Care Home: Litslade Farm

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What the care home does well The home provides support plans in a pictorial format so that people using the service can understand how staff would be supporting them with their identified needs. People using the service are supported to take part in a variety of meaningful activities to ensure that they are able to enjoy a full and stimulating lifestyle. People using the service are supported and encouraged to keep in contact with family members, which mean that family ties are promoted. People using the service rights and responsibilities are promoted, which mean that they are empowered to be independent. People using the service are provided with nutritious and balanced meals at flexible times, to ensure that their health and wellbeing are promoted. The home ensures that people using the service are supported with their personal and health care needs in the way they prefer and is sensitive to their race, age and disability. The home`s complaints procedure is in a pictorial form to ensure people using the service are fully aware of how to make a complaint. Staff ensure that the home is clean, hygienic and well maintained, which mean that people using the service live in a safe and comfortable environment. The home ensures that the staffing levels in the home are adequate to meet people using the service diverse needs. The home`s health and safety practices ensure that people using the service health, safety and welfare are promoted and protected. What has improved since the last inspection? Floor coverings have been replaced in the lounge and in the quiet area to ensure that people using the service live in a home that is appropriately maintained. The home has introduced more user friendly records to enable people using the service to understand what is written about them and to ensure that they are involved in the decision making within the project. People living in the home have had a holiday within the last year, which mean that they are being supported to pursue their own interests. The home ensures that people living in the home have been allocated with a link and co-link worker to support them with any decisions. The evening activities in the home have been increased to ensure that people using the service can pursue their interests and hobbies. The home has updated its filing system to ensure that information can be more accessible. The medication and financial records in the home are now being monitored daily to ensure that people using the service are protected from any potential risk of harm or abuse. What the care home could do better: The home`s recruitment practice must be consistent to ensure that all staff`s files contain a recent photograph to confirm proof of identity and gaps in employment records are explored at the interview and recorded. CARE HOME ADULTS 18-65 Litslade Farm 2 Bletchley Road Newton Longville Bucks MK17 0AD Lead Inspector Joan Browne Unannounced Inspection 14th August 2008 08:30 14/08/08 Litslade Farm DS0000023077.V370478.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 Litslade Farm DS0000023077.V370478.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. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Litslade Farm Address 2 Bletchley Road Newton Longville Bucks MK17 0AD 01908 648143 01908 648143 litslade@nildram.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) Hightown Praetorian & Churches Housing Association Mrs Olive Bateman Care Home 5 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 people, learning disabilities, physical disabilities Date of last inspection 23rd August 2006 Brief Description of the Service: Litslade Farm is a small community home providing care and support to 5 Service Users with learning disabilities. The home is situated in the village of Newton Longville, within driving distance to Bletchley town and Milton Keynes City Centre. The home is a bungalow that has been adapted to meet the long-term needs of the service users. There are pleasant and well-maintained gardens at the front and rear of the building. The Manager is suitably qualified and experienced to undertake her role, providing a high quality service to vulnerable service users. The weekly fees at the time of this inspection were £1507.01. Litslade Farm DS0000023077.V370478.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 3 stars. This means that people who use this service experience excellent quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection (CSCI) was undertaken by Joan Browne on 14 August 2008. The registered manager and team leader assisted in the inspection process, which lasted approximately seven hours commencing at 11:35 pm and concluding at 18:30 pm. The CSCI inspecting for Better Lives (IBL) involves an annual quality assurance assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This document initially helps to prioritise the order of the inspection and identify areas that require more attention during the inspection process. The information contained in this report was gathered from service users’ notes, records kept by the home, a tour of the premises and discussions with the manager, staff team and observation of staff interaction with service users. One requirement was made and this can be found at the end of the report in the requirement section with fuller discussion in the text of the report under standards 34. Three practice recommendations have been made and fuller discussions of these can be found in the text under standards 6, 20 and 34. We (the Commission) would like to thank all the service users and staff who made the visit so productive and pleasant on the day. What the service does well: The home provides support plans in a pictorial format so that people using the service can understand how staff would be supporting them with their identified needs. People using the service are supported to take part in a variety of meaningful activities to ensure that they are able to enjoy a full and stimulating lifestyle. People using the service are supported and encouraged to keep in contact with family members, which mean that family ties are promoted. People using the service rights and responsibilities are promoted, which mean that they are empowered to be independent. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 6 People using the service are provided with nutritious and balanced meals at flexible times, to ensure that their health and wellbeing are promoted. The home ensures that people using the service are supported with their personal and health care needs in the way they prefer and is sensitive to their race, age and disability. The home’s complaints procedure is in a pictorial form to ensure people using the service are fully aware of how to make a complaint. Staff ensure that the home is clean, hygienic and well maintained, which mean that people using the service live in a safe and comfortable environment. The home ensures that the staffing levels in the home are adequate to meet people using the service diverse needs. The home’s health and safety practices ensure that people using the service health, safety and welfare are promoted and protected. What has improved since the last inspection? Floor coverings have been replaced in the lounge and in the quiet area to ensure that people using the service live in a home that is appropriately maintained. The home has introduced more user friendly records to enable people using the service to understand what is written about them and to ensure that they are involved in the decision making within the project. People living in the home have had a holiday within the last year, which mean that they are being supported to pursue their own interests. The home ensures that people living in the home have been allocated with a link and co-link worker to support them with any decisions. The evening activities in the home have been increased to ensure that people using the service can pursue their interests and hobbies. The home has updated its filing system to ensure that information can be more accessible. The medication and financial records in the home are now being monitored daily to ensure that people using the service are protected from any potential risk of harm or abuse. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 7 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. Litslade Farm DS0000023077.V370478.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 Litslade Farm DS0000023077.V370478.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The needs of prospective people to use the service are assessed prior to admission, which should ensure that individuals’ diverse needs would be met. EVIDENCE: Since the last key inspection the home has not had any new admissions. The annual quality assurance assessment (AQAA) stated that ‘the home has an admission procedure and a pre-admission assessment tool in place. The home manager and service manager assess new referrals prior to admission. Prospective service users would be expected to undertake a needs assessment to identify their goals and aspirations. A visit to the home is arranged and the compatibility of existing service users is considered.’ Wherever possible the home would ensure that a family member or an advocate is involved in the development of the service user’s plan. The care plans for the two service users whose care was case tracked reflected that pre-admission assessments had been undertaken prior to admission. Litslade Farm DS0000023077.V370478.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people using the service have a care plan, which reflects their diverse needs. Individuals are enabled to live the life they choose and to take risks. EVIDENCE: Care plans were in place for the two service users whose care was case tracked. Plans were written in a person centred manner and presented in a pictorial format and were reflective of individuals’ ongoing and changing needs. The plans contained information on the following headings: How I communicate, support I need with my personal care, support I need with moving and handling, support I need at mealtimes, things I like to do, things I dislike, support I need when I communicate through my behaviour. Additional information such as, daily diary notes, activity sheets, family and friends contact sheets, monthly weight monitoring sheets, risk assessments and health care appointment sheets were in place. Evidence was seen indicating Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 11 that the plans were being reviewed at least six-monthly and yearly reviews with care managers and relatives were taking place. We noted that key workers were expected to write a monthly summary report on individuals’ progress but the practice in place was inconsistent. It is recommended that staff ensure monthly summary reports on individuals’ progress are written monthly. Staff spoken to were able to describe how they empower service users to be in control of their lives, make decisions and to lead purposeful and fulfilling lives as independently as possible. For example, service users are involved at stage 2 of the staff interviewing process and their input forms part of the recruitment process and offer of employment. Monthly service meetings are held where issues such as, the overall running of the home, activities and outings, holidays and education opportunities are discussed. Staff support service users to manage their finances. Personal allowances are not pooled together and appropriate records and receipts are kept. Secure facilities in service users’ bedrooms were provided for the safe-keeping of money and valuables. Financial records for two service users were checked and balance on transaction sheets corresponded with money available. Risk assessments were seen in service users’ care plans for activities carried out inside and outside of the home. Assessments were detailed and clearly outlined the action, which should be taken to minimize any identified risks to enable people to lead the life they choose. Litslade Farm DS0000023077.V370478.