Latest Inspection
This is the latest available inspection report for this service, carried out on 14th May 2009. CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for Saresta and Serenade.
What the care home does well Listens to people and helps them to do the things they want to do. Looks after people`s health and cares for them well. Helps people keep in touch with their families and friends. Helps people get out do lots of activities that they enjoy. The home has comfortable rooms for people to live in. People have comfortable bedrooms with their own things in them. What has improved since the last inspection? There has been some redecorating. There has been some new furniture and carpets. What the care home could do better: Carry on making the paperwork better.Saresta and SerenadeDS0000017927.V377556.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65
Saresta and Serenade Bromley Road Elmstead Market Colchester Essex CO7 7BX Lead Inspector
Ray Finney Key Unannounced Inspection 14th May 2009 10:00 Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 2 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION
Name of service Saresta and Serenade Address Bromley Road Elmstead Market Colchester Essex CO7 7BX 01206 827034/825779 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) Mr Rohan Vasantha Kumara Dias Mrs Velamba Dias Ms Karon Bosher Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home accommodates 10 people with learning disabilities who may also have physical disabilities 22nd May 2007 Date of last inspection Brief Description of the Service: Saresta and Serenade is situated in the village of Elmstead Market. There is a local shop and garage nearby and the town of Colchester is a short bus or car journey away. There is a car park to the front of the property and wellmaintained gardens to the rear. The home provides care and accommodation for up to ten people with learning disabilities between the ages of 18 and 65, some of whom may have a physical disability. The home consists of two separate bungalows, each accommodating five people in single rooms with en-suite facilities. Each bungalow has living accommodation, kitchen and its own laundry facilities. The home is owned by Mr and Mrs Dias and is one of a small consortium of homes in the area. The manager of the home is Ms Karon Bosher. Information about the service may be obtained by contacting the manager. The home charges between £750 and £1,200 a week for the service they provide. This information was provided to us in May 2007. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Quality rating for this service is 3 star. This means the people who use the home experience Excellent quality outcomes.
EASY READ SUMMARY We looked at lots of different evidence for this report. We looked at paperwork like care plans, staff files and menus. The manager sent us information called an Annual Quality Assurance Assessment or AQAA. This gave us information about how they run the home. We visited the home on 14th May 2009. We looked around the home. We talked to people living in the home and staff. We looked to see if people were happy with what goes on in the home. What the service does well: What has improved since the last inspection? What they could do better:
Carry on making the paperwork better. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 6 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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 Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 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. Through the comprehensive admission process people choosing to live at Saresta and Serenade can be confident that their needs will be met. EVIDENCE: The manager stated in the AQAA, We have produced a brochure that staff were consulted and contributed towards. On the day of the inspection a sample of individual files examined each contained a copy of the homes Service User Guide. The manager has developed a new brochure giving information about the home including the philosophy, the objectives of the home, a description of the home and the surrounding area, activities and transport, staffing and skill mix of the staff team and the selection and placement process. The brochure has up to date photographs of the home and gives sufficient information to ensure anyone wishing to use the service would have a clear idea of what the home offers. Relatives who sent us completed surveys all responded always when asked if
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 9 they received enough information about the service. There have been no new admissions to the home for a number of years, but they continue to have an appropriate assessment process in place. The manager told us in the AQAA, We carry out an individual assessment to ensure the suitability of the home and the compatibility of the service user with people already living in the home. Although there have been no admissions since the last inspection there is an assessment plan to be followed. Through discussions the manager was able to demonstrate a solid knowledge of the importance of having a robust assessment process in place because of the complex needs of people using the service. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 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. People living in Saresta and Serenade receive good quality care based on their assessed and identified needs. EVIDENCE: The manager told us in the AQAA how they gather information to develop the care plans; she stated, Due to the nature of service users learning disabilities they are unable to give their views, so we use the following methods: Advocacy, parents/representatives views, reviews, behaviour monitoring charts, activity monitoring charts. We also seek advice from outside professionals such as outreach, community nurses and other such healthcare agencies. Care plans examined start with a client profile containing relevant information
