Care Home: Jendot

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What the care home does well A person centred approach to care was in place involving people in developing and reviewing their care plans. People were observed being encouraged to be independent, helping around their home, choosing how to spend their time and planning for the summer holidays. People said that they liked the home and staff and were supported to do things that they enjoy such as horse riding, watching cricket and buying a daily newspaper. People are encouraged to join in house meetings and have individual meetings with management to talk about their lives, the home and any concerns they may have. The accommodation provided is of a high standard and fixtures and fittings are of a good quality. People said they are pleased with their bedrooms and their private lounges. All staff have a NVQ in Health and Social Care. What has improved since the last inspection? Six of the seven requirements issued at the last inspection were met ensuring that people are having access to a nutritional diet, medication systems are administered safely and staff work shifts with suitable breaks in between. A quality assurance system is being developed and when a quality assurance report is produced to reflect feedback, outcomes and action plan this will comply with the seventh requirement. CARE HOME ADULTS 18-65 Jendot 3 Little Field Abbey Mead Gloucester GL4 4QS Lead Inspector Ms Lynne Bennett Unannounced Inspection 15th July 2008 14:30 Jendot DS0000069863.V367614.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 Jendot DS0000069863.V367614.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. Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jendot Address 3 Little Field Abbey Mead Gloucester GL4 4QS 01452 535963 01452 535963 dellagilby@yahoo.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cardell Care Limited Mrs Carol Dorothy Dyer Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability - (Code LD) Mental disorder - (Code MD) The maximum number of service users who may be accommodated is 4. 20th August 2007 2. Date of last inspection Brief Description of the Service: Jendot is a small home for up to four people on an estate in Abbeymead in Gloucester. It is close to community facilities and public transport. It is a detached house in its own grounds and provides each person with a bedroom and en suite facilities, with either an additional lounge or space for a sitting area. Shared communal areas include a lounge, kitchen/dining room and meeting room. There are pleasant gardens to the rear of the property. Fees for the home are upwards to a ceiling of £1,800 per week based on individual needs. Additional costs include payment towards transport and a contribution towards a television licence where the person has one in their own room. Copies of the Statement of Purpose and Service User Guide are displayed in the entrance hall. Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place in July 2008 and included two visits to the home on the evening of 15th July and the day of 16th July. All people living at the home were met and spoken with and the registered manager was present for most of the time. The Responsible Individual was at the home during the first visit. Four staff were spoken to about the care they provide. The management of the home had completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. Surveys were received from 3 people living in the home, 2 relatives, 4 members of staff and 5 healthcare professionals. Relatives visiting the home were also spoken with. A selection of records were examined which included care plans, staff files, medical and financial records, health and safety documents and quality assurance systems. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 6 Six of the seven requirements issued at the last inspection were met ensuring that people are having access to a nutritional diet, medication systems are administered safely and staff work shifts with suitable breaks in between. A quality assurance system is being developed and when a quality assurance report is produced to reflect feedback, outcomes and action plan this will comply with the seventh requirement. 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. Jendot DS0000069863.V367614.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 Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place. EVIDENCE: Since the last inspection the home has converted the double garage to provide an additional room with en suite facilities and a lounge, increasing the numbers of people living in the home from three to four. The Statement of Purpose and Service User Guide were amended to reflect this and other changes affecting the home. At the time of the last inspection one person was about to move into the home. She had settled in well and said that she liked living there. She had a three-month review of her placement that confirmed that she wished to continue to live at the home and that they could meet her needs. Two other people had also moved into the home this year and there was evidence that the home had completed their own assessments during visits to the home. The AQAA stated “ We assess using our activity of daily living Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 9 model, we pay particular attention to the individuals interests and personality in order to compliment our existing service users.” Additional information was gained through visits to people at their previous placements and from parents and other healthcare professionals. A copy of assessments and care plans from the placing authority had been obtained as well as reports from other health care professionals and a discharge pack from the NHS Trust. The result was that a robust admissions process was in place providing both the home and the person wishing to move in, with sufficient knowledge and information to make an informed choice about whether the home was the appropriate service. Records confirmed that healthcare professionals had been involved directly with the move into the home and where specialist adaptations or training needed to be completed these were done prior to the admission. Comprehensive records were kept of visits to the home and the opportunity was provided for people already living there to meet and greet visitors, have a drink with them and generally get to know them before moving in. Each person had a copy of their terms and conditions with the home and placing authority on their personal file. They were also given personalised copies of the Service User Guide that gave individualised information about the fees they were to pay, what these included and any additional costs to them. The registered manager indicated that these documents would be reviewed on an annual basis as fees changed. Jendot DS0000069863.V367614.