Care Home: Dalvington

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What the care home does well Information is available about what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Dalvington helps people to do things they like to do and to try new activities. Dalvington looks after people well and writes down what help everyone needs. People are helped with their medical appointments, and staff work well with other professionals and agencies to help people keep well. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Dalvington makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Dalvington. People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly homes. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Dalvington. What has improved since the last inspection? Care plans have been improved and are easier to record information. Care plans are now being reviewed regularly. Risk assessments now have guidelines for staff to follow where needed. People can use computers that have been fitted in the IT suite. People can choose to do their own food menus on the computer. All medication is now stored properly. Some parts of the buildings have been redecorated. A new kitchen has been fitted in The Willows. A staff training record is now kept up to date. What the care home could do better: Complete the hospital booklet for each person. Help people to be more involved in managing their own money. CARE HOME ADULTS 18-65 Dalvington 146 Lower Howsell Road Malvern Worcestershire WR14 1DL Lead Inspector Dianne Thompson Unannounced Inspection 30th July 2008 09:30 Dalvington DS0000018646.V369378.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 Dalvington DS0000018646.V369378.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. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dalvington Address 146 Lower Howsell Road Malvern Worcestershire WR14 1DL 01886 833424 01886 833684 malvernservices@efitzroy.org.uk www.efitzroy.org.uk Elizabeth Fitzroy Support 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) Sandra Ann Hibbert Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This service is primarily for people with a learning disability but may accommodate people who also have an additional physical disability 27th July 2007 Date of last inspection Brief Description of the Service: The registered provider of this home is the charity Elizabeth Fitzroy Support (EFS). A service is offered to a maximum of fifteen adults who have learning disabilities and some people may have a physical disability. Accommodation is divided into three units. Dalvington is the main unit. All facilities are on the ground floor and seven people with moderate to higher dependency needs can be accommodated. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. The Oaks is a separate house and can accommodate six people who are less dependent than those people living in Dalvington and more dependent than those people living in The Willows. The entire complex is registered as one establishment called Dalvington. The registered manager is Sandra Hibbert. The operations manager visits Dalvington monthly, on behalf of EFS. Mr Neil Taggart is the Director of Operations and the responsible individual. Details of the fees for the service are included in the Service Users Guide they range from £800-£1600 per week. This fee information was correct at the time of our inspection. The reader may wish to contact the service for up to date fee information. Dalvington DS0000018646.V369378.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 stars. This means the people who use this service experience good quality outcomes. This was an unannounced inspection visit to see what the service was like for the people who live at Dalvington. Time was spent talking to some of the people who live at Dalvington and some of the staff working there. We looked at some of the records, policies and procedures in the office. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Dalvington and the ways they plan to make the service better. We looked at parts of the premises. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: Information is available about what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Dalvington helps people to do things they like to do and to try new activities. Dalvington looks after people well and writes down what help everyone needs. People are helped with their medical appointments, and staff work well with other professionals and agencies to help people keep well. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Dalvington makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Dalvington. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 6 People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly homes. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Dalvington. 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. Dalvington DS0000018646.V369378.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 Dalvington DS0000018646.V369378.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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Policies and procedures are in place for assessing potential people to live at Dalvington. Information about the service included in a Statement of Purpose and Service User guide that is available for all enquirers and residents. The Statement of Purpose has been updated to reflect the change of manager and changes within the staff team as advised at the previous inspection visit. It is stated in the admissions procedure that full community care assessments are required and in addition Dalvington complete their own assessments. We saw that community care assessments had been completed for the files examined. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. The manager says in the service’s AQAA that ‘prospective service users have a gradual Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 9 introduction into the home over a period of time. This is agreed and assessed to meet their individual needs, and people who know them well are involved in their transition’. People are given an information pack containing a copy of the statement of purpose and service users guide on admission. The service user guide gives information about the service that people can expect, together with details about the fees, the complaints procedure and a copy of their contract with the service called ‘Agreement Between Us’. All staff are encouraged to be involved in the assessment process from introductory visits to focussed support, to the three monthly review and confirmation of the placement. Surveys confirm that information is shared about the service to help people contribute to decisions that involve their relatives. Dalvington DS0000018646.V369378.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, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. EVIDENCE: Care plans for two people were checked and both contained appropriate information about individual needs and how they are to be met. Care plans set out in detail the action to be taken by care staff. Care plans show that reviews are taking place on a regular basis, and this meets the requirement of Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 11 the previous inspection. A review of one of the care plans examined had been completed on 29th June 2008. Information in care plans cover all aspects of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. Details about the ways people communicate are provided. Communication is varied and care plans are made available in a range of formats that includes symbols and pictures. The service is working to a person centred approach to care planning and this is evident in the revised recording system. Care plans are being developed to focus on each person in an individual way, and include a pen picture entitled ‘this is me’ with information about important ‘people in my life’. Staff complete records with people who use the service to make sure everyone is involved as much as possible in their everyday lives and choices, including the running of the home. Each person is allocated a key worker to oversee his or her care. Key workers support people on a one-to-one basis and contribute to the care planning process. Key workers are currently supporting the development of the revised care planning process. Risk assessments are completed to keep people safe and now include additional support guidelines for staff to follow where this is needed. Completed risk assessments show dates for planned reviews and explore ways to make sure that people can be as independent as possible. The manager said that risk assessments and care plans are now completed on the computer, which makes updating information much easier. Surveys confirm that care given is what is expected or agreed with the service. Dalvington DS0000018646.V369378.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, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Dalvington are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. One person returned from a shopping trip and another person was getting ready to go to the hydrotherapy pool for a swimming session. Dalvington employs staff to plan and support daily activities. Each person has an individual activity plan that details any therapies people take part in such Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 13 as Music Therapy, Hydrotherapy, Physiotherapy, and Speech Therapy. A state registered music therapist provides music sessions and also provides people with regular reports on their sessions. The range of activities provided includes grocery shopping, places of interest, lunch out, countryside centre visits, Eastnor Castle, household tasks, personal shopping, and Snoezelen. Some people attend a local college. Individual engagement profiles are completed and give staff guidelines to support people with activities such as clearing the table after meals, making their bed, or personal laundry. The Computer Suite has been developed since the previous inspection and now provides people with the opportunity to use computers with various programmes of interest and skill level. The manager talked about the Service User Forums that some people are involved in, such as the Lichfield Forum and the Comet Advocacy Group. People are encouraged to speak out and have their say. Information from these sessions is fed back to the service to act upon through regional Management Meetings and Team Meetings. People are supported to have a week’s holiday each year. People can choose to have short breaks if they prefer or go out on day trips. Care records show that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirm that they are made welcome. The manager states in the service’s AQAA that ‘people are supported on home visits to see family, and also to keep in touch with friends who have moved on’. The service provides meals that are varied and nutritious, with different choices available where preferred. Snacks and drinks are available throughout the day. People are consulted about their choice of food and diets, and support is given for people who find it difficult to eat and need help. Eating and Drinking Guidelines to support each person are developed with the Speech and Language Therapist. The manager says the food budget has been increased and this has helped with planning menus that focus on healthier options. People are encouraged to be involved in meal preparation as much as possible. Fresh fruit salad prepared by residents and staff was an example of this. There are plans for people to do their own weekly menu’s using a computer programme designed to help with this. We saw a demonstration of this programme that allows people to make food, drinks and snacks choices from a variety of pictures. Dalvington DS0000018646.V369378.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, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Dalvington. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Dalvington has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: People who live at Dalvington have care plans that include their health action plan. These plans give information about personal care needs and the ways people prefer to be supported. Health action plans give detailed information about each person’s health needs and how they are to be met. Records show that all physical checks are completed where people have particular health related issues such as weight and physical functions. Annual ‘Ok Health Checks’ are completed for everyone. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 15 We saw the way information is used to make changes to each person’s support where it is needed, such as eating and drinking guidelines for one person that were reviewed in March 2008. People have good access to medical support through their Primary Health Care Team (PCT) as required. This includes a speech and language therapist, physiotherapist, dietician, dentist and doctors. A record of visits to the doctors or other medical professionals is kept. Physiotherapy routines include pictures to guide staff on how to provide support in a consistent way. We saw staff engage with people in a respectful way, making sure that dignity and self-esteem was important for each person. Although communication with people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. Surveys confirm that staff are ‘very caring’ and ‘look after people well’. A policy and procedure is in place for the administration of medication. Each person has a medical profile with their photograph to tell staff how they like to take their medication. All staff who are involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems which may occur. The manager states in the service’s AQAA that ‘all staff receive medical training and are assessed before they administer medication following the’ Elizabeth Fitzroy Support ‘(EFS) Policy’. ‘Only trained staff administer medication’. Medication is stored securely and given to people at the right time and full records are kept which show this. A medication sheet in each health action plan gives details of current prescribed medication. We saw in one person’s file a blank copy of a ‘Hospital’ booklet. This booklet is to provide easily accessible information should anyone need to stay in hospital. The manager was advised the booklet should be completed and kept up to date so it is ready should it be needed in an emergency. Dalvington DS0000018646.V369378.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, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints and to make sure that people who use the service are protected from abuse. EVIDENCE: Dalvington has a complaints policy and procedure in place which is accessible to people who live at the home and their relatives. The manager says the procedure ‘includes clear guidance on who to contact and how’. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the service’s AQAA that no complaints have been made to the service. We have not received any complaints or safeguarding concerns about Dalvington. The service has a complaints book that records both compliments and any complaints that are made. There are specific policies and procedures in place to guide staff on the protection of vulnerable adults from abuse and on ‘whistle blowing’ for staff. Staff receive training in abuse awareness, and staff training records confirmed this. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 17 The organisation is the appointee for financial matters for people using the service. We talked with the manager to see how systems could be developed so that people are more involved with managing their own money. Some people are supported to go to the bank to withdraw money to be more involved in dealing with money. The manager said that money and accounts for people living at Dalvington are audited each month as part of their regular monitoring process. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Dalvington enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: Dalvington is in a residential area of Malvern with access to shops, leisure centres and doctors surgery locally. The service has access to other recreational activities in the Malvern and Worcester area. Dalvington provides a service to a maximum of fifteen adults who have learning disabilities and some people who may have a physical disability. The manager states in the service’s AQAA that ‘four adapted vehicles are provided for people to go out and about and access activities and the local community. All drivers undertake Midas training, and they are assessed before they can drive vehicles. This is renewed every four years. People are also supported to use local transport’. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 19 Accommodation is divided into three units although the entire complex is registered as one establishment called Dalvington. The registered provider of this service is the charity Elizabeth Fitzroy Support (EFS). We looked at parts of the premises. Dalvington is accessible, comfortable and provides a homely environment for the people who live there. Dalvington is the main unit. All facilities are on the ground floor and seven people live here. The Willows is a first floor flat within Dalvington that accommodates two people to live more independently. The Oaks is a separate bungalow and six people live here. All units have separate communal rooms of lounge, dining room, kitchen, laundry, bathrooms and toilets. Some of the people who use the service were happy to show their bedrooms. All rooms are clean, tidy and well presented. The bedrooms are a good size, suitably furnished and personalised by people living at the home. One person has recently chosen a new carpet for their room. There is a call system for all units. There is a very well equipped sensory room that is available for everyone to use. Dalvington is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Training records show that staff are trained in procedures for the control of infection and health and safety matters. There is a schedule for routine maintenance and upkeep of the buildings. A support worker is currently employed part time for general maintenance and repairs to the buildings. Some communal areas and bedrooms have been redecorated since the previous inspection visit. There are plans to raise money for a conservatory for The Oaks. Scheduled work for the complex includes building a new porch over Dalvington front door, replacing carpets and furnishings in Dalvington and The Oaks. A new kitchen with new flooring has been installed in The Willows. New carpets have been fitted to the lounge and bedroom since the last inspection. The are plans for the spare room (which was previously one of the offices) to be converted into a family or visitors room. The previous office is now a wet room and provides spacious shower facilities. Dalvington DS0000018646.V369378.