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 11 such as detail of next of kin, date of birth, people involved in the care of the person and decision making. The manager told us in the AQAA, We are building life biographies with service users and families. For each person there is a range of individual care plans in place in sections covering Personal Care, Social Skills, Independent Living and Emotional and Physical Well-being. The format of the care plan identifies the need or problem, states what the objective is that they are trying to help the person achieve and an action plan that sets out details of the support or help needed in this particular area. Care plans examined included personal care, continence, communication, eating and drinking and activities. The care plans give details of what staff need to do and what the person is able to do for themselves. They contain good details so that staff are able to provide support consistently in the ways that the person needs and wishes. One care plan stated, X is to use manoy dish [a sloped dish to assist the person to scoop food onto the spoon] and large handled spoon at breakfast and a normal dinner plate at lunchtime with a plate guard and rubber mat under it. X needs a fork with other meals. The manager stated in the AQAA, Through care planning we ensure service users are treated as individuals and We encourage service users to make choices wherever possible. She further told us that what they do well is, Continual assessing of needs are being met through regular liaison with health professionals supporting service users in making decisions and introducing the mental capacity act for those unable to make choices and decisions for themselves. We discussed decision making at length with the manager. This is an area where she feels they have made significant improvements in the past year. Most of the people living in Saresta and Serenade have very complex needs making it difficult or not possible for them to make informed decisions. Individual records examined contained Mental Capacity Act Assessments. Staff know people well and have used this knowledge together with input from relatives, healthcare professionals and past experience of the person to develop communication passports. The communication passports that are being developed detail a wide range of aspects about the persons life including all about the person, what you need to know, family and special people in their life, special things or objects, things I like to talk about, How I Communicate (words, sounds and body language), You can Help me Communicate, I Like Going to..., I cant stand it!!!, Im Working on this..., Help Me Please and Eating and Drinking. There is information in the care plans examined about how the individual communicates. Staff spoken with were able to demonstrate that they are familiar with peoples complex needs and how they communicate their feelings or what they want. One file examined contained a document entitled What is the person saying?, which describes the noises the person makes, signs they use and what certain body language usually means for that person. This included feels bored - yawns and plays with clothes, is tired - yawns and rubs head or face, feels happy - very vocal and shakes arms or head, is frightened - screws up face and goes tense.
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 12 Peoples likes and dislikes are documented in the care plans. Care plans are evaluated every three months or when changes to the persons needs occur and Key workers also complete a three-monthly report. This ensures that people continue to receive appropriate care to meet their changing needs. When asked if the service meets the needs of the service user and whether they take diversity and individuality into account, all relatives who sent us completed surveys indicated always. A member of staff who completed a survey stated, Service users are treated as individuals who all have their own unique needs. Each person has a comprehensive range of risk assessments in place that describe the identified risk and the agreed response to reduce the risk. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 12, 13, 15, 16 and 17 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. People living in Saresta and Serenade can expect to enjoy a lifestyle that meets their wishes and needs. EVIDENCE: No one living in the home has the capacity to take part in educational or college courses but the range of activities in place to enhance peoples lifestyle is good. The manager discussed a training course that she and senior staff have completed and how it has made a huge difference to the way they look at activities. She explained that the course has helped develop their skills, particularly around assessing whether people like a particular activity. The manager has developed an activity monitoring and feedback form that documents how well the person participates in the activity, whether they
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 14 engaged with staff, how they interacted, how well they are aware of where they are and what they are doing, their mood and physical abilities. Those that were examined were completed with good information that showed staff were observing people well. One said, X was happy and was laughing and smiling. X interacted well with the toys that squirt water and the boats that float around in the spa pool. The manager explained that they are using these sheets to build up a picture of what the person enjoys and what they get from the activity. The manager stated in the AQAA, Each service user has a weekly individual activity plan which is monitored and evaluated regularly to ensure suitability of each activity. Among the recorded activities are trampolining at Bounceability, sensory sessions at a Snoozelen, swimming and aromatherapy. A visiting social care