Care Home: Pool View

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What the care home does well Pool view was set up in response to the specific requirements of the individual living there and as such the service offered is centred around their personal needs and preferences. This was reflected in way the service user was introduced to the home, with allowances made for their specific preferences and support that was gender specific. The homes assessment processes were also robust and have enabled the home to develop a care plan that is centred on the needs of the individual. The home provides an extremely comfortable environment that presents a domestic ambience whilst providing ample space for the occupant. The manager of the home showed a commitment to the service user and systems for the management of the service were generally robust and efficient. Staff spoken to showed an interest in their work and a commitment to the ethos of the home. There was seen to be a good level of training provision and steps are been taken to address any shortfalls in this area. There is a commitment to ensuring that resident`s health is monitored with assistance from community health care services. Support for newly recruited staff was seen to be in place and the home was using an appropriate induction and training tool for new staff, this meaning that staff were well supported with training that enabled them to be skilled and knowledgeable. What has improved since the last inspection? This is the first statutory inspection of the home (beyond the initial registration process) and as such it is not possible to make a clear judgment on improvements made by the service at this time. It was noted that a privacy lock has now been fitted to the service users bedroom door since registration however, this to assist the service user with their privacy. What the care home could do better: CARE HOME ADULTS 18-65 Pool View Pool Street Woodsetton Dudley West Midlands DY1 3SN Lead Inspector Mr Jon Potts Unannounced Inspection 25th January 2008 10:00 Pool View DS0000070547.V354785.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 Pool View DS0000070547.V354785.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. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pool View Address Pool Street Woodsetton Dudley West Midlands DY1 3SN 01384 410 418 01384 410 429 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) info@Inshoresupportltd.com Inshore Support Limited Christine Rivers Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Pool View DS0000070547.V354785.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 the following gender: Male Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 1 The maximum number of service users to be accommodated is 1. Date of last inspection First inspection Brief Description of the Service: Pool view is situated in a residential area of Dudley. The home is registered to provide care for one male service user who has been diagnosed as having a learning disability. The home is sited behind another dwelling with the driveway off a cul de sac, this ensuring a good degree of privacy. The home is adapted from a two-bedroom bungalow, which comprises of a kitchen, bathroom, lounge, bedroom, and office/sleep in room. There is also a small and private garden area to the rear. The inspector was impressed with the home regarding its internal fixtures, fittings and furniture. The home is of a good size for one resident and is well presented, well maintained, clean, homely and has a warm welcoming atmosphere. The staff team consists of a registered manager (who also manages another small unit next to Pools view) who is supported by a number of seniors and support workers. The support staff also carry out domestic and catering tasks (supporting the service user as appropriate). The manager is responsible to a responsible individual and other senior managers within a company that runs a number of homes of similar size and purpose. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 5 The charges for accommodation are not currently stated within the homes statement of purpose or service users guide and it was stated that these are were calculated on an individual basis dependent on a pre admission assessment. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 6 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 that use this service experience good quality outcomes. This unannounced inspection was carried out over half a day and involved the inspector assessing the homes performance primarily against the key national minimum standards for younger adults. Evidence was drawn from a number of sources and including case tracking the care for the current resident (this involving looking at all the documentation in respect of their care and cross checking this with outcomes), observation of practice, discussion with the Registered Manager, staff and review of management records. There was also some discussion with the resident. Information was also supplied pre inspection by the home. The resident and staff are to be thanked for their assistance with the inspection. What the service does well: What has improved since the last inspection? Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 7 This is the first statutory inspection of the home (beyond the initial registration process) and as such it is not possible to make a clear judgment on improvements made by the service at this time. It was noted that a privacy lock has now been fitted to the service users bedroom door since registration however, this to assist the service user with their privacy. What they could do better: This was a positive first inspection but there are some areas where improvement could be made as detailed: • • • The development of key policies, procedures and care records in pictorial or alternative formats that allow easier understanding by the resident (although there was evidence that this work had commenced). Whilst the service user has marked to show their agreement on some documents in their case file confirmation through documentation of discussion and agreement with the individual would be helpful. A copy of the guidelines relating to the mental capacity act should be available to assist staff to understand the implications of this law for their practice, ensuring that rights to such as individual bank accounts for the service user are explored with other professionals. When the residents monies are taken out of the home they should be signed out at the point they are removed and booked back in when returned this so that records are accurate at all times. • 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. Pool View DS0000070547.V354785.