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, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Dalvington. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to make sure that everyone living at Dalvington is kept safe. EVIDENCE: Dalvington has a committed and stable staff team. People commented in surveys that they were generally satisfied with the service and the staff. Staff appeared to be enthusiastic and well motivated. Dalvington operates a recruitment policy and procedure where everyone completes an appropriate application form and makes sure that suitable references are obtained including one from most recent employers. The manager said that people who use the service ‘meet candidates at interview Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 21 and are involved in the recruitment process’. Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period. Staff records were examined for three people. All required information was seen and include confirmation of identity and suitable references. The manager confirms that all new staff complete thorough training to make sure they can meet the needs of people they support. All new staff have ‘a three week planned induction programme’ and this includes ‘time to complete first two (Learning Disability Qualification) LDQ Units. All new staff are expected to complete four LDQ Units’. Mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults is provided. All staff will receive training in communication methods provided by the local speech and language therapist. We saw copies of certificates for recent training courses completed that included makaton, Midas car and mpv training dated 27/2/08. The service has a training programme based on the individual training and development assessments for each member of staff. A record is maintained with dates of planned refresher courses identified on the training matrix. This meets a recommendation of the previous inspection. Four staff are currently completing their NVQ qualifications, two of these people working at NVQ level 4. Regular core team meetings are held monthly. Minutes are available and were seen during the inspection visit. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is well managed and staff receive the leadership and support they need. Elizabeth Fitzroy Support (EFS) monitors Dalvington in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Sandra Hibbert has many years experience working with people with learning disabilities. Sandra is qualified to Certificate in Management Studies and NVQ level 3 in care, promoting independence. She is currently completing the Registered Managers Award (RMA). Sandra regularly completes training relevant to her position as registered manager of Dalvington, including Fire Training for Managers, Infection Control and Communication. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 23 The manager said that ‘We have an open door policy’ and surveys confirm that people are made welcome and are able to talk to the manager and staff at any time. Management responsibilities are shared with two assistant managers. They are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Dalvington and the ways they plan to improve the service. The provider’s monthly visits are one of the ways that EFS monitors the service and how it is being run. These visits include interviews with staff and people living in the home. An audit of relevant parts of the service, including records, environment, complaints received, finance and safety is also completed. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of Dalvington’s quality assurance and monitoring system that is intended to form an annual development plan for the service. This report includes the views of people who use the service, stakeholders and interested parties. The manager states in the service’s AQAA that ‘REACH has been adopted as a Quality Assurance tool to monitor how we are doing, and how we can improve. These are available for people to read. Feedback is sought from people supported at the service, and other stakeholders on the quality of service provided’. Supervision of care staff covers all aspects of care practice, philosophy of care in the home and career development needs. Staff appraisals are completed annually, and records confirm that regular supervision takes place. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking mandatory health and safety training topics. The manager said that ‘staff undertake fire training, and fire scenarios are discussed at team Meetings. Staff and residents are involved in fire evacuations’. Generic risk assessments are in place. EFS complete an annual Health and Safety Audit and an action plan from this is provided. Dalvington DS0000018646.V369378.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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 25 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 YA19 Good Practice Recommendations The hospital booklet should be completed and kept up to date so it is ready should it be needed in an emergency. Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Dalvington DS0000018646.V369378.R01.S.doc Version 5.2 Page 27 - 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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