Care Home: Faycroft

Similar services:

• Polesworth Group Friary Road
• Polesworth Group Pooley Heights
• Polesworth Group 32 Station Road
• Polesworth Group 70 Long Street
• Breme
• Polesworth Group 64 Long Street
• Polesworth Group 68 Long Street
• 10 Whitfield Avenue

What the care home does well The home has a committed team of staff who try hard to meet the needs of the people they support. Feedback received from two staff on duty was positive with staff reporting "morale is brilliant, I enjoy coming to work" and "we have a good management team". Staff reported that the team functions well. Individual`s health needs are well-monitored and appropriate referrals to healthcare professionals made where necessary. The manager appears committed to providing a good service to the people living at the home. What has improved since the last inspection? CARE HOME ADULTS 18-65 Faycroft New Street St Georges Telford Shropshire TF2 9AP Lead Inspector Rebecca Harrison Key Unannounced Inspection 7th May 2008 10:00 Faycroft DS0000065004.V363763.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 Faycroft DS0000065004.V363763.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. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faycroft Address New Street St Georges Telford Shropshire TF2 9AP 01952 616515 01952 616515 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) Care Tech Community Services Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2007 Brief Description of the Service: Faycroft is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of six adults with learning disability. At the time of the inspection the home had one vacancy. CareTech Community Services Ltd is the registered service provider and the responsible individual is Mr Stewart Wallace. The home has a manager in place that has recently applied for registration. Faycroft is a large detached property situated in St. Georges, Telford. The home offers access to local amenities and public transport and is in keeping with the local community. Accommodation is based over two floors providing single bedrooms, a kitchen, lounge, dining room, relaxation room, beauty room and enclosed gardens. Caretech’s philosophy is included in the Statement of Purpose for the home and states ‘CareTech and their staff work on the philosophy of enabling people to live as full a life as possible, supporting them in their daily activities and any identified long term plans. We recognise that all people with disabilities should be given due respect to their individuality enabling all to be fully involved in any decisions having an affect on their lifestyle commensurate to the level of their abilities and enabling people to maintain all their entitlement associated with citizenship’. The fees charged were not available in the Service User Guide as required therefore the reader may wish to obtain this information direct from the service provider. Faycroft DS0000065004.V363763.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 two stars. This means that people who use this service experience good quality outcomes. The inspection was unannounced and took place on 7th May 2008 by one inspector over seven hours. A range of evidence was used to make judgements about this service to include discussions with people who use the service, staff on duty, two surveys we received from service users and two from staff, a tour of the home, a review of the homes quality assurance processes and observation of care experienced by people using the service. We also looked at a number of records to include care records held on behalf of two people, complaints and protection, staff training, recruitment and health and safety records. Due to the needs of the people living at the home not all individuals were able to actively contribute to the inspection process and share their own experience of living at Faycroft. During this inspection we carried out a thematic probe, this is where we gather additional information on a particular theme from a key inspection. We focused on safeguarding and asked staff and service users a number of specific questions and looked at recruitment records, staff training and quality assurance processes around safeguarding issues. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. Some of the manager’s comments have been included within this inspection report. The purpose of the inspection was to assess all ‘Key’ National Minimum Standards for Younger Adults and any additional Standards considered necessary. We also reviewed the five requirements that we made as a result of the previous inspection undertaken on 9th May 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although people are given opportunities to develop their interests, access to community activities is limited by staffing levels and therefore should be reviewed. This will ensure the staffing structure is based around delivering outcomes for all individuals using the service. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 7 People have experienced many changes as a result of staff leaving and a change of manager however it is hoped that staff will now develop as a team and the service less reliant on agency staff, which will provide people living at Faycroft with more stability and continuity of care. The manager was advised to review the use of keypads that have been placed on two doors within the home as this restricts freedom of movement for people living at Faycroft and may not be in the best interests of all individuals. One person considered that two people might benefit from their own service as sometimes they are held back from being more independent. The self assessment (AQAA) completed by the manager identifies areas for improvement to include: involving service users more in the recruitment and selection of staff, making a number of records more user friendly, encouraging friendships away from the service to broaden life experience and to continue to develop in house activities to make them more stimulating and therapeutic. The findings of this inspection indicated that improvements have been made. It is hoped that the service can sustain its performance and strive to provide even better outcomes for the people using the service. 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. Faycroft DS0000065004.V363763.