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 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A person centred approach is in place. People are being involved in developing their care plans that reflect their aspirations and needs. Plans could be improved by reflecting the diversity and individual expectations of people. Risks are being mostly identified and managed. EVIDENCE: The registered manager confirmed that a person centred approach to care was being provided with people being involved in the development of their care plans and risk assessments. Where appropriate people had signed some documents. Care plans had clearly been developed from assessments reflecting peoples’ physical, social, intellectual and emotional needs. A healthcare professional commented the home is “good at person centred thinking and attentiveness to people as people.” The care for the three people who had moved into the home since the last inspection was case tracked. This involved reading their assessments, care plans and other related records, talking to them, observing the care being Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 11 provided and discussing with staff the care they provide. Care plans did not indicate people’s religious beliefs or their preferences for the gender of staff providing personal care. Care plans were written in plain English making them accessible to people living in the home. Each plan had a signature list for staff providing evidence that they had read the documents. Some plans had been drawn up in a multi agency forum and they had been asked to sign as acknowledgement of their agreement with the plans. There was evidence that when drawing up care plans and risk assessments the home had considered people’s capacity to consent in line with the requirements of the Mental Capacity Act. Discussions had taken place with people about what they would like to happen should they become ill and unable to consent to treatment, this was recorded. People who were subject to the Care Programme Approach had regular contact with Community Nurses and reviews of their care. Contingencies were in place should the home become unable to continue to meet their needs. Feedback from healthcare professionals indicated that the home “raise concerns that put patient at risk and address the issues in the right channels”. Daily notes were being kept for each person which included reference to each person’s identified needs and provided staff with a snapshot of their day whilst also referring them to other documentation they may wish to see. There was evidence that records were being kept on a daily basis upon the request of the local Community Learning Disability Team and that ABC and other monitoring charts were in place. People do not have formal advocates although the AQAA indicated that they would like these to be in place. The registered manager said that several people have friends who represent them at meetings and where necessary an Independent Mental Capacity Advocate would be appointed. Risk assessments had been developed from hazards identified in care plans and provided staff with guidance about how these could be minimised. Risk assessments for people with epilepsy need to include: How risks of injury due to seizure during the night are minimised and managed • How risks of injury due to seizure whilst having a shower/bath are reduced. Discussions with staff confirmed that systems and practices were in place to monitor and minimise the risk of harm in these incidences. Care plans for two people also indicated that they were at the risk of absconding. Risk assessments did not refer to this although they did refer to the need for 1:1 support whilst in the community. Daily diaries on one Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 12 • occasion referred to staff locking the front door as a preventative measure to stop a person leaving the home when in distress. The registered manager explained that people living in the home were still able to open the door by operating an override device. Care plans and risk assessments need to record when the front door can be locked in this way, taking into consideration the implications of the Deprivation of Liberty Act to be implemented in 2009. Each person has a ‘Thumb sketch’ providing an overview of their personal details and a photograph. This is laminated and provides essential information that might be used if the person becomes missing. Jendot DS0000069863.V367614.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): 11,12,13,14,15,16 and 17. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. EVIDENCE: People living at the home were observed choosing how to spend their time. During the visits they helped around the home, clearing away dishes, setting the table, washing laundry and mowing the lawn. One person went to a day centre and horse riding, another went shopping and to a garden centre and another person played sports at a local playing field. People were observed enjoying the garden and looking after rabbits. One person had visitors who they entertained in the lounge and garden. People also enjoyed going out for drives. One person was looking forward to an evening at a local club. They Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 14 said that they were still being supported with a paper round for which they received payment and had also been attending a local college. Daily diaries recorded each day’s activities and there were times when they noted these had been refused. They provided evidence of a range of activities including utilising local facilities, transport networks, theatre, sporting events and holidays. One person chooses not to go out and will indicate to staff when they are happy to have company. Records indicated that they were deciding when to spend time with others in the main lounge and when to go out for a drive. This appears to be more frequent than when they first moved into the home. They said, “The staff at Jendot are more than willing to help me do what I want to do.” One person had shown an interest in listening to ‘Songs of Praise’ and had been supported to visit a local church. The registered manager confirmed that staff had been made available on a Sunday to ensure they could go if they wished. One parent commented “they look after my son well, take him on outings to football, horse racing etc and he really enjoys these trips.” Staff surveys also commented on the range of activities available to people. One person keeps in touch with their family by writing letters and sending them via fax. Others use the telephone. People were being supported to maintain friendships with people they knew prior to moving into the home. House meetings were being held with records of these meetings being produced providing also a reaction to any concerns or issues expressed and action taken. Individual meetings were also being held with a record of each meeting being taken. Staff and people living at the home were joined for a meal during the visits. It was relaxed and people chatted with each other, no one was excluded. Staff ensured that they included a person with a hearing impairment, signing to them the general topic of conversation. Meals were observed to be freshly produced offering a nutritional meal including vegetables and fruit. A six weekly menu had been put in place with people indicating their preferences and alternative meals for people who did not wish to have the main meal. Daily diaries kept a record of people’s diet and for some their fluid intake. A dietician was involved with one person and staff were observed to be keeping a record of their fluid and food consumption. Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication and training of staff in specialised techniques. EVIDENCE: Peoples’ likes and dislikes were recorded in the Thumb sketch on each personal file. Staff were observed treating people with dignity and respect. One healthcare professional said in response to the question, “does the care service respect individual’s privacy and dignity?” that there is a “very strong emphasis from the top of the organisation on trying to get this right. This is reflected in behaviour of the staff team.” The AQAA indicated, “The service user is encouraged to support their own personal care and clothing choices as independently as possible. Service users dignity and privacy is given the highest consideration.” One person living in the home has a hearing impairment and they have taught staff the sign language they use. The registered manager as a trainer in ‘deaf awareness’ cascaded this training to all staff. During the visits staff were observed using sign language. There was also evidence of good use of Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 16 photographs and objects of reference. The person also had a litewriter which they choose to use occasionally. Each person had been registered with a local Doctor and Dentist. Records were being kept for all appointments with healthcare professionals including an outcome of each appointment. The home works closely with the local Community Learning Disability Team. Comments from healthcare professionals included: “liaison with appropriate professional colleagues”, “excellent to work with” and “professional attitude”. People do not have a Health Action Plan in place. This was discussed with management. Concerns were raised at the last inspection about the administration of medication. These were examined and found to be satisfactory. Consent to medication had been obtained and recorded from people living in the home. The administration of medication was observed on three occasions during the visits and this was satisfactory. The temperature of the medication cabinet was being recorded. Stock records were being kept for any medication stored in boxes and not in the monitored dosage system. Medication administration records were being completed correctly. Medication was labelled with the date of opening and a returns book was being kept for any items going back to the pharmacy. A medication error had occurred when medication had not been given. NHS Direct and the home’s Doctor were contacted for advice. A Regulation 37 notification was completed for us. Staff have completed training in the safe handling of medication and the administration of Midazolam. Jendot DS0000069863.V367614.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 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to express their concerns and they are confident that they will be listened to. People are safeguarded from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure that people living in the home indicated they were aware of and knew how to use. A copy of this procedure was displayed in the hall. The AQAA stated, “Myself (Responsible Individual) and the registered manager have an individual meeting with each service user at least weekly, concerns are discussed. If it was felt that a service user had a complaint then the complaints procedure would be implemented immediately, with appropriate support offered throughout the process.” A complaints folder had been put in place which also contained copies of compliments received from parents. The DataSet indicated that three complaints had been received since the home opened. Copies of these and the action taken were logged. There was also evidence that any concerns expressed to the home were taken seriously and action taken as a result. Staff confirmed they had attended training in the safeguarding of adults and The Mental Capacity Act. Discussions with staff confirmed their understanding of abuse and their roles and responsibilities in identifying and reporting suspected abuse. The home had liaised and worked with the local Adult Protection Unit protecting people living at the home from possible harm. Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 18 The AQAA identified that staff at the home had used physical intervention on one occasion. Staff had completed training in the management of challenging behaviour and use of physical intervention, although the trainer had not been accredited with BILD. Care plans and risk assessments made reference to the use of physical intervention as a last resort and the registered manager stated that an additional strategy was being produced for individuals for whom this might be needed. This was not seen during this inspection. The use of physical intervention was noted in ABC monitoring charts but should also be recorded in a separate log. For further information see www.csci.org.uk/professional/default.aspx?page=7926&key Financial risk assessments had been put in place for each person identifying the level of support required. Financial records were being maintained with receipts being obtained. Regular checks were in place evidenced by staff initials. Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is safe, clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. EVIDENCE: Jendot is a detached house in a cul-de-sac position on a large housing estate. The home blends in with other houses in the vicinity. There is parking to the front of the property and a large secluded garden to the rear of the house. Each person has their own bedroom with en suite facilities that includes either a shower, bath/shower or bath and separate shower. All rooms have a sitting area or separate lounge adjacent to them. People had chosen colour schemes and decorated their rooms to reflect their interests and lifestyles. Inventories had not been put in place. Communal areas are pleasantly decorated and fitted out with good quality furnishings. The registered manager confirmed that areas of the home had Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 20 recently been redecorated. General maintenance was being identified on a day-to-day basis and dealt with as soon as possible. Prior to admission advice had been sought from an Occupational Therapist about specialist adaptations and equipment that might have been needed. Where recommended this was put in place. Good infection control measures were observed to be in place. Paper towels and liquid soap had been provided in the laundry and communal toilet. Staff were observed following safe practice in the kitchen. An environmental health inspection had no concerns and commented on the good hazard analysis procedures in place. Jendot DS0000069863.V367614.