Care Home: Breakaway

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What the care home does well The care home provides guests with a warm and homely environment that is spacious and fully equipped to meet their needs. Visitors to the home are made to feel welcome. Food provided to guests is of a good quality and comments from guests relating to meals provided, was positive. There is a varied menu and various alternatives are available if required. People at the home are supported to lead an active life, to undertake a variety of activities, which meet their individual needs according to their personal preferences and to use the local community.Staff at Breakaway are motivated and committed to provide a good service to the people who utilise the service. Staff, have a good rapport with guests and interact well. The service is well run and managed. The service continually strives to implement new innovative ways to communicate with guests and for them to interact effectively within the confines of the home. The management team of the home and staff are forward thinking in their approaches to care practices and endeavour to provide an excellent service to guests, which is personal and meets their needs. The needs of individual people are clearly documented, with clear guidelines for staff as to how to meet these. What has improved since the last inspection? Requirements highlighted following the last inspection have been addressed and dealt with. This refers specifically to the devising and implementation of PRN (as and when required medication) protocols, improvements to the care planning and risk assessment processes and regular supervision for support staff. The manager has been approved by us to become the registered manager of the service. What the care home could do better: As part of good practice procedures, undertake regular competency assessments for those people who administer medication to guests. This will ensure that staff, remain competent and able to administer medication safely to guests and in line with regulations. CARE HOME ADULTS 18-65 Breakaway 23 Park Lane Aveley Essex RM15 4UB Lead Inspector Michelle Love Unannounced Inspection 28th July 2008 09:00 Breakaway DS0000018070.V370401.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 Breakaway DS0000018070.V370401.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. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breakaway Address 23 Park Lane Aveley Essex RM15 4UB 01708 861520 01708 868857 breakaway@east-living.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) East Living Limited Andrew John Williams Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service category: Care Home only. Service user categories: learning disability and physical disability. Maximum number of registered places: 4 (both sexes). Placements must be arranged to ensure that the two categories of service users (learning disability and physical disability), are not accommodated together in the home for the same period of short-term care. The home is to provide short-term care for periods of no longer than four weeks at a time. 10th August 2007 5. Date of last inspection Brief Description of the Service: Breakaway is owned and managed by East Living Ltd. The property is detached which has been adapted and refurbished as a care home to provide respite care for up to four adults with a learning or physical disability. The home is situated close to local amenities with good bus and train links to the area. A vehicle provided with a tail lift is available and is used regularly for the benefit of guests to give them easier access to the local community and surrounding area. The accommodation, which is situated at ground floor level, includes four single bedrooms, a lounge and dining room, kitchen, bathroom and shower facilities. The accommodation and facilities have been specifically designed for disabled people. There is a large garden with a patio area to the rear of the property and off-road parking to the front. Information about the home is made available to prospective guests in the Statement of Purpose and Service User’s Guide. The current service charge for a one day and night stay is £399.50 per person. This is a standard rate and is subject to variation to accommodate need. Guests bring in their own pocket money to cover any additional expenditure such as hairdressing, toiletries and chiropody. Breakaway DS0000018070.V370401.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. This was an unannounced key inspection. The visit took place over one day and lasted a total of 8 hours, with all key standards inspected. Additionally, the manager’s progress against previous requirements from the last key inspection was also inspected. Please note that throughout this report, the people who access this service are referred throughout as `guests`. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document detailing what the home does well, what could be done better and what needs improving. As part of the process a number of records relating to guests, support staff and the general running of the home were examined. Additionally a full tour of the premises was undertaken, guests and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the site visit, surveys for relatives, staff, care managers and healthcare professionals were forwarded to the home. It was disappointing that no surveys were received from relatives, care managers or healthcare professionals. However 9 staff surveys were returned. The manager, deputy manager, senior and other members of the staff team assisted the inspector on the day of the inspection. Feedback on the inspection findings were given throughout and summarised at the end of the day with both the manager and deputy manager. The opportunity for discussion and/or clarification was given. What the service does well: The care home provides guests with a warm and homely environment that is spacious and fully equipped to meet their needs. Visitors to the home are made to feel welcome. Food provided to guests is of a good quality and comments from guests relating to meals provided, was positive. There is a varied menu and various alternatives are available if required. People at the home are supported to lead an active life, to undertake a variety of activities, which meet their individual needs according to their personal preferences and to use the local community. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 6 Staff at Breakaway are motivated and committed to provide a good service to the people who utilise the service. Staff, have a good rapport with guests and interact well. The service is well run and managed. The service continually strives to implement new innovative ways to communicate with guests and for them to interact effectively within the confines of the home. The management team of the home and staff are forward thinking in their approaches to care practices and endeavour to provide an excellent service to guests, which is personal and meets their needs. The needs of individual people are clearly documented, with clear guidelines for staff as to how to meet these. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 7 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 Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective guests can expect to be properly assessed prior to admission and assured that their care needs can be met. EVIDENCE: A copy of the service’s Statement of Purpose and Service Users Guide was clearly displayed within the entrance hall of the home. This was seen to provide detailed information about the service so that prospective guests and their representatives can make an informed choice as to whether or not this is the right place for them. The Service Users Guide is compiled in an appropriate format for potential guests (written/pictorial). The Annual Quality Assurance Assessment (AQAA) details that work is in progress to update both documents into an audio format. There is a new formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective resident’s needs. In addition to the formal assessment procedure, supplementary information is sought from the individual resident’s placing authority and priority is given to those people who live within the Thurrock area and who wish to access the service. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 9 On inspection of two care files evidence showed that pre admission assessments were completed by the management team of the home prior to the person’s admission. Information recorded was observed to be detailed and informative and included evidence that prospective people are given the opportunity to visit the home prior to admission and to undertake a period of transition dependent on their needs e.g. lunch/tea visits, overnight or weekend visits. The AQAA details that the service has started work on looking at transition visits for proposed new guests who are moving up from within children’s services. The pre admission assessments showed that this process is conducted with the prospective guest and their member of family/representative. Two guests and one relative confirmed to the inspector that they had visited the service prior to admission and had been provided with sufficient information so as to make an informed choice as to its suitability. Staff surveys returned to us confirmed that staff, are provided with sufficient and up to date information about individual residents. One recorded, “We are always provided with detailed pre assessments for our guests at Breakaway. From these pre assessments and consultation with the service user/families/carers we are able to build a comprehensive care plan”. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests can be safe in the knowledge that their individual care needs will be clearly recorded and met by support staff. EVIDENCE: There is a formal care planning process in place so as to ensure that the staff team are able to meet the prospective resident’s needs. At this site visit, 2 care files were examined and these were seen to be comprehensive and informative, detailing the person’s individual care needs and how staff are to meet these. It was evident that the management team of the home and staff have a good understanding of person centred care and guests care files are used as a working document. In addition to the care plan, each file contained a `grab card` for quick reference, detailing important specific information, which could be used in an emergency. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 11 For those guests who have utilised the service previously there is a sheet, which records any new information/change of needs since their last stay, and this is compiled with the guest and their member of family/representative. The care planning format was easy to follow and information was easily accessible and clearly laid out. There was sufficient information to show that care files are regularly reviewed and updated. The `document review sheet` was seen to contain information relating to individual’s routines and to provide a good snapshot` of information about the person. This is seen as particularly beneficial for newly appointed staff and/or agency staff deployed to the service. The AQAA details that care plans are being developed to incorporate outcome measures. The service recognises that this is difficult to undertake for those people who only stay at the service one day every month. All team members contribute to the care planning process. Risk assessments were devised for all identified risk areas and included information for staff as to how these were to be minimised. The manager and deputy manager advised the inspector that a new format was introduced in June 2008 and includes information/guidance for staff and guests as to why risk assessments need to be completed and devised. After every stay staff complete a summary of the guests stay, detailing how this went and if any problems were encountered. This provides the management of the service with vital information as to what works well and areas, which need to be looked into so as to continually improve the service. Three guests spoken with on the day of the site visit confirmed to the inspector that they found staff to be very supportive and had a good understanding of their individual care needs. The rapport between staff and guests was observed to be positive and staff demonstrated a good understanding and awareness of guests care needs and how they wished to be supported. Guests also advised that they are enabled/empowered to make choices and to exercise control over their lives with the support from staff e.g. rise when they wish to/go to bed when they choose, choice of whether or not they participate in activities. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests can be assured that their social care needs will be met and that they will receive a varied diet that meets their needs. EVIDENCE: Of those care files examined information recorded included a planned activity programme for individual guests. Wherever possible existing day care arrangements and further education classes are accommodated when guests have respite at the service. One guest advised the inspector that they had recently enjoyed a visit to the Tate Modern in London and attended a BBQ and themed fancy dress party during their stay. The care file for one person recorded that during their stay they participated in a variety of activities both `in house` and within the local community and Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 13 these included: arts and crafts, head massage, facial treatments, board games, watching films, visiting local shops and parks. It was also positive that guests are encouraged to have friends visit and on the day of the site visit, one guest was noted to have a visitor from another local service. Guests also spoken with confirmed that they also enjoyed the opportunity