Care Home: Champion House - Leonard Cheshire Disability

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What the care home does well All members of the staff team are involved in making sure new people are helped to settle in to the home; for example, the head of housekeeping makes sure that there are flowers and a "Welcome" card waiting for the person in their room when they arrive. It was clear from everyone`s support plans that although there was a structure to the way their records were kept, each one was individual and reflected the issues for that person. People`s support plans are in their own rooms, thereby ensuring that they have ownership of the way they are being supported. The creative use of alternative means of communication, e.g., pictorial symbols, means that the support planning process is inclusive. The service looks at the balance between minimising risk and encouraging someone`s independence and personal choices. The service employs an Activities Co-ordinator and a Volunteer Co-ordinator, both of whom have a major part to play in making sure that people have the support they need to fulfil their social needs and leisure interests, within the house and outside in the wider community. The manager and staff listen to, and act on, the concerns expressed by others living in or working at the home, and take complaints seriously. The staff team are aware of the required standards of professional conduct and quality of care that people must have, and have shown willingness to "whistle blow" on poor practice. The involvement of people in the staff recruitment and selection process means that they have some real say in who comes to work with them. Staff are well trained and supported in their roles, which means that people are given support by a skilled team of people that understand their individual needs. Record-keeping and administration is good and the service knows its` responsibilities in this area. Accident recording in particular was very good, in that it also recorded "near miss" incidents, as a learning point. Where areas for improvement have emerged, the service recognises and manages them well. What has improved since the last inspection? There has been an excellent improvement in the standard of Individual Support Plans (ISPs) & Risk Assessments. These improvements and the flexibility of the staff mean that care is delivered in a much more personcentred way. What the care home could do better: The inclusion of people with complex care needs should be given greater prominence in social care planning, to ensure that they have the social opportunities that other people do. The manager has identified further areas for improvement in the building, including the installation of more overhead tracking and finding a workablesolution to the heavy bedroom doors that cause difficulty for wheelchair users to access without staff help. Some of the care files could benefit from the archiving of old material, so that it is easier for new staff, or agency staff, to locate the most up to date information. CARE HOME ADULTS 18-65 Champion House - Leonard Cheshire Disability Clara Drive Calverley Yorkshire LS28 5PQ Lead Inspector Stevie Allerton Unannounced Inspection 23rd March 2009 10:00 Champion House - Leonard Cheshire Disability DS0000001329.V374698.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 Champion House - Leonard Cheshire Disability DS0000001329.V374698.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. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Champion House - Leonard Cheshire Disability Address Clara Drive Calverley Yorkshire LS28 5PQ 01274 612459 01274 619221 mary.harrison@lc-uk.org www.LCDisability.org Leonard Cheshire Disability 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) Mary Louise Harrison Care Home 27 Category(ies) of Physical disability (27) registration, with number of places Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of srvice only Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Physical disability - Code PD, maximum number of places 27 the maximum number of users who can be accommodated is 27 Date of last inspection 16th February 2007 Brief Description of the Service: Champion House, a converted, extended stone built property, provides care for people with physical disabilities. Care is provided on two floors in singly occupied rooms, some of which are very spacious. The third floor of the home is used as a training area for staff. Each person has their own private room decorated to their own personal taste, and is provided with all necessary aids and adaptations to suit their individual requirements. The home is located in Calverley, a rural area mid-way between Leeds and Bradford. There are shops, a Post Office and supermarkets close by, and a large retail park is only a short drive away. Entry to the home is down a long private driveway and there are extensive gardens and a large car park. There are three lounge areas provided, one of which is set aside for those people who smoke. The home has a mini bus and a people carrier, which are used to take people out on arranged visits, activities and shopping trips. Meals are taken in the large dining area, which also has an activities area and a newly built kitchen that people can access. The care fees are determined by the level of personal and nursing care each individual requires. This information can be obtained from the manager. Additional charges are made for transport, hairdressing, newspapers, magazines, holidays, TV licences, reflexology, aromatherapy and horse riding. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior announcement and was done by one inspector over the course of one day. Before the visit, the information we already had about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection. This information was used to plan this inspection visit. The home completed their Annual Quality Assurance Assessment (AQAA) fully. The manager was not on duty; however, the Administrator made all of the information available that was needed on the day, and other key staff provided assistance throughout. Feedback was given to the staff at the home, and subsequently by telephone to the manager when she returned to work. Recommendations made during this visit can be found at the end of the report. Five people were case tracked, and other files were looked at. Case tracking is how we decide if people receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. We looked at written records, looked round the house and spoke to the staff as well as the people living there. Using this method, all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit, were able to be assessed. The inspection report is divided into separate sections for each outcome group, for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. The overall judgement for this home is that it provides an excellent service. What the service does well: All members of the staff team are involved in making sure new people are helped to settle in to the home; for example, the head of housekeeping makes sure that there are flowers and a “Welcome” card waiting for the person in their room when they arrive. It was clear from everyone’s support plans that although there was a structure to the way their records were kept, each one was individual and reflected the Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 6 issues for that person. People’s support plans are in their own rooms, thereby ensuring that they have ownership of the way they are being supported. The creative use of alternative means of communication, e.g., pictorial symbols, means that the support planning process is inclusive. The service looks at the balance between minimising risk and encouraging someone’s independence and personal choices. The service employs an Activities Co-ordinator and a Volunteer Co-ordinator, both of whom have a major part to play in making sure that people have the support they need to fulfil their social needs and leisure interests, within the house and outside in the wider community. The manager and staff listen to, and act on, the concerns expressed by others living in or working at the home, and take complaints seriously. The staff team are aware of the required standards of professional conduct and quality of care that people must have, and have shown willingness to “whistle blow” on poor practice. The involvement of people in the staff recruitment and selection process means that they have some real say in who comes to work with them. Staff are well trained and supported in their roles, which means that people are given support by a skilled team of people that understand their individual needs. Record-keeping and administration is good and the service knows its’ responsibilities in this area. Accident recording in particular was very good, in that it also recorded “near miss” incidents, as a learning point. Where areas for improvement have emerged, the service recognises and manages them well. What has improved since the last inspection? What they could do better: The inclusion of people with complex care needs should be given greater prominence in social care planning, to ensure that they have the social opportunities that other people do. The manager has identified further areas for improvement in the building, including the installation of more overhead tracking and finding a workable Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 7 solution to the heavy bedroom doors that cause difficulty for wheelchair users to access without staff help. Some of the care files could benefit from the archiving of old material, so that it is easier for new staff, or agency staff, to locate the most up to date information. 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. Champion House - Leonard Cheshire Disability DS0000001329.V374698.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 Champion House - Leonard Cheshire Disability DS0000001329.V374698.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): 1&2 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides people with a very good level of information about what it can provide, which helps them to make informed choices about where they live. People are only admitted after a full assessment of their needs, which makes sure that the service is suitable for them. The practice of welcoming new people with flowers and a card in their room demonstrates the staff’s commitment to helping people feel comfortable in their new surroundings. EVIDENCE: Information contained in the AQAA was verified during the inspection, looking at records and written information, speaking to people who live there and speaking to staff. Information available to people about the service can be produced in different formats when required, to meet the diverse needs of individuals. The service’s own multi-disciplinary team is included in the assessment process, e.g., Physiotherapist & Activities Co-ordinator. Case files contained a very good information checklist to be completed when someone is newly admitted, to ensure that all information required to be given Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 10 by the home has been, and that practical aspects of the admission are sorted out. This is completed by the member of staff and either the person themselves, or their representative; both parties sign it. Other members of the staff team are also involved in making sure new people are helped to settle in to the home; for example, the head of housekeeping makes sure that there are flowers and a “Welcome” card waiting for the person in their room when they arrive. There was evidence in the files for one of the people who were case-tracked that the staff team has a very sensitive approach to helping people make decisions about where to live, and that advocacy services are engaged to help people through this process. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been an excellent improvement in Individual Support Plans (ISPs) & Risk Assessments. People’s support plans are in their own rooms, thereby ensuring that they have ownership of the way they are being supported. The creative use of alternative means of communication, e.g., pictorial symbols, means that the support planning process is inclusive. People receive the help they need to make decisions about their lives and are assisted by the staff to take responsible risks as part of an independent lifestyle. EVIDENCE: We found evidence of people’s involvement in how their home runs, by way of resident meetings, held every 2 months. These are chaired and facilitated by the Volunteer Co-ordinator and the Activities Co-ordinator. The minutes that were seen contained some good information presented to the meeting by a staff member, informing them that a series of evacuation drills would be happening and seeking people’s co-operation in this important piece of staff Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 12 training. The minutes also provided good evidence of how people exercise choice. Five people were selected for case-tracking, with a wide range of care needs. ISP files contain an index at the front, directing staff and other professionals to the relevant part of the file for the information required. These are comprehensive, covering all aspects of a person’s life, and include a Personal Profile and Lifestyle Choices & Preferences section, outlining skills and interests, what input is needed from Volunteers and Occupational Therapists, and a risk assessment relating to social care. The section for Personal Care & Support Plans also contains relevant risk assessments and reviews. For some of the people we looked at, their social interests and activities were very prominent; others have much more need around physical nursing care and specialist input from other professionals. It was clear from everyone’s support plans that although there was a structure to the way their records were kept, each one was individual and reflected the issues for that person. Some excellent practice was seen in the use of authorisation forms for the sharing of information with other named people. This made it clear to staff what information may or may not be shared, with family members, for example. The use of pictorial symbols, seen in one file, was also excellent practice, ensuring that the person could be fully involved in drawing up their own support plan, which was written in the first person. Each file also contained a comprehensive list of risks to be considered, which again varied for each individual. There was evidence through risk assessment documents that the service looks at the balance between minimising risk and encouraging someone’s independence and personal choices. Bathing in privacy was a good example, also the way that smoking and alcohol are managed. It was clear in the support plans where people needed the assistance of advocates or solicitors, for example, an appointed Power of Attorney for managing their finances. The ISP files refer to equality and diversity and address any needs identified, for example, through gender, age, religion or belief, and disability. Champion House - Leonard Cheshire Disability DS0000001329.V374698.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, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to identify their goals, and achieve them, with as much or as little assistance as they need. This means that people take part in meaningful and fulfilling activities of their own choice. The inclusion of people with complex care needs should be given greater prominence, to ensure that they too have the social opportunities that other people do. The menu is varied and provides sufficient choices for people, who report that they are satisfied with the food. EVIDENCE: The service employs an Activities Co-ordinator and a Volunteer Co-ordinator, both of whom have a major part to play in making sure that people have the support they need to fulfil their social needs and leisure interests, within the house and outside in the wider community. An example was: one of the people who was case-tracked has been expressing a wish to attend church. He was supported to attend the previous Sunday and had enjoyed it. This person Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 14 has complex physical and nursing care needs, with detailed support plans in place, but was found to have no written social care plan. It was fortunate that he had made his needs known, as there was no formal mechanism in place to try to find this out. This was highlighted as a recommendation at the last key inspection. Volunteers have been recruited to lead specific sessions, e.g., baking, or to transport people to the places and events they want to go to. The minutes of the last residents’ meeting reflected the introduction of two student Occupational Therapists on placement for 7 weeks. People have opportunities to go on holiday, for example, 7 residents were going to Majorca in June along with 6 staff and volunteers. Some prefer short stays at centres such as Butlins, or have exchange holidays with people living in other Leonard Cheshire homes. There is a new adapted vehicle, which enables people to be transported, whatever their disability. There was evidence from the support plans and from speaking to people during the site visit that there is a good range of things that people are involved in: college courses, pub quiz nights, shopping, bowling, swimming, Horse-Riding for Disabled People, for example. One person has regular one-to-one time with a named supporter to help them get out into the community. People with hearing impairments are encouraged to use modern technology, such as laptop computers, to help them communicate. Volunteers support the home to maintain their garden, which recently won a silver medal from the Leeds in Bloom competition, presented at the Civic Hall. The service uses a Nutritional Risk Assessment Tool to identify people who are at risk of not receiving the correct nutritional intake; an Eating and Drinking Action Plan is then put in place. Some people have alternative means of feeding than by mouth, e.g., a P.E.G. (Percutaneous Endoscopic Gastrostomy) tube. One person who was case-tracked has a P.E.G. fitted and is fed by this method overnight; however, they still enjoy mealtimes and can take small amounts of food by spoon. They have a very detailed support plan about their risk of choking, which states that volunteers are not to support them with eating. Another person we case-tracked is able to make their own hot drinks in the kitchen area, their risk assessment stating how this should be supervised. We saw the evening meal, which included a special cake for one person’s birthday. The menu was written up on the whiteboard so that everyone knew what the meals were that day. The menus showed a good range of choices. People said they enjoyed the meals, particularly the home-baking. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual Support Plans clearly record people’s personal and healthcare needs and detail how they are to be delivered. This ensures that staff know at all times what the main issues are for people and what they must do to meet their needs. The improvements made to the ISPs and the flexibility of the staff mean that care is delivered in a much more person-centred way, and the manager has identified areas in which practice could be further improved. Medication is managed well, which makes sure that people get the treatment they need at the right time. EVIDENCE: Case tracking provided evidence that the information provided by the AQAA was correct. People with complex needs have relevant support plans in place, arrived at through multi-disciplinary assessment. As noted previously, Nutritional Assessment Tools are used to identify those people who need extra assistance with their diet; for example, overnight feeds via naso-gastric tube or PEG feeds. There was evidence that people get Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 16 referred for specialist input, e.g., from Speech & Language Therapists, Dieticians, Physiotherapists, etc. The in-house Physiotherapists also provide guidance to the staff on how best to move someone, e.g., 3 – 4 people required to achieve the best postural position in a moulded wheelchair seat. Notes from the Physiotherapy team meetings were seen, with recommendations to the manager that 2 or 3 recliner chairs should be obtained, to alter people’s posture at different times during the day. Staff meeting minutes provided evidence that general care issues are discussed on a regular basis, to guide the staff in continually improving practice. People said they felt they were treated with dignity and their privacy was respected. Observations of staff interventions with people confirmed that they had good awareness of privacy and dignity and were knowledgeable about how each person wants to be supported. Accident records were seen, which had space to identify lessons learned that might be useful to other services within the organisation, very good practice. Detailed risk assessments and risk management plans are in place for each person who presents health related risks, such as epilepsy and choking. The service uses a pre-dispensed system of medication management, provided by Boots’ chemist. This was checked at random and no anomalies were found. We also followed up the storage and recording of some controlled drugs, which were found to be managed correctly. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The way that complaints are managed gives people confidence that they are listened to and that their views matter. There are effective mechanisms in place for worries and concerns to be reported and practice has shown that people are kept informed of the process throughout, making people feel safe and supported. EVIDENCE: The manager and staff listen to, and act on, the concerns expressed by others living in or working at the home, and take complaints seriously. The manager states that prevention is important, but that the service learns from its’ mistakes. The complaints file contained good records of action taken to address problems, and also contained compliments too. The “Have Your Say” leaflet has been re-issued to everyone that has contact with the service. The service notifies us of incidents that have given rise to disciplinary action and the outcome of such investigations. The staff team are aware of the required standards of professional conduct and quality of care that people must have, and have shown willingness to “whistle blow” on poor practice. Records showed that appropriate checks and balances are in place regarding people’s finances. The service submits quarterly returns to the organisation regarding POVA (the Protection of Vulnerable Adults) and complaints. Information on these was Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 18 good. It showed that there are not very many complaints or safeguarding issues, but they are always treated seriously. People said they felt comfortable about raising concerns. The service is actively seeking independent advocacy for someone who has difficulty in making their views known. Champion House - Leonard Cheshire Disability DS0000001329.V374698.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, 29 & 30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This is a very well maintained, well equipped and attractive home. The physical environment of the home provides very good standards for the people who live there, reflecting their individual needs and keeping people safe. The manager also identifies areas where further improvements could be made and plans for people’s future needs. This makes sure that the building is fully able to meet a wide range of physical disabilities. EVIDENCE: Management of the systems to keep the building safe and clean is devolved to the heads of housekeeping and maintenance. The head of housekeeping is also the Health and Safety link, providing general Health and Safety and Infection Control training to the staff. The laundry was seen and found to be well organised. Protective equipment for staff was at hand in various locations throughout the building. The kitchen Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 20 is going to be refurbished, which is due to begin in April. A recent Environmental Health report graded it 5* for the good practices in place regarding safe food storage, hygiene and record keeping. The physiotherapy/treatment room is very well equipped, as are the bathrooms. A lot of the bedrooms now have overhead tracking for hoists, and all of the bedrooms seen were well equipped, but also personalised. Everywhere was clean. The head of housekeeping said that room audits were carried out, focussing on infection control and general tidiness. The equipment that was stated in the support plans as being needed to meet people’s needs was found to be in place in the relevant bedrooms, e.g., a profiling bed, pressure relieving mattress, evacuation sledge stored on the underside of the bed. Records of fire evacuation drills demonstrated good team work from the staff, ensuring a safe and speedy evacuation. Volunteers give good support to the maintenance of the garden, as well as people on Community Service placements and it has won awards within the local community. The manager has identified further areas for improvement in the building, including the installation of more overhead tracking and finding a workable solution to the heavy bedroom doors that cause difficulty for wheelchair users to access without staff help. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment procedures show that there is a very good understanding of equality and diversity throughout. The organisation follows good practice and protects the people living at the service from those who may be unsuitable to work with them. The involvement of people in the recruitment and selection process means that they have some real say in who comes to work with them. Staff are well trained and supported in their roles, which means that people are given support by a skilled team of people that understand their individual needs. EVIDENCE: We sat in on the staff handover at 2:30pm. Every person in the home was mentioned – how they were, what they were doing on that day – and staff on the afternoon shift were allocated areas for work. The staff rotas showed that on a morning shift there was a minimum of 5 staff plus one “meal support” volunteer (or 6 staff); afternoon shifts consist of 4 plus one “meal support” (or 5 staff). There is a qualified nurse on every shift, day and night. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 22 At the time of the inspection visit, 2 of the nurses were on sick leave. Staff showed flexibility in the way they cover shortages on the rota and the home tries not to use Agency nurses unless they really have to; even then, they try to get the same nurses from the Agency, for continuity for the people living there. The staff spoken to during the inspection demonstrated a thorough understanding of the needs of the people they support. They said that they had a good level of training and felt they were supported well in their various jobs. Some had taken on new responsibilities, which had increased their pride in their job. There is a system in place for formal supervision of the staff, which includes looking at training and personal development. The information provided by the manager prior to the inspection showed that 77 of the care staff have qualifications at NVQ level 2 or above. Minutes of team meetings were seen. Some of the meetings are job role specific, e.g., physiotherapists, night staff or nurses, and there are full staff team meetings as well. Personnel files for two of the more recent recruits were seen. They contained evidence that people living at the service are included on interview panels, and also that some training is given prior to the staff member working their first shift. Induction training covers all of the mandatory areas. The manager uses a training matrix to identify training needs and plan ahead. She has identified a need to recruit more male carers if possible, as at the time of inspection there was only one. This would improve choice for the men living at the home. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is managed well to achieve the desired outcomes for the people living there. The policies, procedures, written records and quality measures in place make sure that people’s health safety and well-being are promoted and protected. EVIDENCE: We looked at a sample of regulatory and operational records and written policies, which included: • the Statement of Purpose • Individual Support Plans and daily records • accident records • medication records Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 24 • • • • • • • • • menus food hygiene records complaints records fire safety records staff personnel records training records minutes of staff meetings staff rotas minutes of residents’ house meetings. All were readily available, despite the manager not being on duty, and other staff were able to answer questions that arose. No anomalies were noted in the records and some very good practices were seen. The accident recording in particular was very good, in that it also recorded “near miss” incidents, as a learning point. The manager also provided a lot of information prior to the inspection in the AQAA, which was verified on site by the evidence gathered during the course of the visit. The administrator was very helpful in making sure that all of the records we needed to see were available. She said she had worked at the service for 15 years and had seen great improvements in the quality of care during that time. She felt that the training provided by Leonard Cheshire Disability was good, and that the present manager had introduced new practices that resulted in a much better quality of life for people. The introduction of a Volunteer Co-ordinator for 18 hours per week, with a remit to recruit and support volunteers to work within the home, has resulted in people receiving more one to one time, whether this be for accessing the community or for helping them to eat. There has been a marked increase in the involvement of people living at the home in the decision-making processes that affect them, and in the internal audits that are carried out to measure quality. The organisation arranges for a visit to be carried out every month, in accordance with Regulation 26; the records showed that this is not always carried out by staff from Leonard Cheshire Disability – it could be an external volunteer or a service user from another area. Some of the care files could benefit from the archiving of old material, so that it is easier for new staff, or agency staff, to locate the most up to date information. Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 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 4 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 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 4 3 X 4 X 4 X 3 3 X Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 26 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 YA14 Good Practice Recommendations The manager should make sure that the leisure needs of residents who have complex needs are fully considered and addressed. The manager should explore workable solutions to the heavy bedroom doors that cause difficulty for wheelchair users to access without staff help. Some of the care files could benefit from the archiving of old material, so that it would be easier for new staff, or agency staff, to locate the most up to date information. 2. YA24 3. YA41 Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Champion House - Leonard Cheshire Disability DS0000001329.V374698.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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