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 Faycroft DS0000065004.V363763.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 and 2 Quality in this outcome area is good The home provides prospective people looking for a residential service with the necessary information to help them make an informed decision about whether the home will meet their needs. The service has appropriate assessment and admission processes in place to ensure the home is able to meet people’s individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the service is readily available in the Statement of Purpose and Service User Guide, which have been reviewed and updated since the last inspection to reflect the change in manager. The manager reported that the Statement of Purpose is currently under further review and will include details on Equality and Diversity, Quality and Performance and the Mental Capacity Act. She further stated that she intends to develop the Guide in a more ‘user friendly’ format for people currently living at the home and any potential service users. Both documents provide people with information to help them understand the services provided. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 10 There have been no new admissions to the service since the last inspection however assessment and admission procedures were considered satisfactory at previous inspections of this service. It was reported due to the varied needs of the individuals living at the home that a reassessment of people’s individual needs is currently being requested. The self assessment (AQAA) completed by the manager states ‘There have been no new admissions to Faycroft within the last twelve months due to managerial change over and environmental issues such as refurbishment plans. It is a credit to the service that it was deemed inappropriate to admit anyone during this period of instability. It could potentially have been detrimental to the current service users and to the prospective person. When a suitable person applies, then the company assessments and admissions policy will be referred to and the opinions of the current service users will be considered and respected. It is the aim to include current service users in the process with the hope that this will support rapport and provide ease for all during admission’. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good Staff are provided with detailed information to ensure peoples individual needs are met and regularly reviewed. People living at Faycroft are supported to make decisions and enabled to take responsible risks to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who live at Faycroft have support plans that identify and provide staff with detailed information about how their individual needs should be met. Discussions held with two service users indicated they are involved in planning their care. Support plans seen have been developed using a person centred approach and staff spoken with considered they are provided with sufficient information for the delivery of care and support. Files have recently been condensed and historical information archived ensuring staff have access to relevant information required. Identified behaviours are supported by management guidelines that have been developed by the manager who stated Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 12 these would be shared with significant others at forthcoming reviews and any amendments considered made. Historically the service has experienced significant difficulties arranging for individuals to be formally reviewed and reassessed by placing authorities. However since the last inspection two people have formally been reviewed and reviews have been scheduled for the other three people currently living at the home. People have designated key workers who are responsible for completing monthly reports and updating records to reflect any change in need. Likes and dislikes were seen recorded on the two files examined and daily routines clearly written to enable staff to support individuals how they prefer and follow the routines that are important to them to ensure continuity of support. It was reported that two people living at Faycroft currently have an independent advocate and that a referral has recently been made for one individual to access a Befriending Scheme. Records seen on one file clearly evidenced that the person has benefited from the support of a local advocate who has worked in the person’s best interests. The self-assessment completed by the manager states: ‘All service users are supported and empowered by staff to make informed decisions regarding their lives’. Evidence of decision making processes were available on records seen to include 1:1 Talk Time, minutes of service user meetings and daily records. During the inspection people were offered choices in relation to activities and meals. Risk assessments to support community activities and daily living tasks were available on the files examined with evidence of review. The manager has obtained a new format for assessing risk and is in the process of completing new assessments in conjunction with individuals using the service. These are more person focused and not generic like the format currently in use. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good People living at Faycroft are provided with some opportunities to develop and maintain their educational, social and recreational interests and are enabled to keep in contact with family and friends. People receive a varied diet that reflect their individual tastes and meet their dietary and cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people currently access educational opportunities provided through the local college and discussions held with them evidenced that they enjoy attending this facility. It was reported all of the people living at the home were recently supported to attend an open evening held at the college and have identified courses they are interesting in commencing in September. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 14 Throughout the inspection people were supported to access the community to include food shopping, personal shopping, banking and visit friends at a nearby home. One person was supported to have a manicure and hair care. Leisure preferences were documented on the files examined and evidenced people access local community facilities on a regular basis however discussions held and observations made clearly evidenced that more opportunities could be sought. One person stated ‘People who are more vocal get out more and it is not fair on others left behind. Another person said ‘we could offer more opportunities if there were more staff’. This was also identified in a recent quality assurance audit undertaken by the provider, which states ‘While staffing is adequate to meet individual needs within the home, it is difficult for residents to access varied community facilities due to requiring staff support’. Since the last inspection all of the people who live at Faycroft have been supported to go on a holiday, which proved very beneficial as evidenced in discussions held with service users. People are currently being supported to complete a questionnaire about their choices for future holidays. Observations made and records evidenced that people are encouraged and supported to partake in domestic routines around their home as much as possible as evidenced in daily records and weekly activity records seen on the two files examined. People are encouraged to maintain contact with their families and friends if desired. Contact sheets were available on the files examined and indicate people have regular contact. Links with people living in other local services managed by the provider has also been promoted which has developed people’s social networks and proved positive. It was reported that families are invited to attend reviews and that family and friends are also invited to social events organised by the home. Discussions held with the manager indicated that she has a clear understanding of rights and values. The self-assessment completed by the manager states ‘Through regular communication with staff, advocates and other health care professionals, service users are informed of their rights and how to exercise these appropriately’. An example of this was evidenced on one file seen in relation to food with a positive outcome for the individual concerned. Keypads have been fitted to the kitchen and a further door. Reasons for this was shared with the inspector and it was reported that risk assessments have been undertaken however the manager was advised that this prevents freedom of movement for people living at Faycroft and may not be in the best interests of all individuals. People spoken with told us they enjoy the food and that they choose what they wish on a daily basis as observed during the inspection. A record of food eaten was available on the two files examined however the manager was advised to ensure that staff are aware of meals eaten on the previous days to ensure people receive a balanced diet. Cultural needs are catered for and people are Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 15 encouraged to try new dishes through themed events arranged by the home or the providers other homes locally. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. People living at Faycroft are safeguarded by the home’s systems for handling, storing and administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Health records held on behalf of two people were examined and included people’s personal preferences in relation to personal and health care needs. Discussions held with two people using the service indicated that they are happy with the way staff support their personal care needs. Records evidence that people are supported to access routine healthcare appointments and outcomes documented. The manager expressed concern in relation to the health of one person in particular and during the inspection a health professional telephoned the home to offer some reassurance. The team are currently working with individuals to develop new Health Action Plans. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 17 Medication procedures were examined and appeared satisfactory at the time of the inspection. All staff have received in-house training or attended a distance-learning course in safe handling and administration of medications. There has been one medication error, which has been investigated, and the necessary action taken by the provider. Staff were seen to observe a new procedure in relation to administering medication to ensure they are not distracted from their duties by other people living at the home. The manager ensures that staff giving medication are competent to do so and staff are assessed for their ongoing competence in administering medication. Records seen on the two files sampled evidence that medication reviews are undertaken on a regular basis by the local team. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 18 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 The home has a complaints procedure in place that ensures people’s views are listened to and acted upon. Procedures are in place to safeguard people using the service from potential abuse and staff receive the necessary training to ensure people are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at the home and their representatives have access to a complaints procedure in an appropriate format which was seen available in the homes statement of Purpose, Service User Guide, complaints file and displayed in the dining area. The procedure has been developed in an easy read format and there was clear evidence seen recorded in service user meetings that the process had been discussed with people receiving a service. A service user spoken with during the inspection demonstrated an understanding of whom to approach if she was unhappy with the service provided or if she suspected abuse. We have not received any concerns or complaints in relation to this service since the last inspection. Two complaints were found recorded in the complaints log and the necessary action taken. The manager confirmed that these have since been resolved. During this inspection we carried out a thematic probe on safeguarding. Those people spoken with were very helpful with the process and demonstrated an understanding around protection. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 19 Since the last inspection five referrals have been made under local safeguarding adult procedures. Three have been investigated by the local team and the provider has attended all meetings held and the cases have since closed with recommendations made. Two have been investigated under the provider’s own disciplinary procedures as advised by the local team and the outcomes were shared with us during the inspection. The home has a clear system for staff to report concerns about colleagues and there is evidence that this has been used and the necessary action taken to safeguard people. On occasions appropriate physical restraint has been used however the manager stated that this is used as a last resort and alternative methods used. Staff have received training in safeguarding and physical intervention and records are maintained. The home has a policy in place for the management of service users’ finances and it was reported that all people now have their own bank accounts. Financial procedures were discussed with a member of staff and the manager who considered these to be robust and safeguard both people using the service and staff. Records evidence that the manager completes regular audits and monthly checks are also undertaken by the area manager. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 20 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, 27 and 26 Quality in this outcome area is good The environment has improved to provide people living at Faycroft with a clean and comfortable home to live. Infection control procedures are in place to protect people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated on the outskirts of Telford Centre and provides good access to community facilities and services. The accommodation is provided over two floors. People using the service were keen to show us their bedrooms, which they have been supported to personalise. Since the last inspection many environmental improvements have been made to provide people with a more comfortable home to live. Improvements include refurbishment of both bathrooms, redecoration of a number of bedrooms and communal areas in consultation with individuals, replacement of a number of floor coverings and furniture in some rooms. Discussions with the manager evidenced her commitment to continue to improve the environment Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 21 to include a new relaxation room with sensory equipment for the people accommodated. People spoken with indicated that they have enjoyed improving their home and choosing colours, materials and soft furnishings. Evidence of consultation with people who use the service was also seen recorded in the minutes of service user meetings. The self-assessment completed by the provider states ‘The service users have been encouraged to take ownership of the home and empowered to make changes with the support of the staff. This is evidenced in the beauty room where as a team a whole room was refurbished with all service users playing an active and vital role in doing this’. Since the last inspection the grounds have been tided and old furniture removed from the garden however there are still areas that require attention such as the maintenance of the lawn. The home was generally found clean at the time of this unannounced inspection however a slight odour was detected on the landing, which the manager acknowledged and committed to address. New soap, paper towel and toilet tissue dispensers have been purchased and fitted improving infection control. People using the service are encouraged and supported to partake in domestic tasks. It was reported that most staff have received training in infection control procedures. Products hazardous to health are appropriately stored and the manager reported that the necessary assessments are available. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is adequate There has been a considerable period of instability within the team, however staff continue to work positively with the people they support and are provided with good training opportunities to ensure they are fully equipped to meet the individual needs of the people accommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The self-assessment completed by the provider states ‘The staff team at Faycroft are very supportive and understanding and pride themselves in providing a quality care service through continued training and updating their knowledge and skills’. Staff were seen to interact well with the people they support throughout the inspection and demonstrated a good understanding of the individual needs of people. It was reported of the eight permanent support staff employed, three hold a recognised care award known as a National Vocational Qualification and two staff are currently working towards their award. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 23 The team consists of a manager, a deputy manager, four seniors and three support workers. It was reported that four staff have left since the last inspection and that the home currently has three support worker vacancies and is actively recruiting. Records seen and discussions held evidence that the home continue to use agency staff on a daily basis however the same agency staff are used to ensure continuity of support as acknowledged in the self assessment completed by the manager. On arrival there were three members of staff on duty in addition to the manager. It was reported that the usual ratio during the day is three staff to support five service users reducing to two staff of an evening. A recent quality assurance audit undertaken by the provider states ‘Staffing levels whilst adequate to ensure peoples safety do not allow for a variety of external activities due to the many and varied needs of the service user group’. This was fully supported by discussions held with people and observations that we made during the inspection. A member of staff spoken with stated ‘Staff morale is brilliant and we all pull together. I enjoy coming to work’. A survey that we received from a staff member stated ‘Caring is very good involving the residents in daily activities and the environment is excellent. The staff work well as a team and support for both staff and service users is excellent’ Two staff have been recruited since the last