professional who completed a survey told us, The service users have regular opportunities to attend social activities to enhance their well-being and a member of staff stated, Our service users have a number of activities suited to their individual needs. They also go on holiday with a team of carers. In the AQAA we asked what issues have made it hard for the service to improve as much as they would wish. The manager responded, We continue to encounter problems around 1 to 1 support for our service users to access more community facilities. Most of our service users are wheelchair users and require extra support either with supervision or pushing wheelchairs. This is discussed at each review but funding authorities refuse to acknowledge these issues. The service has tried to reduce the impact of these barriers by, Continuing to organise leisure pursuits in a way that allows all service users to participate in activities on a regular basis and arranging staff accordingly. However, despite identified barriers around one to one funding, as previously reported, community links continue to be good. Records examined contained evidence that people regularly use community facilities such as going swimming, shopping or using community day centres. On the day of the inspection people were out for a number of hours in the morning. There is ample evidence in records examined that input from relatives is valued and people are supported to keep in touch with families and friends. Some relatives visit on a weekly basis. When asked if the service helps the person to keep in touch, all relatives who completed our surveys responded always. Events such as birthdays are celebrated and there are parties and discos for events such as at Christmas. The manager told us that there are three birthdays in May and June so they are going to have a summer party and BarB-Que and relatives are invited. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can expect their personal and healthcare needs to be identified and provided with the support to ensure these needs are met as they would wish. EVIDENCE: The manager said in the AQAA, [We] aim to meet personal care in a way that is preferable to the service user. Care plans examined contain sufficient information about the way people wish to have their personal care carried out to ensure staff provide this care consistently. Observations on the day of the inspection confirm that staff provide care discretely and are considerate of maintaining peoples dignity. A visiting social care professional who completed a survey for us stated, During my visits to the home I have observed the staff working to a high standard, respecting the service user’s dignity and privacy at all time. The manager told us in the AQAA that they, Support service users to attend
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 16 regular and relevant medical appointments [and they] record relevant information in the care plans and We promote a healthy lifestyle and manage conditions such as constipation with diet as opposed to medication with the support of the dietician. When asked if they are kept up to date will all issues affecting the service user, relatives who completed surveys all responded always. Records examined contain Health Information Files with individual Health Action Plans. There is ample evidence that peoples healthcare needs are given high priority. The manager and staff spoken with all were able to demonstrate a good awareness of individual needs around health and well being. Records examined contain evidence of appointments with healthcare professionals including Gastroenterology, physiotherapy, optician, Speech and Language Therapy and Occupational Therapy. There are a range of recording tools for people with specific conditions including weight charts and information about epilepsy and seizure charts. Relatives who completed surveys made positive comments about the care provided by the home. One told us, They meet the needs of every individual 100 per cent. This gives us complete peace of mind that [our relative] is being looked after in every respect and another stated, My [relative] is always looked after to the highest standard. [They are] happy and content. Another relative told us, Notice is taken if we suggest anything to benefit [our relative] and the home. Care plans contain a Personal Medication Profile detailing prescribed medications, what it is prescribed for, when the medication started and any possible side effects. Medications are stored securely in a locked cupboard. The manager told us in the AQAA, We have installed a controlled drugs cabinet for use if necessary. There are no controlled drugs currently in use in the home but we saw that they have had a new controlled drugs cabinet installed in the event that someone is prescribed medication that may require this level of secure storage. The manger was able to demonstrate a thorough understanding of their responsibilities around the storage and recording of controlled drugs. Medicines Administration Record (MAR) sheets examined were all completed appropriately. The manager told us in the AQAA, All senior staff have appropriate medication training and our observations on the day of the inspection were that staff followed appropriate practices when administering and recording medication. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that their concerns about how they are treated are listened to and acted upon as stated in the complaints and safeguarding procedures. EVIDENCE: The manager told us in the AQAA they, Encourage staff to be aware of the complaints procedure [and] Deal with minor complaints before they become problems and [the] Manager is available on a daily basis to discuss any concerns with staff or parents and visitors. As previously reported there is an appropriate complaints procedure in place. Since the last inspection there have been no formal complaints received by us and there have been none recorded by the service. The manager explained that they ensure they deal with minor concerns as they arise and she has now introduced a comments book so they can record any concerns or positive comments that relatives and visitors may have. Relatives who completed surveys all said they knew how to make a complaint and when asked if the service had responded appropriately to concerns all responded always. The manager stated in the AQAA, [We] ensure all checks are carried out at the start of employment and all staff have an enhanced CRB in place and Ensure staff update POVA training yearly. Records examined confirm that all
