Care Home: Shamu

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What the care home does well People who use the service are supported to live an independent lifestyle and make their own decisions and choices. Risk assessments have been put into place to support them. The assessed needs of the people who use the service are recorded and care plans are in place based upon those needs. Health needs are also recorded and support is provided to attend GP and other health related appointments. People who use the service know who their key worker is and say that they feel supported. People who use the service meet regularly with staff both in groups and for individual sessions to discuss their day to day lifestyles and care needs. The home is in keeping with other residential housing stock in the area and provides a homely domestic environment with sufficient private and communal space. All bedrooms are single and the people who use the service can have their own keys if they choose to. Staff training is provided and is up to date, staff receive 1:2:1 supervisions and also meet regularly as a team. Staff recruitment procedures are satisfactory and protect the people using the service. What has improved since the last inspection? The manager has confirmed that the main areas of concern identified at the last key inspection have been addressed. The manager of the service is now registered us. The service is in the process of introducing person centred approaches, and has involved people who use the service with health planning and the development of individual activity plans. The organisation has introduced a resident`s forum for all of the homes in Stoke-on-Trent, a representative from each of the services attends these meetings. The complaints procedure has been changed to a more user-friendly format. The bathroom and shower room have been refurbished and redecorated. The kitchen has been repainted. A new induction programme for new staff has been introduced. The manager is now registered with us. What the care home could do better: There is evidence of improvement in a number of areas since the last key visit, but some of the recommendations of the last report have not been fully acted on. People who use the service should know what the fees and costs of the service are. The introduction of the new person centred plan should be completed and staff should be provided with the training or the guidance they need to be confident they can support service users. The records of medication administration should be accurately maintained. The service should continue with the necessary upgrading and redecoration of Shamu. Staffing levels should remain under review to ensure that they are sufficient to meet service users needs, and all staff must receive mandatory training. The number of staff training to National Vocational level 2 should be improved. An annual development plan should be produced based upon the outcomes of the quality audits of the service. The manager should complete the NVQ level 4. CARE HOME ADULTS 18-65 Shamu 126 Regent Road Hanley Stoke on Trent Staffordshire ST1 3AY Lead Inspector Wendy Jones Unannounced Inspection 31st July 2008 15: 40 Shamu DS0000064026.V369362.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 Shamu DS0000064026.V369362.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. Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shamu Address 126 Regent Road Hanley Stoke on Trent Staffordshire ST1 3AY 01782 284520 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd Mrs Pauline Adams Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2007 Brief Description of the Service: Shamu is a residential care home, which provides to six service users who have a learning disability and who may also experience mental health difficulties. It is owned by Delam Care, a company that owns five similar care homes in the vicinity. Delam Care is owned by Care Tech. People using the service have their own bedrooms, four of which are on the ground floor. There a lounge, separate dining room, kitchen and a laundry shared with the adjacent care home. The home has a small garden area at the front and a larger area at the rear with a grassed area and trees and flower borders. There are facilities for the people using the service to sit in the garden. There is a shower room downstairs and a bathroom upstairs. The home is located close to Hanley centre, with access to some local shops and a 20-minute walk to the main shopping area. Some of the people using the service attend a local college and they are all able to access the community independently. The aim of the home is to promote the independence of the service users and to support and encourage them to develop their life skills. The service user guide is currently under review. Any prospective service user or their supporters should contact the service if they want to know the cost of the service and the fees charged, Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star, This means the people who use this service experience good, quality outcomes. This was a key inspection site visit of this service undertaken on 31 July 2008 and included formal feedback to the manager. In total the visit took approximately 6:00 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 31/07/07 have been acted upon; looking at information the service provides for prospective residents, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, staff and people who use the service were spoken to during the site visit and a brief tour of the building was undertaken. Before the visit began, the service provided it’s own assessment of it’s performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to residents, relatives and any professional that has involvement in the service. We have not received any completed surveys, this means we cannot ascertain the views of relatives and other supporters of the people who use the service. The service provides for younger adults who have a Learning Disability and may have a mental health disorder. Dependency is generally low with the current service user group, levels of independence high, with support and prompting from staff. As a result of this visit we made one requirement and 11 recommendations. Since the visit, we have received representation form the service about some aspects of the report we have looked at the areas identified and made changes if needed. What the service does well: Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 6 People who use the service are supported to live an independent lifestyle and make their own decisions and choices. Risk assessments have been put into place to support them. The assessed needs of the people who use the service are recorded and care plans are in place based upon those needs. Health needs are also recorded and support is provided to attend GP and other health related appointments. People who use the service know who their key worker is and say that they feel