inspection and a further person has transferred from another of the providers services. Caretech has obtained our agreement for the centralisation of staff records to be held at their Head Office and keep a pro-forma (basic details) of staff information in the home in line with the Commissions policy and guidance. Pro-forma’s were available on the files examined and contained all the required information with the exception of staff photographs. This shortfall was acknowledged by the manager who committed to address this at the earliest opportunity. All staff spoken with during the inspection considered the provider’s recruitment procedures are robust and confirmed all pre-recruitment checks had been undertaken. Our Provider Relationship Manager has recently met with the providers Director of Quality and intends to visit the provider’s regional offices shortly to check on their recruitment procedures and follow up on specific services as necessary. A staff training matrix has been developed and indicated that all but one member of staff has received training in safe working practices and a number of staff have attended service specific training to include autism, mental health, communication, person centred planning and learning disability qualification. Staff spoken with considered the provider offers good training opportunities however obtaining places on training is difficult due to courses being over subscribed or cancelled. It was reported staff training needs are identified through formal supervision. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 24 Records seen evidence that staff receive formal supervision at the required frequency and agreements for this are in place and signed by the supervisor and supervisee. The manager was advised to develop a supervision matrix to help record dates of meetings held. Staff spoken with confirmed that they are in receipt of regular training and team meetings, which are held monthly. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good The manager has a clear vision for service and an understanding of the areas in which the service needs to improve in the best interests of people living at Faycroft. The home has effective quality assurance systems in place to assess performance and evaluate outcomes for people using the service. Overall the premises are managed and maintained in a manner, which ensures the safety of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 26 The previous manager has left employment and a new manager was appointed to manage the service in July 2007. The manager previously managed one of the provider’s other homes in Birmingham and has numerous years experience of working with people with a learning disability and behaviours that can challenge. Discussions held with the manager and staff evidence that a number of improvements have been made and that the management team recognise the services strengths and areas for improvement. A full time deputy manager has been appointed to assist with managerial duties, which has enabled the service to develop following a period of instability with change of managers and staffing. The manager has been allocated additional managerial time to improve service delivery. It was reported that an application to register the manager has recently been submitted to our offices and reasons for the delay shared with the inspector. Staff spoken with indicated that they feel well supported by the manager and stated ‘She has a firm but fair approach...we have a good management team’ ‘The manager is brilliant and is very helpful’ The manager stated that she holds the NVQ level 4 Award, is currently working towards the Registered Manager’s Award and has recently commenced managers training organised by the provider. She reported that she is well supported by her line manager. The provider undertook a Quality Performance Assessment of the service on 1st April 2008 and a detailed report of the findings was available. The assessment links to the intended outcome groups for people using the service and provided valuable recommendations. The report details the strengths and areas for improvement in addition to those provided in the self-assessment completed by the manager. It is evident that suggestions to improve the quality of the service are welcomed and the manager has worked towards implementing suggestions made following the audit. Monthly visits required under Regulation 26 are undertaken by the area manager and detailed reports available. An Annual Development Plan has been developed for the service and findings of this inspection evidence that people using the service are consulted with. The manager stated that ‘Service users have a right to their home and are included in decision making processes and empowerment’. The manager stated that satisfaction surveys were distributed to relatives however only one completed one was returned. The survey indicated that the relative was happy with the service provided at Faycroft and that staff are polite, attentive and behave in a supportive manner however would welcome more contact with their relative. Health and safety procedures appeared satisfactory at the time of this inspection. Certificates for the servicing of equipment are maintained and safety checks are undertaken at the required frequency however the manager was advised that the service of the electrical installation was overdue. The staff-training matrix identified that all but one member of staff have received training in safe working practices and that courses for this person have been Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 27 booked. All risk assessments for safe working practices have been reviewed since the last inspection and these were seen readily available. The Fire Officer has recently inspected the service and the outcome was satisfactory. No visits have been made by the Environmental Health Officer since we last inspected the home. Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 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 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 29 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 30 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 Faycroft DS0000065004.V363763.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!