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 18 staff have yearly refresher training around safeguarding (previously referred to as Protection of Vulnerable Adults or POVA). Staff spoken with were able to demonstrate a commitment to ensuring people are safeguarded and are well aware of their responsibilities. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can enjoy living in an environment that suits their lifestyle and which is well maintained and clean. EVIDENCE: The manager told us in the AQAA about improvements they have made to the environment in the past twelve months. She stated, [We have] upgraded the bathroom in Serenade to a wet room more suited to the service users needs. Introduced industrial washing machine as recommended by water regulations. All bedrooms and dining area in Serenade have had carpets replaced by more suitable flooring. Replaced carpet in Serenade lounge. All bedrooms have been redecorated in the past twelve months. Serenade kitchen retiled and painted and new work surfaces in both kitchens. As previously reported Saresta and Serenade provides a comfortable and
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 20 homely environment for the people who live there. Both bungalows are bright and well maintained with good quality furnishings. We noted on a tour of the premises that, since the last inspection, there has been redecoration in many areas and some new furniture, including a leather suite. Many areas have had new specialist flooring, which has the appearance of laminate but is softer underfoot. Bathing facilities are good. The bathroom in Serenade has a jacuzzi bath and overhead tracking that ensures people with limited mobility are able to access the bath with ease and have a relaxing experience. Peoples individual rooms are decorated to a high standard and contain ample evidence of personal possessions and items that reflect their individual tastes and interests. A social care professional who completed a survey told us, They provide a safe and homely environment to the service users in their care. and a member of staff, when asked what the home does well, stated, Provides a bright, comfortable home. To the back of the premises is an extensive well maintained garden. There is a large wooden gazebo where people can relax or eat meals when the weather is good. One person enjoys using a sandpit and this can be accommodated in the gazebo as well. When asked what they could do better, one member of staff who completed a survey told us, Nothing at present but would like to see the garden space developed in the future and another stated, Make more use of large rear garden. The manager explained that they have plans for improvements outside, including a sensory garden. There is a good standard of cleanliness throughout both bungalows, including the kitchens and laundry rooms. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 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 living in the home can be confident they are cared for by a competent staff team who can meet their needs and who have been employed following thorough recruitment checks to ensure people are safeguarded. EVIDENCE: The manager stated in the AQAA, We encourage all staff to undertake NVQ training so that competently trained staff are able to deliver a high standard of care. This is reflected in our quality assurance programme. Through discussions the manager and staff were able to demonstrate a commitment to achieving National Vocational Qualifications (NVQ). On the day of the inspection an NVQ assessor was visiting the home and working with some members of staff. All but two of the current staff team have either completed an NVQ award or are in the process of doing NVQ at either level 2 or level 3. Out of a total of twenty one staff seventeen have completed the award and two are in the process. An NVQ assessor who completed a survey
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 22 told us, The staff are always professional and are committed to completing their NVQ awards. On the day of the inspection we observed that members of staff carried out their duties confidently and in a professional manner. Staff spoken with said they ensure knowledge and information is shared through a good handover process. When asked if the carers have the right skills, all relatives who completed surveys told us, always. The manager said, Staff have a clear understanding of service users’ needs and their preferred methods of communication. Our observations on the day of the inspection confirmed that staff communicated well with people living in the home. A sample of three personnel files were examined and found to be well organised. They contained all the documentation required by regulations including Photographs, application forms with appropriate employment history, job descriptions, two written references, Criminal Record Bureau (CRB) enhanced disclosures, PovaFirst checks and appropriate proofs of identity. Personnel records examined contained evidence that staff have an induction using the Skills for Care Common Induction Standards and staff receive a handbook. Through discussion the manager explained how she uses the Skills for Care Knowledge sets to work with small groups of staff to develop