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 Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Any prospective individual looking to use the service, and their representatives have the information (in a standard written format) needed to choose a home, which will meet their needs. Any prospective resident has their needs assessed and opportunity to sample the service and meet staff. A written contract, which clearly tells them about the service, is available and is explained verbally in accordance with the individual’s communication needs. EVIDENCE: There was clear evidence from records and discussion with the homes manager that significant time and effort was spent planning to make the service users admission to the home personal and well managed. There was clear evidence that an individual approach had been taken to ensure the service user was treated as an individual with allowances made for the life-changing decisions they needed to make in respect of moving home. The gender of the staff member introducing the service user to the home was clearly considered with the male manager of another home utilised to assist this process and in doing so respond to individual needs for information, reassurance and support. The assessment indicated that the service user related better to males, although Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 10 later on in the process the manager of Pool’s view and other staff became involved in the admission process. The homes statement of purpose is a specific document to the home based on a generic format used by the companies other homes (which all offer a similar service). It clearly sets out the objectives and philosophy of the home and includes a range of information about the service provided, the accommodation, staffing (experience and qualifications) how to make a complaint and so on. The resident has a copy of the statement of purpose/service user guide available to them in their case file although the use of a more pictorial based document maybe better for them. A contract (called the lifestyle agreement) is also available and this sets out the basic terms and conditions of the service but again would benefit from presentation in a format that would better suit resident communication needs, although it was stated by the manager that verbal explanation suitable to the service users needs had been given throughout the admission process. The range of fees for the service for a prospective resident are not stated in the Statement of Purpose or Service User’s guide, the manager stating that these are calculated on an individual basis following assessment and as such it should be possible to provide an illustration as to a fee range within which the cost of the service would fall. There was clear evidence of the service user having involvement in a review and comprehensive needs assessment before admission through care management arrangements and this was also supported by the homes own assessment, which was carried out by experienced staff. The homes involvement with the resident began well before their admission to the home, this evidenced by numerous pages of documentation and reports detailing initial contact with the individual to first form a relationship and then introduce them to the possibility of a move to Pool’s view. This first meeting was held at the service user’s favourite café and later meetings continued within the community rather than at the care home until there was a gradual move to coming to see Pool’s view and the service user deciding as to whether it was right for them. The home’s procedures in respect of the admission process supported the practice that the home had carried out although there was some variation that was based on the needs of the service user (such as gender and disability). The home and service, as only provided for the one service user, was built around their individual needs and the assessed requirements detailed with care management assessments and the homes own. An example of this was the provision of staffing in accordance with those laid down in the care management assessment. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff at the home involve the service user in day-to-day decisions about their life, and encourage them to play an active role in planning the care and support they receive, if not through discussion then through observation of the individuals preferences and responses to situations. EVIDENCE: The care plan for the individual living at the home has been developed from the assessment, which in turn is clearly based on the needs and preferences of the individual. Any changes and updates are based on preferences that are expressed by the individual prior to or since they have moved into the home and as such are in accordance with their choices. There is clear reference to communication and sexuality and how the home can meet any needs related to equality and diversity. The plan is centred around the personal needs of the service user and whilst not directly written with the individual (as there is a need to ensure that information is tailored according to understanding) it is Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 12 based on observation of that person’s likes, dislikes and behaviour. The plan details health requirements and staff are aware of these as well as the rest of the care plan, with other staff seen to have signed to show they have read and understood the resident’s requirements. The care plan details how the home can provide for the service users individualised care, and as such the service at present has been built around these. The provider is responsive to training needs and there is clear evidence that the homes training plan considers training that is important to meet the needs of the individual beyond the basic requirements of mandatory training, this including such as administration of rectal medication. There is however a need to ensure that there is a copy of the guidelines relating to the mental capacity act so as to assist staff understanding of the implications of this law for their practice. Care plans are supplemented by a comprehensive risk assessment, which was seen to be subject to review as needed. The service has a ‘can do’ attitude and risks are managed positively to help people using the service lead the life they want. There is an emphasis on minimising limitations on freedom, choice or facilities with any in place demonstrably in the person’s best interests. The manager stated that time is taken to try and present information so that the individual understands and agrees these. The service user was stated to be unable to sign to agree documents (although has put their mark on some). The manager was advised to document when information has been verbally relayed to the resident and this then signed and dated by staff. The service user is continually consulted on how the service runs on a daily basis (as was seen to be the case) and the staff gave examples of how the resident influenced their own day-to-day and key decisions in the home. The resident was demonstrably fully involved in decisions about such areas as dayto-day routines, life of the home, and its future development. Policies and procedures, the manager stated, are as far as possible explained to residents in so far as they impact upon them, although this needs to be in presented in manageable and appropriate ways to assist understanding. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The one resident at the home is supported and encouraged to make choices about their life style, and to develop their life skills within any agreed limitations. Social, educational, cultural and recreational activities are aimed at meeting the individual’s identified preferences. EVIDENCE: The home’s procedures set out how the home should understand and actively promote the importance of how staff are to respect the human rights of people using the service, with fairness, equality, dignity, respect and autonomy all being seen as central to the care and support being provided. The service user has opportunity to enjoy a full and stimulating lifestyle with a variety of options to choose from on a day-to-day basis, this based on views expressed through assessment and on going consultation. The service user has Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 14 access to activities either in the local community (the home is sited close to the service users preferred locality) or within the home. Routines are very flexible, this helped as there is only one resident, and the resident can make choices in major areas of their life as was shown within documented activity records that followed those likes, dislikes and preferences explored within assessments. Documented information clearly showed the home had explored diversity in respect of sexuality, gender of carers, disability and communication. The manager was advised to raise the right of the resident to have their own individual bank account at their next multidisciplinary review however, as this was apparently closed prior to their move to Pool view. The service user’s plan details that they need to be given choices on a daily basis; this as opposed to a set activity programme and staff spoken to are well aware that this was necessary. There was clear documented evidence that the service user has involvement in some housework tasks as able including such as hovering, laundry etc. In addition they are able to have some involvement in food preparation with staff, this limited by risk though (as summarised in risk assessments). The service user was seen to have access to the majority of the house with only limited access to some service areas of the home for safety reasons, this not including the kitchen. The staff record the meals the resident has on a daily basis and these reflected a number of the likes and dislikes that were documented within assessments and a list of preferences. With only the one resident there is flexibility in respect of when they chose to eat. The resident has received advice from staff as to healthy eating and has agreed the implications this has for their diet. Pool View DS0000070547.V354785.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 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care provided to the individual living at the home is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The service at Pool’s view has been set up in response to the needs of the current resident and as such the service they receive is based on their individual needs and preferences. The homes policies and procedures reflect the need to provide flexible and sensitive support to the individual with their choices in respect of such as personal care documented in care plans, these understood by staff (from discussion with us). Staff were also clear as to ways they could positively support and respect the individual’s privacy and dignity, as detailed in the care plan. The home has employed a number of male staff to allow for provision of gender sensitive care when needed. Staff fully recognise the need to encourage independence as set out in the individual’s plan. The manager was very clear that she expected staff to include the individual in all discussions (with their involvement in staff meetings and part Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 16 of the inspection) as it was the resident’s home and as such they must be involved in what’s happening. There was an expectation by the manager that staff must introduce the resident to any visitors to the home at the point of their arrival. Personal healthcare needs including specialist health and dietary requirements are clearly recorded in the resident’s individual plan. This plan gives a comprehensive overview of health needs and details what input is needed to ensure the individual’s health is maintained. Access to healthcare services is facilitated in accordance with the individual’s planned requirements, with visits to local health care services as needed. The individual who lives at the home is physically able, although some aids have been provided to accommodate any areas of potential difficulty that may arise such as a bath seat and grab rail in the bathroom. The home’s training plan shows areas where the service has identified where staff need training in health care matters and in part this has been complied with, although further training is planned (such as epilepsy awareness). The aims and objectives stress the importance of treating individuals with respect and dignity. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain all required entries, and are signed by staff. There is still a need for some staff to undergo accredited medication training this identified as a training need that is to be addressed immediately by the homes responsible individual. Regular checks by the manager are undertaken and recorded, these to monitor compliance and in addition to those carried out by the contracted pharmacist, the record of this last visit showing that there were no issues of concern, but also evidencing that the manager sought appropriate advice on medication related issues. The home has sought the consent of the resident in respect of administration of medicines and followed this up within a risk assessment framework. The home does not currently handle any controlled drugs. Pool View DS0000070547.V354785.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 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The individual who uses the service is able to express their concerns where possible and staff are aware of the need to monitor resident’s behaviour for signs of dissatisfaction. The home has a robust, effective complaints procedure and safeguards are in place to protect the individual from abuse. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It is available in written format, this supplemented by an easy read large print/pictorial version. Discussion with the manager and staff indicated that the individual at the home was able to express their views and any dissatisfaction this seen during the course of the inspection. The Resident has ready access to professionals independent of the service (psychiatrist, social worker etc) on a regular basis and this has been known to provide a means by which concerns can be picked up and addressed. The homes procedure makes it very clear as to what can be expected to happen if a complaint is made. Unless there are exceptional circumstances the service would be expected to respond within the agreed timescale. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff in discussion knew when incidents need external input and who to refer the incident to. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 18 Whilst staff displayed a good awareness of safeguarding issues there is a need for training for some in this area. This has been identified by the company’s responsible individual and dates set for the training. Other training around dealing with physical and verbal aggression is also made available to staff as needed, and discussion with staff as well as records related to dealing with challenging behaviour showed that the homes procedures in respect of the management of potential or actual aggression are well understood and followed in practice. The staff understand what restraint is and alternatives to its use in any form are always looked for, with a measured response to challenges presented by residents well documented in behaviour plans. These aforementioned plans related to individual’s assessed needs, and did not involve the use of any physical restraint, but verbal distraction, which based on records has proved successful in de-escalating any potential challenges. Pool View DS0000070547.V354785.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): 24,25,26,27,28,29 & 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables the individual who lives there to reside in a safe, well-maintained and comfortable environment, which encourages their independence. EVIDENCE: The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the resident who lives there. The living environment is appropriate for the particular lifestyle and needs of the individual and is homely, clean, safe and comfortable. As the sole occupant the resident is encouraged to see it as their own home. It is a very well maintained, attractive home, which is accessible to community facilities and services. There are some limited adaptations (this as the resident is quite physically able) in place to meet individual resident’s needs such as the provision of a bath seat and grab rail in the bathroom. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 20 The home is designed to provide a suitable home for the resident and provides maximum independence in a discrete non- institutional environment that resembles a domestic dwelling. The individual plan details how the resident is fully involved in decisions about the décor and any changes to the accommodation within a risk assessment framework, this also underlined by the views of the manager. The resident has access to their own bedroom (which is of good proportions), this furnished with good quality furniture and the residents own possessions. A privacy lock has been added to the bedroom door since the home opened. There is also a good size lounge, kitchen and bathroom available to which the resident has access. Fixtures and fittings throughout are of good quality, well maintained and adapted to meet the wishes of the present service users. The management has a proactive infection control policy and staff understood how to promote infection control and maintain a safe and clean environment. Risk assessments and items necessary to support infection control were seen to be available (such as liquid soap and paper towels). Pool View DS0000070547.V354785.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 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are generally well trained, skilled and available in sufficient numbers to support the people who use the service in all aspects of their lifestyles, in accordance with the assessment of dependency and need. EVIDENCE: Staff rotas and staffing levels seen on the day of the inspection show that the home is staffed in accordance with the expectations of assessments carried out under care management arrangements with particular attention given to the needs of the individual who lives at the home. Clearly the staffing structure is built around the needs of the individual and not staff requirements. The home was seen to have a clear training plan and although there are some areas where staff require some further training this has been identified and training is been booked or planned to address these gaps (such as adult protection, medication and epilepsy). Where there have been issues with the training plan falling behind or particular training needs not been met these have been picked up by the responsible individual within their monthly visits to Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 22 the home. The training plan and certificates show that staff are expected to undertake training beyond the basic mandatory requirements and in accordance with the specific needs of the individual resident. Staff were positive as to the training made available to them by the provider and the manager was well aware of the benefits of a skilled, trained workforce. There is a good recruitment procedure that clearly defines the process to be followed. From sight of staff files it was evident that this was followed in practice with the exception of one file where there was an incomplete working history. In discussion with the staff member they confirmed this information had been provided and the lack of information was due to some information not having been transferred from the Inshore support home where they were previously employed. Enhanced disclosures were seen for all the staff team this an important factor in ensuring staff are safe to work with a vulnerable adult. Staff spoken to confirmed that they were involved in an induction in accordance with national minimum standards and it was pleasing to see that some of the staff team had been drawn from staff already employed by the company prior to the opening of the home, this ensuring that there were staff that were familiar with the companies policies and procedures and experienced in the care of individuals with a learning disability. Where there are sickness and vacancies the home has access to three bank staff although the manager did state that staff going off sick at the last minute prior to a shift had created some difficulties at times, this a matter that had been taken up as a supervision issue. Staff meetings take place regularly and include the resident. Supervision sessions have not always been carried out on a regular basis. Those supervision sessions that have taken place were seen to be documented. Pool View DS0000070547.V354785.