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): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people are able to enjoy a full and stimulating lifestyle with a variety of options to meet their diverse needs. Their dignity and rights are respected in their daily life. EVIDENCE: The annual quality assurance (AQAA) stated the following: “The staff encourage and support the service users to be actively involved in the running of the home and to take part in the many activities that we offer in the home and out in the community.” During the site visit staff were able to evidence what activities service users were accessing at the local college and the community centre. Paintings and ceramics made by service users were displayed in the home. A coffee table made by service users was being utilised in the lounge area. Staff spoken to said that all service users attend the local college, which helps them to improve on their social, communication and lifestyle skills. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 13 Staff support service users to enjoy a full and stimulating lifestyle with a variety of options to choose from. For example, service users attend coffee mornings arranged by the local church. They also take part in horse riding and cycling lessons and some of them are members of the local gym. They attend activities organised by the local community such as, line dancing, village shows and participate in competition events such as, baking at the annual village fete. Photographic evidence of service users participating in activities was made available for the inspection process. Those service users who have a passion for football have been escorted by staff to attend a football match at the new stadium in Milton Keynes. Trips are arranged regularly to the local theatre and cinema. Those service users who wish to promote their spiritual needs are escorted by staff to the local church. Staff said that service users are recognised and spoken to by people living in the village when they are out and about. We were told that the home held an open day recently and invited members of the local community to view the home. The event was a positive experience for service users and people living in the community. Service users are all members of the national trust gardens and this gives them free entrance to gardens and places of interests. As well as enable them to have safe places to walk and explore. Service users are encouraged to have visits from family and friends. Information reflected in the home’s annual quality assurance assessment (AQAA) stated that ‘improvements had been made within the last twelve months to ensure that contact with service users’ family is maintained.’ Staff requested photographs of service users’ parents and family members and these were displayed in their bedrooms. The AQAA indicated that ‘within the last year the home had regained contact with the family of one particular service user.’ The atmosphere in the home was warm and welcoming on the day of the inspection. Staff encourage service users to maintain their independence. They are supported by staff with household chores. They have access to all areas of the home apart from other service users’ bedrooms. All staff are expected to knock on service users’ bedroom doors and wait for a reply before entering. Bedroom doors are locked when individuals are out of the home. Any mail that is received is opened and read in private with the service user in their bedroom. Each individual is responsible for participating in the weekly grocery shopping with a staff member and for maintaining the garden and their personal laundry. Staff prepare a variety of meals for service users, which meet their dietary and cultural needs and respect their individual preferences. We were told that the dietician was involved in advising staff and service users on menu planning to cater for their individual requirements including weight control. We were Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 14 invited to participate in the midday meal, which was home made chicken and sweet corn soup served with bread rolls followed by fresh fruit salad and jelly for dessert. This was a relaxed and unhurried activity. Staff supported those individuals who needed assistance sensitively and discretely. Litslade Farm DS0000023077.V370478.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): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a good system in place to ensure that people receive support with their personal and health care needs in the way they prefer and is sensitive to their race, age and disability. EVIDENCE: Care plans seen reflected services users’ preferences on how they wished to be supported by the staff team with their personal care, what time they wish to rise and retire, and the level of support required to access facilities in the local community. This information was presented in a pictorial format to meet service users’ needs. We were told that service users choose their own clothes and regular visits to the barber are arranged by staff. Care plans seen for the two service users whose care was case tracked reflected that care was being provided in a flexible and person centred manner. The home employs a mixed staff team to ensure that service users have a choice of staff to work with such as, same ethnic background or the same gender. The home provides aids and equipment to encourage and promote service users to be independent. The community physiotherapist provides specialist advice to staff to ensure that equipment provided is used appropriately. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 16 The home’s AQAA stated the following: “The home has excellent communication and support with the GP practice. The staff team closely monitor any changes to the physical health of service users and contact the relevant professional immediately for advice if deterioration in mental or physical health is noticed.” Evidence was seen to support these statements for example, staff were able to access support and advice from the community physiotherapist and dietician from the learning and disability team as and when required. Several service users were members of the local gym and one particular service user had their own treadmill machine, which staff were supporting him to use daily to maintain his health and weight. Service users have regular health checks with their general practitioner and their medication is reviewed regularly. All medical appointments were recorded in individuals’ files to ensure that they were not missed. Service users’ weights were being monitored monthly and recorded. Other health checks such as optical dental and chiropody were routinely followed up. Several service users were having aromatherapy treatment approximately every two weeks. We were told that the staff team had discussions with a number of health professionals who provide hearing, dental and optical checks to ensure that they had a good understanding and were comfortable treating people with a learning disability. The home uses a monitored dose medication system. The medication administration record (MAR) sheets were examined and there were no unexplained gaps. There were no service users assessed as capable to selfmedicate on the day of the inspection. We noted that the home had robust systems in place to ensure that individuals’ medication was stored, recorded and administered appropriately. For example, a record was being maintained for all PRN (which means give when necessary) medication and daily checks are carried out at each handover to ensure that a clear audit trail of medication was in place. There were no service users in receipt of controlled medication on the day of the inspection. A record was in place for all medication leaving the home or disposed of to ensure that there was no mishandling. Staff confirmed that they had undertaken training in the safe handling and administration of medication and their skills were regularly updated. To enhance on the good practice in place a recommendation is made to ensure that the home retains a list of staff members authorised to give medicines, which should include a record of their approved initials. Litslade Farm DS0000023077.V370478.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a complaints procedure in place to ensure that people using the service or their representative are able to express their concerns and action taken to put things right. EVIDENCE: The home has a complaints procedure in place, which is clear and easy to follow and a record is maintained for all complaints received. The complaints procedure was available in a pictorial format to enable service users how to use it if required. The annual quality assurance assessment (AQAA) stated that the home has not had any complaints within the last twelve months. The Commission has not been made aware of any complaints about the service. The home follows the Buckinghamshire inter-agency policy for the safeguarding of vulnerable adults. The AQAA stated that the home has not had any safeguarding referrals or investigation within the last twelve months. Staff spoken to were aware of the action that should be taken if they witnessed or suspected an incident of abuse. They confirmed that they regularly undertake training to update their knowledge and skills in the protection and safeguarding of vulnerable adults. Litslade Farm DS0000023077.V370478.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People live in a home that is clean and hygienic and ensures that the lay out and size promote their diverse needs and safety. EVIDENCE: The home is a large detached bungalow set in spacious grounds. It is well equipped to meet the needs of the people using the service. All bedrooms are single occupancy with wash hand basins and were personalised reflecting the characters of individuals. It was recently re-decorated and looked warm and welcoming. There is a lounge and open plan kitchen /diner. All door spaces were wide enough to allow wheelchair access. Specialist bathing and showering equipment was available to promote independence and choice. The water temperature in toilets and in the bathroom was checked and was within the appropriate range to ensure service users’ safety. All service users have been issued with a key for their bedroom and are encouraged to see the home as their own. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 19 There is a large enclosed garden, which service users are able to access and spend some quiet time. The home’s staff support service users to grow vegetables and flowers and each service user had been allocated an area which they were responsible for maintaining. On the day of the inspection the laundry room was clean and tidy and fitted with a washing machine and drier. The home looked bright and airy and was free from offensive odours. Litslade Farm DS0000023077.V370478.