supported. People who use the service meet regularly with staff both in groups and for individual sessions to discuss their day to day lifestyles and care needs. The home is in keeping with other residential housing stock in the area and provides a homely domestic environment with sufficient private and communal space. All bedrooms are single and the people who use the service can have their own keys if they choose to. Staff training is provided and is up to date, staff receive 1:2:1 supervisions and also meet regularly as a team. Staff recruitment procedures are satisfactory and protect the people using the service. What has improved since the last inspection? What they could do better: Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 7 There is evidence of improvement in a number of areas since the last key visit, but some of the recommendations of the last report have not been fully acted on. People who use the service should know what the fees and costs of the service are. The introduction of the new person centred plan should be completed and staff should be provided with the training or the guidance they need to be confident they can support service users. The records of medication administration should be accurately maintained. The service should continue with the necessary upgrading and redecoration of Shamu. Staffing levels should remain under review to ensure that they are sufficient to meet service users needs, and all staff must receive mandatory training. The number of staff training to National Vocational level 2 should be improved. An annual development plan should be produced based upon the outcomes of the quality audits of the service. The manager should complete the NVQ level 4. 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. Shamu DS0000064026.V369362.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 Shamu DS0000064026.V369362.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who may use the service can be sure that their care needs will be assessed to ensure that the service is suitable to meet their needs. But they cannot be sure that the information they receive about the home provides up to date details of the costs and fees. EVIDENCE: The service told us that, “Should a vacant room become available at Shamu and a referral be made an assessment tool is in place to ensure that a full preadmission assessment takes place. This assessment aims to determine suitability for the home and to ensure that the individuals needs can be met. The process involves a full and thorough assessment followed by visits to the home, where the prospective service user is allowed the opportunity to interact with both staff and residents. Service users at the home are aware of their rights and responsibilities in relation to the home through the provision of the home contract and statement of purpose.” At the last inspection we asked that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. The manager told us that this had not been completed and that work was being carried out to update both the Service User Guide and Statement of Purpose. We saw a Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 10 revised version of both documents to which the correct fees needs to be added. This matter was previously a requirement of the last key report. Following changes to our guidance, we have included this as a recommendation of this report. One service user we spoke to said they thought they knew what the service user guide was but couldn’t be sure. No new admissions have taken place since the last key inspection. Service users have lived at the home for a number of years. Previous key inspection visits have found that pre admission assessments have been carried out satisfactorily. Service users we spoke to said they are happy at the home and Had been involved in the decision to move into the service. Shamu DS0000064026.V369362.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that care plans are in place and they will be involved in discussions about them. But they should be certain that they can actively supported to make their own decisions about the care they wish to receive. EVIDENCE: The service told us, “The support plans that we have in place are detailed and are split into sub-categories that are in line with the principles upon which our homes are based. Service users at the home are fully in control of their lives and should any risks occur that may limit this these are fully assessed and controls are put into place to reduce the risk but to continue to allow the individual to control all aspects of their lives. Support plans are reviewed six monthly in co-operation with the individual and any changes needed are made.” Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 12 People who use the service said, “Staff have care plans in the office.” It was confirmed from discussion that staff talk to service users about their care plans. We have been told by the manager and staff that the service arranges regular meetings for people who use the service, these include monthly 1:2:1’s, weekly menu and activity planning and monthly house meetings. We saw some evidence in the records made available to us during the visit and also spoke to people who use the service to confirm this. The organisation has introduced a service user forum, where a representative from each of the local homes meet to discuss issues affecting them. We looked at the care records for two people. They included assessments of care and plans to address any care needs. Risk assessments are in place and are also subject to regular review. The service is in the process of introducing a person centred approach to care planning, and has included a 24 hour plan of care for each person. It is hoped that the service will fully implement this new model of care planning for the benefit of the people who use the service. All staff have yet to receive training in the use of the new model of planning. Shamu DS0000064026.V369362.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service are supported to live independently as possible and are involved in decision-making. Their rights to choose are respected. EVIDENCE: The service told us in the AQAA that, “The home ensures that provisions are made should residents wish to partake in activities in accordance with the lifestyle that they choose to lead. Service users are also encouraged to maintain contact with family and friends where possible. Where possible residents are encouraged to access the community independently although where this is not possible staff will assist service users in accessing the community. On induction into the home and thereafter residents are introduced to the surrounding area and local facilities are highlighted and the ways in which service users can best utilise and access them is explained.” Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 14 People who use the service said, “ I go out to the shops when I want to and use the bus, I have my own bus pass.” “I’m going to go to college again, staff have been helping me to look at new courses.” “ I enjoyed my holiday.” “ I ‘m hoping to start with a new group after the summer holidays, I think I’ll enjoy it.” The service has it’s own transport; this is paid for by a monthly contribution by all service users. All service users have been on a holiday this year they all went to Tenby in North Wales. When suggested that this arrangement did not reflect person centred approaches, we were told that service users had made that choice. Evidence has been provided that the service supports service users in maintaining relationships with families and friends, within the boundaries of risk assessment if necessary. Weekly meetings are held to discuss menu and activity planning; the records available are not up to date. A meeting was organised on the day of the visit, (informally) as is the norm around the dining table, service users were encouraged to participate, some did, some declined or attended for a short period. Service users accompany staff to purchase the weekly food shopping, and can choose to help with meal preparation and cooking if they want to. We observed that some service user actively enjoy being involved others choose not to. The meal of the day was minced beef and gravy potatoes and vegetable. All service users had the same meal no alternative was offered or recorded. Residents said, that if they didn’t want what was available they could have something else. Staff discussed specific dietary issues that they are aware of and described how they support service users in understanding the importance of good diet. Shamu DS0000064026.V369362.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): Quality in this outcome area is (Good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their health needs are known and monitored. Systems for the safe administration of medication need to be robust to ensure that people who use the service are not at risk. EVIDENCE: The service told us in the AQAA that, “All personal and healthcare support that we offer at Shamu is provided in a way that maintains both independence and personal dignity. Service users are encouraged to tend to their personal care as far as they are able to and with the appropriate level of support. The administration of medication in the home is also dependent upon the individuals requirements.” We looked at the health records of two service users, and saw that health needs are recorded and monitored regularly. People who use the service are offered support to attend health related appointments, and there is evidence of good communication and working relationships between the service and health professionals. Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 16 People who use the service are relatively independent in relation to their personal care requiring minimal intervention or support, but this can vary. One service user discussed specific details about some health advice she had been given, staff were observed to be supportive. We looked at the services medication administration records and the procedures relating to the stock control of medication. We looked at the storage facility and spoke to staff about their training. The medication records show one error from the sample seen and there was concern that the new monitored dosage system did not include a description of the medication dispensed. This means that the staff cannot be sure that the medication supplied was the medication prescribed. The manager agreed to contact the dispensing pharmacist about this. We have since been told that this has been rectified. Protocols have been developed for all PRN medication and explanations as to the reason and effects of medication are available for staff. We have previously recommended that they are signed by the general practitioner. The manager stated that she has spoken to the GP about this but he had not agreed to sign them. Information shows that staff have received training in the administration of medication and the manager confirmed that the training provided met the recommended standards; staff have also had a competency assessment. We have been informed of one medication error since the last key inspection site visit. The records show that the service took appropriate action to ensure that well-being of the service user. One person who uses the service currently self medicates. A risk assessment is now in place. At the last inspection visit we recommended that the service consider the subject of death and dying, to establish service users spiritual wishes in this respect, and to ensure suitable arrangements are put in place. The manager told us that this is something they are continuing to look into but have not completed, due to the sensitivity needed in approaching this topic. Shamu DS0000064026.V369362.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that any concerns they have will be listened to and can be confident that the majority of the staff team know what to do to protect them from the risk of abuse. EVIDENCE: The service told us in the AQAA that, “The safety of our service users is paramount and is ensured at all times. Policy and protocol in relation to safety and security is followed closely and any concerns are carefully explained to residents through the medium of service users meetings and key working discussions. Any complaints that may be made are documented fully and are investigated as per policy and procedure. The complaints procedure is available to all service users, their families and staff and an easy-read version is displayed in the entrance corridor of the home. The complaints procedure is also included in the service user guide which each resident has their personal copy of.” People who use the service said, “ If I’m worried about anything I’ll speak to my key worker or any of the staff and the manager.” “ The staff make sure I’m okay. I don’t have any complaints.” The service has a complaints procedure; this has been developed into a userfriendly format and is displayed in the home. People who use the service know about it and what to do if they have any concerns. We have not received a complaint about Shamu, since the last key visit and the manager said they have not received a complaint in the last 12 months. Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 18 We spoke to a member of staff who confirmed that safeguarding training had been given and confirmed his understanding of the procedures. The manager said that updated safeguarding training has been provided for all staff and is included in the new induction. We have been informed of one safeguarding referral since the last visit to Shamu, the concerns were not related to the care and support given at the home. Records show that the service user has been supported by the service and safeguarding procedures followed. We looked the financial records of two service users and found they were accurate. We understand that checks of the amounts recorded against the actual money in the home are undertaken at every handover. We are informed that all service user are registered on the electoral role and vote on local and general elections if they choose to. Shamu DS0000064026.V369362.