knowledge and skills, thereby improving practices. She also felt that training has improved staff morale and peoples confidence has grown as a result. The manager told us in the AQAA some of the things they have done in the past year relating to staff training. She stated, Six members of staff have undertaken training in providing activities within the care setting. Staff training around conflict management so staff are able to deal with issues effectively and appropriately and Successful funding gained for training staff allows us to spend more money in other areas. The manager told us in the AQAA, Low turnover of staff ensures continuity of care for service users and a member of staff who completed a survey said that what the home does well is, Good staff team with a low turnover. The staff training and Development Plan for the year was examined and Personnel records contained evidence that staff undergo a range of training including safeguarding (previously referred to as Protection of Vulnerable Adults or POVA training), food hygiene and a comprehensive distance learning pack for Infection Control. Staff have yearly updates on Manual Handling and Fire Safety training. Other external courses run by the local authority have also been used, including Managing Behaviours that Challenge and Delivering Personal Care. The manager explained that they also have three staff on the waiting list for a training course for carers to support people through breast screening. The manager and senior staff have completed an extensive distance learning course on activities. The manager explained that this has made them re-think activities and see the wider picture of what constitutes an activity. They are monitoring what they are doing by completing activity monitoring sheets.
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 23 Personnel records contain supervision agreements between the member of staff and the management. Each member of staff has a minimum of six formal supervisions a year as well as observations and a yearly appraisal. Supervisions are recorded, including what was discussed and any agreed actions. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 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 is appropriately managed in the best interests of people living there. EVIDENCE: Since the last inspection the manager has completed the Registered Managers Award (RMA) and continues to update her skills and knowledge with ongoing training. We observed at the last inspection of the service, that the manager had developed her management skills and greatly improved procedures, since then this process has continued. In addition to demonstrating an excellent knowledge of the needs of people living in the home, the manager now also shows excellent management skills. She is proactive in taking processes within the home and looking at ways to improve and develop them in the best
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DS0000017927.V377556.R01.S.doc Version 5.3 Page 25 interest of people who live there. The NVQ assessor who completed a survey stated, The management have been totally committed to ensuring the staff have adequate learning time to work towards their NVQ awards. A member of staff who completed a survey told us, Our manager is always on hand for us as carers if we have any concerns. Recording continues to improve and the manager works well with the managers of the other two homes in the group so that they all benefit from one another’s individual strengths, such as updating Policies and Procedures or accessing training. We stated in the last report that the excellent approach to leadership and management ensures that the ethos of the home values person centred working practices. This continues to be the case and people using the service can be confident that the home is managed in their best interests. The manager provided evidence that the home has a robust Quality Assurance System in place. They seek the opinions of staff, relatives and any other interested parties. There are a number of ways of getting this information including questionnaires sent to relatives, the comments book and concerns forms that are readily available for anyone to complete. The manager also collates other evidence as part of the quality assurance process including the local authority quality monitoring report and contract monitoring room assessments, Health and Safety information, monitoring of activities, the concerns and complaints process and staff training and development. All this information is collated in the Quality Assurance file to demonstrate how they respond to information to develop and improve the service. The manager told us in the AQAA that one of the improvements they have made in the past year has been, Introduced a kitchen diary via the food standards agency to ensure a high standard of safety around food hygiene and infection control. A range of Health and Safety documents examined were all found to be in order and up to date. A visit from the Essex County Fire and Rescue Service in September 2008 found a satisfactory standard of fire safety was evident. Health and Safety certificates examined included a Landlords Gas Safety Certificate, emergency lighting test and electrical installation test certificate. The fire detection system was updated in June 2008 and new electronic door closures were fitted on some individual bedroom doors. Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 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 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 4 X X 3 X
Version 5.3 Page 27 Saresta and Serenade DS0000017927.V377556.R01.S.doc 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. Refer to Standard Good Practice Recommendations Saresta and Serenade DS0000017927.V377556.R01.S.doc Version 5.3 Page 28 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk
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