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The staffing levels in the home were satisfactory to ensure that people are supported by staff in sufficient numbers to meet their diverse needs. The home’ recruitment practice needs to be consistent to ensure that staff are appropriately recruited. EVIDENCE: At the time of this inspection the home was fully staffed to ensure that the needs of people using the service would be met. We were told that the staffing numbers provided met service users’ assessed needs. During the course of the day there are three to four staff covering the morning and afternoon shifts and one staff covering the night shift with a sleep-in person. Staff were observed interacting with service users in a kind and respectful manner. They looked comfortable in service users’ company and were knowledgeable of individuals’ diverse needs and specific conditions. Staff spoken to confirmed that regular staff meetings and supervision sessions take place. Evidence of minutes of meetings and supervision records was made available for the inspection purpose. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 21 We were told that five members of staff had completed the national vocational qualification (NVQ) in level 2 in direct care and a further two were working towards achieving the qualification. Training records seen indicated that all staff undertake ongoing mandatory training as well as other training to support them in their personal and professional development and to ensure that the needs of people using the service are met in a person centred way. We were told that the organisation has introduced an electronic-learning package which all staff were able to access to update some mandatory training. We were told that service users are regularly involved in the recruitment process. Prospective staff members are judged on their attitudes, skills, qualifications and experience. They are also observed interacting with service users and how service users respond to their presence. The recruitment files for three staff members were examined. All files contained the following documentation: application form, two references, criminal record bureau clearance and terms and conditions of employment. We noted that in two of the files there were no recent photographs to confirm proof of identity. To comply fully with the regulation the home must ensure that recent photographs of staff members are provided to confirm proof of identity. In one particular file gaps in employment record were noted. No evidence was seen to indicate that there were followed up at the interview. A recommendation is made to ensure that any gaps in the employment record are explored at the interview and the outcome is recorded. Litslade Farm DS0000023077.V370478.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home’s health and safety practices ensure that people using the service and staff’s safety is not compromised. EVIDENCE: The manager has worked for the organisation since 2001 and prior to that worked for the health authority as a registered learning disability nurse. She has obtained the registered manager’s awards qualification and undertakes periodic training to update her knowledge and skills. She has a clear understanding of the service and works to continuously improve it. Staff spoken to said that the manager was approachable and supportive. The home has an improvement plan which is updated yearly and outlines a variety of areas to support the home and to improve on the service delivery. Equal opportunities are promoted in the home. For example, equality and Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 23 diversity is an agenda item at all staff’s meetings. This ensures that the care provided to service users is person centred. Monthly regulation proprietor’s visits take place, which promotes an open positive culture within the home and with the organisation. Annual service users’ satisfaction questionnaires are carried out and issues requiring action are incorporated into the home’s development plan. The home’s annual quality assurance assessment was returned on time. It contained clear and relevant information, which was supported by a wide range of evidence supporting the claims made. Information reflected in the AQAA indicated that servicing of equipment used in the home was up to date. A sample of health and safety records and accident and incident forms was seen and were satisfactorily maintained. We observed that regular fire drills were taking place and the names of staff members participating in fire drills were listed, which is good practice. Litslade Farm DS0000023077.V370478.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 2 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 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 X 3 X X 3 X Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation Schedule 2 Requirement To comply with current regulation staff’s files must contain a recent photograph to confirm proof of identity Timescale for action 30/09/08 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 YA20 YA34 Good Practice Recommendations The home should ensure that summary reports on people using the service are written monthly. To comply with best practice guidelines the home should ensure that it retains a list of staff members authorised to give medicines including a record of their approved initials. The home should ensure that any gaps in staff’s employment records are explored at the interview and the outcome is recorded. Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 27 Litslade Farm DS0000023077.V370478.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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