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): 37,39,41 & 42 Quality in this outcome area is good 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 and is supported by an effective quality assurance systems developed the provider and carried out by an experienced manager. EVIDENCE: Whilst the manager has qualifications in care appropriate to her role these do not meet the full expectations of the NMS. The manager does however have extensive experience of working with adults with a learning disability, and has worked with her current employer at a senior level for a number of years. The manager stated that she is considering retirement in the very near future which would mean her pursuing a registered manager’s award at this time would be an inappropriate use of training resources. As the manager of Pool’s Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 24 view and an adjacent home (owned by Inshore support) and the fact that her management has generated what are good outcomes for the service user at the home, coupled with good support for the provider, it was agreed that the necessity for the her to pursue this training would be relaxed, with the expectation that any replacement has or obtains the said qualification. The manager in discussion was able to demonstrate a clear understanding of the key principles and focus of the service that drew from corporate aims and priorities. The establishing of the service at the home was primarily to create an increased quality of life for the individual resident and the homes aims, policies and procedures, coupled with outcomes from this inspection show that there is a focus on equality and diversity issues and promoting human rights, especially in the areas of dignity and respect. The manager leads by example having involvement with the care of individuals and whilst staff supervision could be better (in terms of formal one to one sessions) the staff team have been recruited and trained to a generally good standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. Whilst the AQAA submitted to the CSCI could have been better the fact that the home has only been open a few months needs to be considered and the responsible individual has sourced training for managers within the company in respect of how these annual quality assurance assessments are completed. The data section of the AQAA is accurately and fully completed however. The home works to a clear health and safety policy and in discussion the manager and staff were fully aware of this and had received training that helped them put theory into practice. Regular random checks take place to ensure they are working to it. Safeguarding is given high priority and the home provides a range of policies and guidance that underpin legal requirement and good practice. It is too early to say whether the home will have a consistent record of meeting relevant health and safety requirements and legislation, although involvement with the provider through inspection of their other services would indicate that they do work hard to address any issues that may arise through closely monitoring their own practice. Records are of a good standard and were found to be routinely well completed during the course of case tracking the care of the individual resident. The manager was seen to have completed or obtained copies of appropriate risk assessments that took into account the resident’s preferences. The individual residents was seen to be supported to manage their own money where it was possible and again in accordance with preferences although discussion indicated that the resident does not at this time have their own bank account. The manager was advised to raise this matter at the next review (which was planned for the near future) with the resident’s social worker. In addition the manager and staff need to ensure that when money is taken out of the home it is booked out at the point removed and any change booked back in on return so that records are accurate at every given point. Pool View DS0000070547.V354785.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 3 3 4 4 4 5 3 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 4 26 3 27 3 28 4 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 2 3 X Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 26 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Registered Persons should develop all key policies and procedures (such as the service users guide) and care records (such as care plans, activity records) in pictorial or alternative formats that allow easier understanding by the resident. The Registered Provider should ensure that the range of fees that a prospective resident may pay are detailed within the home’ s service user guide or statement of purpose. The registered manager should ensure that where the care plan and other care records and associated documents have been discussed with the resident a record is made of this discussion to compensate for the lack of signatures to indicate their agreement/confirmation of understanding. The registered manager should ensure that there is a copy of the guidelines relating to the mental capacity act so as to assist staff understanding of the implications of this law. The registered manager should raise the right of the DS0000070547.V354785.R01.S.doc Version 5.2 Page 27 2. YA1 3. YA7 4. 5. Pool View YA7 YA16 6. YA41 resident to have their own individual bank account at their next multidisciplinary review. The registered manager should ensure that when the residents monies are taken out of the home (for such as shopping with the resident) they should be signed out at the point they are removed and booked back in when returned this so that records are accurate at all times. This is a recommendation (rather than requirement) due to the fact that receipts were readily available at the time to evidence the exact amounts not accounted for on the records seen. Pool View DS0000070547.V354785.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Pool View DS0000070547.V354785.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. Re-publishing this information is in breach of the terms of use of that website. 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