager through the home’s own training programme. 7 Fairmile Drive DS0000070272.V356255.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team were aware of the procedures and practices to keep people safe and free from harm. EVIDENCE: A formal Complaint Policy and procedure sets out the steps and timescales for making a formal complaint. A copy is made available to people and their families before coming to stay for a short-break. In addition, the Service User’s Guide sets out a more person centred procedure for people to follow if they have any concern or worry. Each person has a support plan for helping them raise their concerns and worries. This sets out how a person would communicate if they were feeling sad, worried, scared or angry. An example of a communication support plan was seen and found it to be detailed and person centred in that it described how the person would let staff know how they feel through words, noises and actions. A copy of the local multi-agency adult and child protection procedures was available for management and staff to follow. The staff team also followed their own policy and procedures. Staff had attended Child Protection training because it supported young people under 18 years of age, but not Protection of Vulnerable Adult (POVA) training. It is recommended that the staff team undertake POVA training. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 18 The manager was able to clearly describe the steps they would follow in the event of an incident or allegation of abuse/harm towards a young person on a short-break. Staff followed a clear procedure for looking after and helping people with their personal monies and spending whilst on a short-break. Records of spending and the receipts were seen. However, completed sheets were normally returned to people’s families at the end of their stay. This meant that there was no audit trail maintained at the home. 7 Fairmile Drive DS0000070272.V356255.R01.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a warm, comfortable and homely environment that is safe and meets their needs. EVIDENCE: The short-break service is set in a domestic house on a residential estate. The communal space is well decorated and furnished and offers flexibility with a number of rooms that people can use. The bedrooms are also well decorated and furnished with a ground floor ensuite bedroom that has been adapted with a tracking hoist and accessible shower room. The laundry facilities were enough to cope with people’s needs and there was sufficient protective aids and equipment to provide staff with what they need to keep the home hygienic and free from infection. 7 Fairmile Drive DS0000070272.V356255.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): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are supported by a staff team in sufficient numbers and who have the necessary skills and knowledge. EVIDENCE: The staff team consists of the manager, deputy manager, a senior support worker and three other support workers. Between 7am and 9pm there are always at least two staff on duty and often two staff up to 11pm and a member of staff sleeping in overnight. Two of the staff team had achieved the NVQ Level 2 in adult care. The whole team were currently undertaking the NVQ Level 3 in children and young people. At the time of the site visit only one person was staying and a member of staff was supporting them. The person had no verbal speech and so was not able to comment on their experience using the short-break service. The interaction between the person and staff was seen as positive with the staff member talking to the person, asking them about choices and offering chances to go for walks. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 21 The recruitment of staff is organised through the main organisation that own and manage the service. Their Human Resources department arrange the adverts and then send the completed application forms to the manager who decides who to call for interview. They undertake the interview and decide who to employ. Samples of references and application forms were seen and relevant Criminal Record Bureau certificates. The service uses the Protection of Vulnerable Adults (POVA) First service to allow staff to start work before the certificate was available. The manager was clear on the conditions under which staff had to be supervised during this period. The staff team had participated in a comprehensive training programme. The two week Induction programme included core skills and was undertaken before the staff member came to work at the home. Further training was undertaken on site and from external providers in areas such as medication, child protection, health and safety and other general and specialist training relating to supporting learning disabled people. To show that the staff member understood and knew how to apply the training they had participated in the manager uses a system of competence assessment. This is an ongoing process where staff are observed and asked about their work. The manager would then decide when that staff member was competent and use the recording system to evidence this. This system was used throughout the staff members’ career and examples were seen where staff had gone through various competence assessments. This is considered to be an example of good practice and is commended. 7 Fairmile Drive DS0000070272.V356255.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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and health and safety systems were in place to keep people safe and to allow them to express their views on the service. EVIDENCE: The registered manager has over six years of management experience in social care services with learning disabled people. She has an NVQ Level 4 in Management and is currently undertaking the NVQ Level 4 in Care. She is aware that she needs to undertake the Registered Managers Award qualification. The manager spends 16 hours on the staff rota supporting people and 24 hours undertaking her operational management role. The manager was knowledgeable about the direction and aims of the service and the quality of service that people needed. She appeared open and honest 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 23 and comments from staff, in the surveys we sent, were positive about her attitude and availability. Regular individual staff supervision and team meetings are held to share information and keep people informed. The main organisation that runs the service has a structured and in-depth quality assurance system that looks at operational policies and procedures as well as staff practice. Information would be gathered from people, families, staff and other relevant people to gain their views about the service. At the time of the site visit there was no completed report for the service but examples were seen from other services the organisation operates. A senior manager visits the service every four weeks to talk to people and staff to find out how the service is running. The manager was not aware if this manager records these visits. Unless recorded elsewhere under regulation 26 of the Care Home Regulations, it is recommended that these visits were recorded as part of the quality assurance process. The manager was aware that many of the people they supported had limited verbal communication and completing questionnaires would not be appropriate. It is recommended that the service look at different ways that people can express their views of the quality of the service to allow then to develop an action plan for the service. The manager and staff team carry out regular health and safety audits on the environment and facilities in the home to make sure that they are safe. Monitoring of temperatures for hot water sources, fridges and freezers were being maintained. All staff had undertaken training in health and safety, food hygiene and fire safety. The fire log was seen and found that the required checks were being carried out and recorded to make sure that all the equipment was working correctly. An annual fire risk assessment had been completed and the fire evacuation procedures had been carried out for every person. The procedures involved removing people from the building. It is recommended that the local Fire Officer be contacted to clarify that the fire evacuation plan meets the needs of any relevant legislation, guidance and the needs of individuals. 7 Fairmile Drive DS0000070272.V356255.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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 34 3 35 4 36 X 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 25 NA 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 YA23 Regulation 17(2) Requirement A record of all people’s spending transactions must be maintained by the home so that an audit trail is maintained. Timescale for action 15/02/08 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 YA2 Good Practice Recommendations It is recommended that all information gained through the pre-admission meetings and visits be clearly recorded and used as part of the assessment and care planning process. It is recommended that staff review those situations where they intervene and offer support to maintain people’s safety and make sure that this was formally recorded through the risk assessment process. It is recommended that the social and leisure activities that people become involved in both at home and in the community be clearly recorded and evidenced. It is recommended that the audit system be reviewed and updated to make sure that errors are being picked up DS0000070272.V356255.R01.S.doc Version 5.2 Page 26 2 YA9 3 YA13 YA14 4 YA20 7 Fairmile Drive promptly. It is recommended that the recording sheets used for the medication administering and auditing be reviewed to make sure that they reflect the short-break services needs. 5 6 YA23 YA39 It is recommended that the staff team undertake POVA training. Unless recorded elsewhere under regulation 26 of the Care Home Regulations, it is recommended that visits are recorded as part of the quality assurance process. It is recommended that the service look at different ways that people can express their views of the quality of the service to allow then to develop an action plan for the service. 7 YA42 It is recommended that the local Fire Officer be contacted to clarify that the fire evacuation plan meets the needs of any relevant legislation, guidance and the needs of individuals. 7 Fairmile Drive DS0000070272.V356255.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Regional Contact Team 3rd Floor Unit 1, Tustin Court Port Way Preston PR2 2YQ 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. 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