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 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A competent and skilled staff team support people living in the home. Their continuing professional development must mirror the complexity of people’s needs. Improvements in recruitment and selection processes will safeguard people from possible harm. EVIDENCE: The DataSet confirmed that all staff had a NVQ Award in Health and Social Care. This exceeds the National Minimum Standards. Most of the staff had completed the Learning Disability Award Framework or were registered to do the Learning Disability Qualification. Healthcare professionals commented that staff had the right skills and experience to support people living at the home but expressed reservations about how they would cope as the complexity of people living in the home increased. Several new staff had been appointed since the last inspection. Recruitment and selection files were examined for them and for a volunteer. Whilst there had been improvements there continue to be some shortfalls. The registered manager must make sure that they obtain: Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 22 Written evidence of the reason why people left former positions in care working with either adults or children (over the previous 5 years) • It is recommended that two professional references be obtained rather than one professional and one personal. There was evidence that where there were gaps in employment history additional information was being obtained from applicants. Two references and a current CRB check had been obtained prior to starting work at the home. Proof of identity and a current photograph had been obtained. The home does not presently have a training matrix. Copies of certificates of courses attended were kept on their personal files. However this did not evidence such things as open learning, training cascaded internally or training provided by other health care professionals. Staff had completed mandatory training, training specific to learning disability and deaf awareness. One of the people recently admitted has Autistic Spectrum Disorder and others have associated mental health needs. Staff will need to show that they have the knowledge and skills in these particular areas. • Jendot DS0000069863.V367614.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 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Effective quality assurance systems are in place involving people who live at the home. Satisfactory health and safety systems are in place providing a safe environment. EVIDENCE: The registered manager has considerable experience working in this area of care and was previously registered as manager of another home in the area. She has the Registered Managers Award and NVQ Level 4 in Health and Social Care. Her continuing professional development includes attending training in assessment and a non-aversive approach to management of challenging behaviour. She has a person centred approach and staff confirmed that she was approachable and accessible. Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 24 The Responsible Individual confirmed that she conducts monthly-unannounced visits to the home; copies of the reports were being forwarded to us. A newsletter was produced this year and sent to all people with an interest in the home also asking for their feedback about the service provided. Copies of responses were seen. One respondent said that they felt people living in the home should have more regular medication checks and so the home set this up with their Doctor. The Responsible Individual said that a report would be produced once all feedback had been received with an action plan and the home’s response to suggestions. Systems for the management of health and safety were examined and found to be satisfactory. Good practice was observed to be in place in respect of monitoring temperatures for water, fridges and freezers, labelling food in fridges and infection control. Servicing of equipment including electrical appliances, boilers and fire equipment was in place. The home had a current fire risk assessment and regular checks were being done on fire equipment. Jendot DS0000069863.V367614.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 4 4 4 5 4 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 4 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 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 Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA9 Timescale for action 13(4) The systems in place to minimise 30/08/08 the risk of harm to people with epilepsy during the night, when having a shower/bath must be recorded in their risk assessments. This is to make sure that all staff are aware of the procedures to safeguard people from possible harm. 13(4) The risk of people absconding 30/08/08 must be logged in risk assessments and strategies recorded for dealing with this. This is to make sure staff are fully aware of the risks and their roles and responsibilities. 17(2) Sch Any furniture or valuables that 30/08/08 4.10 people have brought to the home must be recorded. This is to provide evidence of their personal possessions. 19(5) Sch Before appointing staff written 30/08/08 2.4 evidence must be obtained of the reason why they left former positions in care working with children or adults. This is to safeguard people from possible abuse. 18(1)(c)(i) Staff must have knowledge and 30/11/08 understanding of people with DS0000069863.V367614.R01.S.doc Version 5.2 Page 27 Regulation Requirement 2. YA9 3. YA24 4. YA34 5. YA35 Jendot Autistic Spectrum Disorder and Mental Health. This is so that they are able to meet their individual needs. 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. 2. 3. Refer to Standard YA6 YA19 YA23 Good Practice Recommendations Care plans should identify people’s religious beliefs and their preferences for the gender of staff providing their personal care. Health action plans should be put in place for each person. A trainer accredited with BILD should provide physical Intervention training. The use of physical intervention should be recorded in a log. A training matrix should be put in place to evidence all training, courses and open learning accessed by staff. 4. YA35 Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Jendot DS0000069863.V367614.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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