of being able to participate within the daily routines of the home. The manager and deputy manager of the home spoke enthusiastically about plans to implement by January 2009, a new total communication multimedia interactive service for guests. This will include a number of touch screens (plasma screens/video projection) displayed throughout the scheme offering guests the opportunity to enjoy an `interactive experience` of themed sensory packages, orientation programme to assist with mobility around the scheme, internet access, education for IT (Information Technology), educational games, interactive quizzes and audio and video information relating to trips out etc. This will enable guests who use the service to develop new skills during their stay, to give the person control of their environment e.g. colour of their surroundings, what they wish to watch on the television and the sounds they may like to hear and the ability to communicate on a wider scale irrespective of their needs and disability. The AQAA details under the heading of `what we do well`, “We actively encourage a stimulating and meaningful lifestyle for our guests during their stay at Breakaway. Whilst we will always adopt valuable routines that may take place at home, we also have a wide choice of indoor and outdoor activities, which are planned in association with the guest and others as a group”. Staff surveys returned to us confirmed that a varied programme of activities is provided. Menus are planned and compiled by staff on the basis of seeing, which guests are due to visit the service the following week. Within each guests care file a list of their personal food likes/dislikes is recorded and is taken into account when planning the week’s menu. Both staff and guests advised that all sit down together to enjoy the main meal of the day and this is seen as a big social event. Guests spoken with confirmed that meals provided is plentiful and of good quality. The AQAA details under the heading of `our evidence to show that we do it well`, “ evidence of this can be found from parent/carer feedback/guest questionnaire and visual observation during mealtimes”. The AQAA details that it is hoped within the next 12 months to increase the interaction of preparation of meals and drinks for guests and for educational packages and training to be developed so as to enable guests to prepare their own meals. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 14 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. Guests who experience a period of respite at Breakaway can be assured of having their healthcare needs met. EVIDENCE: All guests have their own support plans in place detailing their healthcare needs and how these are to be met. Evidence was in place to show that these are reviewed and updated every time a guest visits the service. Both the manager and deputy manager advised the inspector that local healthcare provision/services utilised by Breakaway are good, but these are often underused as guests generally do not come in for respite if unwell. Medication practices and procedures were seen to be appropriate and recording on Medication Administration Records (MAR) satisfactory and up to date. To ensure safe medication recording, audits are undertaken regularly so as to identify any errors or mishandling of medication. Storage facilities were seen to be appropriate and secure, and each guest has an individual lockable facility for medication in their room. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 15 Guests wherever possible are encouraged to self-administer their own medication. A copy of the Royal Pharmaceutical Guidelines for Medication in Care Homes was evident and since the last inspection the medication policy had been reviewed and updated. Since the last inspection PRN (as and when required) protocols have been implemented and devised. A local procedure for PRN medication is in place, both in written and pictorial format. Evidence was available to indicate that staff had received training relating to the administration of medication. The manager was advised to consider regular competency assessments for those members of staff who administer medication to ensure their practice remains appropriate and they are competent to administer medication. Following the inspection, an assessment format to record the above was devised. Additionally where staff, have undertaken training relating to epilepsy/administration of rectal diazepam, confirmation from the trainer that staff are deemed competent to undertake this task should be sought. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place to ensure that guests are safeguarded and that any concerns raised are dealt with proactively. EVIDENCE: A written/pictorial complaints procedure was evident and this was clearly displayed within the main reception area of the service. The manager advised that a new complaints logbook has been purchased but not yet implemented. No complaints have been received at the service since the last inspection. Guests, spoken with stated that if they should have any concerns, they would know who to speak to. One relative spoken with also confirmed that they were confident that should they have any issues, this would be dealt with appropriately. Since the last inspection one safeguarding issue had been highlighted. Following discussion with both the manager and deputy manager, it was evident that appropriate action had been undertaken and relevant agencies contacted. Policies and procedures relating to safeguarding were clearly available and the manager was aware that new recent guidance has been developed and issued. Staff spoken with demonstrated an awareness and understanding of safeguarding procedures and appeared confident about what they would do should a suspected incident arise. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 17 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. Breakaway provides a clean, comfortable and safe environment for guests, which meets their needs. EVIDENCE: A full tour of the environment was undertaken. All accommodation is provided on ground floor level and there is easy access for those people, who have a physical disability and/or who are wheelchair dependent. All areas of the home are spacious and suitably furnished for the numbers and needs of people who can use the service at any one time. Bedrooms are spacious and include en-suite facilities and storage for personal items/equipment. Appropriate equipment e.g. hoist tracking systems, handrails and assisted baths/shower facilities are available. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 18 The garden was observed to be well maintained and secure. A summer house is available within the garden area for guests use. The manager advised the inspector that in the future it is hoped that a hydra therapy pool for the service will be developed. On the day of the site visit the home was observed to be clean, tidy and odour free. No health and safety issues were highlighted at the time of the site visit. The deputy manager undertakes regular monthly health and safety checks and every 6 months a health and safety/welfare and environmental audit is completed. There was evidence of a fire risk assessment/risk factor matrix and records showed that fire drills are regularly undertaken and fire equipment serviced. Any maintenance issues are highlighted to East Living Head Office by staff, whereby jobs are prioritised and timetabled for between 24 hours to 30 days for completion. A gardener visits the service once fortnightly to cut the lawn and to see to the borders. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests who receive respite care can be assured an effective staff team will support them. EVIDENCE: Staffing levels at the home are flexible and calculated according to the numbers and needs of guests at any one time. The manager’s hours are supernumerary Monday to Friday, however these are also flexible and include evenings and weekends. On inspection of staff rosters, these showed there are sufficient staff on duty at all times for the needs and numbers of guests at all times. Where agency staff are utilised, the staff roster should also include their full names. The staff rosters showed that staff are having appropriate days off duty and are not working excessive hours. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 20 A random sample of staffing training records were inspected and these evidenced since the last inspection that some staff have received training relating to epilepsy awareness and safe administration of rectal diazepam, infection control, basic first aid, manual handling, food hygiene and safeguarding. Four members of staff are currently completing a distance learning course pertaining to equality and diversity. The manager advised that 11 staff have attained NVQ Level 2, 1 staff member has achieved NVQ Level 3 and 4 staff, are currently undertaking NVQ Level 3. Staff recruitment files were examined for 3 people. Records showed that the majority of records as required had been sought, however no proof of identification was available for one person, no copy of a job description was available for one person and no health declarations were available for the 3 people case tracked. The manager advised that the latter is held at the organisation’s head office. Records showed that staff working within the service are regularly supervised and supported in line with regulatory requirements and recommendations. Staff confirmed the above and advised that they receive both formal and informal supervision. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests, who come to Breakaway, benefit from a well managed service. EVIDENCE: The manager has been at Breakaway since September 2004 and has experience working in care for the past 8 years. The manager is close to completing the Registered Manager’s Award and there was evidence to indicate that he also undertakes training alongside his staff team in core subject areas and specialist training courses appropriate to the service user group. The manager has recently undertaken an interview with the Commission for Social Care Inspection to be formally registered, and is awaiting a new certificate to be issued to confirm he is the registered manager. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 22 The manager was able to demonstrate a clear understanding of the main principles and focus of the service. Staff spoken with confirmed that they felt the manager was approachable and the staff team supportive and caring of one another. The manager stated that he feels that his role/job is easy as a result of staff’s enthusiasm, motivation, continued commitment and dedication. The AQAA details, “we have a creative staff team that will go out of their way to implement new and refreshing ideas around the scheme, for the overall benefit of the guests”. One staff member spoken with advised, “staff morale within the service has always been brilliant with staff bringing a variety of different skills and experiences to the work place and there is a good skill mix and team spirit”. The manager advised that the `ethos` of the service is to provide a “service for people who require a period of respite/short term care within a safe and homely environment”. The manager advised that the staff team are 100 focussed on the guests and strive to ensure that people who use the service, experience all aspects of life. The AQAA details that at a recent award ceremony, Breakaway was called “the respite service of hotel standard”. The main aims of Breakaway are to provide a homely, relaxing atmosphere with an emphasis on quality to both guests and their families. Staff surveys returned to us recorded, “The team at Breakaway are always looking to improve the service we provide-never complacent. Even the best can improve or do things differently to make a difference” and “The service that Breakaway provide is excellent for the guests and the families”. The manager confirmed that he feels supported by the organisation and has a very good working relationship with his line manager. The manager stated that he receives regular formal supervision. The manager advised the inspector that he operates an open door policy enabling staff, guests, their families and other interested parties the opportunity to speak with him about any concerns they may have. A Quality Assurance System is in place to seek people’s views about the service provided at Breakaway. Guests are asked to complete an annual questionnaire and after each period of respite, they are asked to make comment about their stay. A spreadsheet has been devised to collate the results from the questionnaires and these are summarised every quarter. The AQAA details, “we are a fully transparent service and are always open minded to on going improvement and development”. The AQAA was detailed and informative and recorded areas of good practice and areas, which still need improvement. A random sample of health and safety records and certificates were examined and seen to be satisfactory. Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 23 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 3 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 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations As part of good practice procedures ensure that competency assessments for staff are undertaken to evidence their continued ability to administer medication to guests safely. Obtain confirmation from the trainer that staff, are deemed competent to administer rectal diazepam. As part of good practice procedures the staff roster should include the full names of staff, irrespective if they are bank and/or agency staff. 2 3 YA20 YA33 Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Breakaway DS0000018070.V370401.R01.S.doc Version 5.2 Page 26 - 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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