Care Home: Pershore Short Term Breaks Service

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What the care home does well Pershore Short Term Breaks gives people information about their service to help people make choices about their future support needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Pershore Short Term Breaks helps people to do things they like to do and to try new activities. Pershore Short Term Breaks looks after people well and writes down what help everyone needs. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Pershore Short Term Breaks makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Pershore Short Term Breaks.People can choose what they want to eat from the varied menu. Other choices to the main menu are made, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Pershore Short Term Breaks. What has improved since the last inspection? Care plans are now done in a more person centred way. Key workers help to make sure that support is given to people in the way they would like Care plans have been developed and information is easier to find. This makes it easier for staff to know how to give the support people need. Staff have done first aid training to help people safe who are at risk. What the care home could do better: A list of risk assessments with dates when they need to be checked would help staff keep them all up to date and make sure that none are missed. CARE HOME ADULTS 18-65 Pershore Short Term Breaks Service 48 Station Road Pershore Worcs WR10 1PD Lead Inspector Dianne Thompson Unannounced Inspection 1st September 2008 09:30 Pershore Short Term Breaks Service DS0000037468.V371925.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 Pershore Short Term Breaks Service DS0000037468.V371925.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. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pershore Short Term Breaks Service Address 48 Station Road Pershore Worcs WR10 1PD 01386 552978 01386 553018 pershoresb@worcestershire.gov.uk www.worcestershire.gov.uk Worcestershire County Council Home Care Services Mr John Masterson Care Home 5 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) Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate people for short-term care only. Date of last inspection 19th September 2007 Brief Description of the Service: Pershore Short Term Breaks is situated on a service road, off the main A1041, in a pleasant residential area approximately one mile from Pershore town centre. It is situated at the end of a building shared with a day centre and provides a short-term respite care service. Worcestershire County Council operates the service and the responsible individual is Amanda Nally. Mr John Masterson is the registered manager. The main entrance to the building and car park are shared with the staff and users of the day centre. Pershore Short term Breaks has its own front door and apart from the joint use of a bathroom and the garden, the accommodation is self-contained. All the accommodation used by service users is on the ground floor with staff facilities on the first floor. The service can accommodate a maximum of five people at any particular time staying for short periods of care. All the people who use the service have learning and physical disabilities. The aim of the service is to offer support based on the principles of dignity and respect in a safe, warm and friendly environment. Details of the fees for the service are included in the Service Users Guide, and start at £9 per night. This fee information was correct at the time of our inspection. The reader may wish to contact the service for up to date fee information. Pershore Short Term Breaks Service DS0000037468.V371925.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 the people who use this service experience excellent quality outcomes. This was an unannounced inspection visit to see what the service was like for the people who use the service at Pershore Short Term Breaks. Time was spent talking to some of the people who were using the service and some of the staff working there. We looked at some of the records, policies and procedures in the office. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Pershore Short Term Breaks and the ways they plan to make the service better. We looked at parts of the premises. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: Pershore Short Term Breaks gives people information about their service to help people make choices about their future support needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Pershore Short Term Breaks helps people to do things they like to do and to try new activities. Pershore Short Term Breaks looks after people well and writes down what help everyone needs. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Pershore Short Term Breaks makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Pershore Short Term Breaks. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 6 People can choose what they want to eat from the varied menu. Other choices to the main menu are made, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Pershore Short Term Breaks. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pershore Short Term Breaks Service DS0000037468.V371925.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 Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people start to use the service to make sure their individual needs can be met. EVIDENCE: Policies and procedures are in place for assessing potential people to use the service at Pershore Short Term Breaks. Information about the service is included in a Statement of Purpose and Service User guide and this is available to people requesting information. The service user guide is available in different formats to suit individual needs, such as pictures, signs and symbols. Full community care assessments are received for everyone and in addition Pershore Short Term Breaks complete their own assessments. We saw that community care assessments had been completed for the files examined. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. The manager says in the service’s AQAA that ‘the service has improved its care planning Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 9 system to ensure that they represent each service user in a more individual way’. People are given an information pack containing a copy of the statement of purpose and service users guide on admission. The service user guide gives information about the service that people can expect, together with details about the fees, and a copy of the complaints procedure. All staff are encouraged to be involved in the assessment process from introductory visits to focussed support. Surveys confirm that information is shared about the service to help people contribute to decisions that involve their relatives. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life when using the service. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. EVIDENCE: Care plans for three people were checked and all contained appropriate information about individual needs and how they are to be met. These plans set out in detail the action to be taken by care staff and show that reviews are taking place on a regular basis. A review of one of the care plans examined had been completed on 20th February 2008. Each file has an index to sections Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 11 and this provides easy access to all information. The service has improved its care planning approach to one that makes sure each service user is considered individually. Information in care plans cover all aspects of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. Details about the ways people communicate are provided. Communication is varied and care plans are made available in a range of formats that includes symbols and pictures. Staff complete records with people who use the service to make sure everyone is involved as much as possible in their everyday lives and choices during their stay at Pershore Short Term Breaks. A staff signature sheet is included to show that guidelines and risk assessments have been read. One signature sheet was dated 31/3/08. Each person is allocated a key worker to oversee his or her care. Key workers support people on a one-to-one basis and contribute to the care planning process. The manager states in the service’s AQAA that ‘we have key working groups led by a senior to ensure that there is a team to support the individuals needs and wishes’. Risk assessments are completed to keep people safe and include additional support guidelines for staff to follow where this is needed. Completed risk assessments show dates for planned reviews and explore ways to make sure that people can be as independent as possible. We saw completed risk assessments to promote and maintain people’s mobility in and outside the building. The manager was advised that although most of the risk assessments seen had been reviewed and are up to date, a monitoring checklist would be useful to track when reviews are due and make sure that none are missed. We saw where two risk assessments had become due and had not been reviewed or updated to reflect this, such as communication guidelines dates 18/2/08 with risk assessment due for review 30/7/08. We saw eating and drinking guidelines with a completed risk assessment reviewed 21/2/08 but guidelines say due 30/6/08. We saw that risk assessments have improved following the last inspection, to include more information and guidelines for staff to follow. Staff have now received in first aid where they needed to be trained to manage identified risks and this meets the requirement of the previous inspection. Surveys confirm that care given is what is expected or agreed with the service. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People using the service are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People are supported to make choices about what they want to do during their time at the service. Four people arrived from their day services for an overnight stay and examples of their involvement were observed during the inspection visit. The range of activities provided includes grocery shopping, places of interest, being in the garden, Snoezelen, walks, listening to music, being read to, people watching, church, and pampering sessions such as manicures and Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 13 pedicures. Activity records record information that includes time spent at day centres, interaction with staff and other people who use the service and trips out for lunch. The manager states in the service’s AQAA that ‘we need to ensure the rotas are flexible to use the staff resources to the maximum benefit of the individuals’, and that ‘the staff team are motivated to provide activities and experiences within the community’. This is a view supported by some staff with comments in surveys. Staff indicated that with more staff ‘they would be able to go out more often’ and ‘offer genuine choices, organise and prepare for weekends’ and ‘see what is on locally’. The service provides meals that are varied and nutritious, with different choices available where preferred. Snacks and drinks are available during people’s stay. People are consulted about their choice of food and diets, and support is given for people who find it difficult to eat and need help. Eating and Drinking Guidelines to support each person are developed with the Speech and Language therapists. We saw people given choices about their evening meal, and being supported to make those choices in a patient and considered way. Menu options include fish pie, parsley sauce, cheesy mash, peas, carrots and cauliflower; pasta in tomato sauce with cheese; sweet and sour chicken with rice. Various options for dessert include fruit, yogurt and lemon cheesecake. We saw detailed recording of menus and food eaten that shows an increase in the use of and availability of fresh vegetables. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Pershore Short Term Breaks. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Pershore Short Term Breaks has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: People who use the service have care plans that include their health action plan. These plans give information about personal care needs and the ways people prefer to be supported. Health action plans give detailed information about each person’s health needs and how they are to be met. Main carers or family usually complete physical checks and monitoring for people using the service, and this is maintained as needed by staff at Pershore Short Term Breaks. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 15 People have good access to medical support through the local Primary Health Care Team should this become necessary during their stay. Emergency contact details are available in each person’s care plan to liaise with main carers should there be any concerns, and staff have access to an on call system to support in the absence of a manager on site if required. The manager states in the service’s AQAA that ‘all specialist interventions are recorded in care plans and health action plans (where individuals choose to have one). Staff feed back into health action plans by updating carers on any issue’ that may arise while people stay for short breaks. We saw staff engage with people in a respectful way, making sure that dignity and self-esteem was important for each person. Although communication with people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. Surveys confirm that staff are ‘very caring’ and ‘look after people well’. A policy and procedure is in place for the administration of medication. All staff who are involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems which may occur. Additional guidelines for are in place for the administration of medication on day trips and outings. This meets the recommendation of the previous inspection. Medication is stored securely and given to people at the right time and full records are kept which show this. A medication sheet in each person’s plan gives details of current prescribed medication. The manager states in the services AQAA that ‘the local pharmacist has recently conducted an audit of the medication system and records and their suggestions have been implemented’. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints and to make sure that people who use the service are protected from abuse. EVIDENCE: Pershore Short Term Breaks has a complaints policy and procedure in place which is accessible to people who use the service and their relatives. The manager says the procedure ‘includes clear guidance on who to contact and how’. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that one complaint has been made since the previous inspection. The manager confirms that the complaint made to the service is being responded to according to Worcestershire County Council policies and procedures. We have not received any complaints or safeguarding concerns about Pershore Short Term Breaks. Each person’s file has a compliments and complaints section that also provides feedback each time people use the service, such as ‘thank you’ notes and cards. There are specific policies and procedures in place to guide staff on the protection of vulnerable adults from abuse and on ‘whistle blowing’ for staff. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 17 Staff receive training in abuse awareness, and staff training records confirm this. Financial policies and procedures are in place for all financial matters. The service does not have main responsibility for the finances of people using the service. People take money to use during their stay and systems are in place to manage such monies. We saw two members of staff check in money for people as they arrived. Two staff check this out again when people return home. Receipts and detailed records are kept for all expenditure. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who stay at Pershore Short Term Breaks enjoy a comfortable and homely living environment that is spacious, kept clean and well maintained. EVIDENCE: Pershore Short Term Breaks is in a residential area of Pershore with access to shops, leisure centre and doctors surgery locally. The service has access to other recreational activities in the Evesham and Worcester area. Pershore Short Term Breaks provides a service to a maximum of five adults who have learning disabilities and some people who may have a physical disability. We looked at parts of the premises. Pershore Short Term Breaks is accessible, comfortable and provides a homely environment for the people who stay there. There are separate communal rooms of lounge, dining room, kitchen, laundry, bathrooms and toilets. We saw that all rooms are clean, tidy and well presented. The bedrooms are a good size and suitably furnished. There is a Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 19 call system in place. Photographs of the people using the bedrooms have been attached to the door so everyone knows which room they are using. Sensory equipment is available for everyone to use and people who use the service can also access the sensory garden that is shared with the day centre. The office on the ground floor is to become a computer room for people using the service. Computer equipment, including touch screens are ready to be installed. A room on the first floor is now being used as an office with computer facilities for all staff. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Training records show that staff are trained in procedures for the control of infection and health and safety matters. There is a schedule for the routine maintenance and upkeep of the buildings and maintenance logs are kept. Surveys indicate that the ‘short breaks accommodation is fresh and clean and offers a homely and friendly atmosphere’. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who stay at Pershore Short Term Breaks. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to make sure that everyone staying at Pershore Short Term Breaks is kept safe. EVIDENCE: Pershore Short Term Breaks has a committed and stable staff team. People commented in surveys that they were generally satisfied with the service and the staff. Staff appeared to be enthusiastic and well motivated. Pershore Short Term Breaks operates a recruitment policy and procedure where everyone completes an appropriate application form and makes sure that suitable references are obtained including one from most recent Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 21 employers. Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period. Staff records were examined for three people. All required information was seen including confirmation of identity and suitable references. The manager said that four new staff has been interviewed last week and that the process of offering posts and obtaining references has started. The manager confirms that all new staff complete an Induction course and thorough training to make sure they can meet the needs of the people they support. Training is organised through Worcester County Council (WCC) and training programmes are based on individual training and development assessments for each member of staff. A record is maintained with dates of planned refresher courses identified in the training matrix. Mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults is provided. We saw that first aid training took place 15/4/08 and 17/6/08. All staff completed additional training such as risk assessments in February, March and April of this year. Training courses and staff attendance has much improved since the previous inspection. Additional training has been sought to support a new admission to the service. Deafblind training has helped staff develop their skills and awareness that has benefits for other people too. Regular core team meetings are held with minutes available and these were seen during the inspection visit. Minutes of the staff meeting on 7/7/08 included discussions about the Mental Capacity Act with the date of the next meeting booked for 15/9/08. The manager states in the service’s AQAA that regular ‘supervisions and annual appraisals take place’. Staff surveys confirmed this. Time was spent talking with staff on duty at the time of the inspection and included a senior member of staff and two support workers. Staff were comfortable in their roles, very positive about the service they provide and the support they receive from the management team. Comments from staff surveys indicate that people feel they are well trained, and the service ‘has a good friendly atmosphere’ where people ‘are put first to make their stay safe and comfortable’. ‘We have a good team here and can rely upon each other to pass on information, concerns, and ideas’. Staff say they work ‘to give the best possible to service users’ and ‘provide a safe and homely environment with very experienced and qualified staff team who also provide a stimulating environment’. Surveys from carers and people who use the service commented that ‘the staff are very caring’ and ‘skilled staff will know’ what people prefer to do. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The service is well managed and staff receive the leadership and support they need. Worcestershire County Council (WCC) monitors Pershore Short Term Breaks in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager John Masterson has many years experience working with people with learning disabilities and is qualified to NVQ level 4 Diploma in Management of Care Services. John has recently completed the Registered Managers Award (RMA) and regularly completes training relevant to his position as registered manager of Pershore Short Term Breaks. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 23 The manager said that there is an open door policy at Pershore Short Term Breaks and surveys confirm that people are made welcome and are able to talk to the manager and staff at any time. The manager states in the service’s AQAA that ‘policies and procedures are available in all aspects of the management of the service. This includes Organisational policies and locally developed protocols to support staff within their roles’. Management responsibilities are shared with one deputy manager and two senior support workers. They are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. The manager said that staff work well as a team, although some staff indicated in surveys that they had missed the manager’s support during times he has been supporting another service. The manager said that a deputy manager has provided support and that work has continued to develop the service during his absence. Core staff have become more involved in review meetings held in day centres for people who use the short stay service. The Annual Quality Assurance Assessment (AQAA) was comprehensively completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Pershore Short Term Breaks and the ways they plan to develop the service. The provider’s monthly visits are one of the ways that WCC monitors the service and how it is being run. These visits include interviews with staff and people using the service. An audit of relevant parts of the service, including records, environment, complaints received, finance and safety is also completed. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of Pershore Short Term Breaks quality assurance and monitoring system that is intended to form an annual development plan for the service. This report includes the views of people who use the service, stakeholders and interested parties. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking mandatory health and safety training topics. The manager said that ‘staff undertake fire training and are involved in fire evacuations’ and records confirm this. Generic risk assessments are in place. WCC complete an annual Health and Safety Audit and an action plan from this is provided. Pershore Short Term Breaks Service DS0000037468.V371925.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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 4 X 3 X X 4 X Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations A monitoring checklist would be useful to track when risk assessments are due to be reviewed to make sure that none are missed. Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pershore Short Term Breaks Service DS0000037468.V371925.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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