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service enjoy a comfortable, homely environment that is showing signs of improvement and is safe, but would benefit from further upgrading. EVIDENCE: The service told us in the AQAA that, “Shamu provides a homely environment that is comfortable and friendly. The home is clean and work has been carried out to update areas that were in need of modernisation. All amenities are on hand for service users and the environment provides a safe area that meets resident’s needs.” We have also been told that improvements since the last inspection site visit include, “The bathrooms have both had a complete upgrade. The kitchen has undergone changes to its layout to enable to staff better access to all areas of the kitchen. The kitchen has been repainted.” The manager said that other redecoration is planned in the next 12 month, the service would benefit from some general upgrading, and the stair carpet is Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 20 looking worn. Service users said, “ I’d like my bedroom decorated it hasn’t been done for a while.” The service is located in a residential area and is in keeping with the other residential properties. The main entrance and small garden area is poorly maintained and would benefit from some attention to make it more welcoming. Communal facilities include spacious lounge and a separate dining room, the kitchen is galley style so limited in terms of space. A laundry and garden is shared with the property next door. Staff said they were working with service user to improve the garden area. All bedrooms are for single occupancy, none have en-suite and service users have a key to their bedroom and the front door if they want to. At the last inspection we recommended that the service adopt infection control advise by including paper towels in communal bathrooms, toilets, kitchen and laundry. The manager stated that paper towels and dispensers have been purchased but have yet to be fitted. Audits of the service and maintenance requests are completed regularly and environmental risk assessments are in place. Shamu DS0000064026.V369362.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that recruitment procedures are robust and staff are regularly supervised, but some gaps in the training may affect the quality of care and support they receive. EVIDENCE: The service told us in the AQAA that, “Staff are subject to a full training programme and the training that is provided is to a high standard which will result in a good level of care and support being provided. New starters are subject to a two week induction period which sees them undertake the LDQ (Learning Disability Qualification). Staff are CRB checked before being able to work unsupervised and along with the recruitment process two satisfactory references are also required.” We spoke to a member of staff who usually works in the home next door. He confirmed that he had received mandatory training sessions and that this was up to date, including a 10 week infection control course, manual handling, health and safety, fire safety and first aid as well as a medication course and assessment of competence. Additional training includes, Mental Health, Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 22 management of challenging behaviour, he has also completed National Vocational Qualification (NVQ) 2 and is enrolled on NVQ 3. He has not completed an update on safeguarding but will be booked in, and booked on None Violent Crisis Intervention training. We looked at a staff training matrix and while there is evidence of good staff training, there are gaps in infection control and safeguarding. Of the four staff employed at Shamu the records show that only one has an NVQ qualification this is less than the 50 recommended. We have been told by the service that all staff are working towards an NVQ qualification. We understand that staff have received training or guidance in relation to equality and diversity, the records we have seen don’t reflect this. Staffing levels equate to 1 person throughout the waking day and 1 sleep in at night additional hours are provided by the manager when needed. Additional staff can be allocated if the need arises, to accommodate service user outings/ appointments. Staff rota’s confirmed this. We have asked the service to continue to keep staffing levels under review to ensure that they don’t limit spontaneous activities. We have been told that full time staff receive a monthly 1:2:1 supervision session, part time have bi-monthly supervision, in addition staff have an annual appraisal. Staff meetings are also held on a monthly basis. Shamu DS0000064026.V369362.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the manager of the service has the necessary experience to manage the service but they must be assured that the outcomes of quality audits are collated and an annual development plan produced o evidence continual improvement. EVIDENCE: The service told us in the AQAA that; “The Registered Home Manager has a number of years experience working in the field of care and in care management. The service users benefit from having a deputy home manager in addition to the home manager. The management team ensure that service users rights are promoted and that support plans are followed appropriately in accordance with their aims.” The manager has been registered and approved by us, she has completed her RMA and we understand is enrolled on NVQ level 4 in care. People who use the Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 24 service confirmed that the manager is supportive of them, and said, “ I can go to Pauline if I need to and she will help me.” We found that the AQAA provided good information about the service, but the service should ensure that the Statement of Purpose and Service user guide are up to date. The manager said in the AQAA that all equipment in the home is serviced regularly, we checked and found that the current insurance certificate for the home is up to date and the certificate of registration with us is accurate. It has been reported to us that the organisation Caretech has recruited a Quality Manager, to undertake audits of the local services on a regular basis. A report is produced with action points for the service to address within given time scales. This is in addition to the monthly visits that are carried out by the local operational manager. The service has yet to produce an annual development plan. But progress has been made in relation to listening to service users views; the introduction of a service user forum is reported to be very positive. Fire safety officers have said they are satisfied with the standards of fire safety at the home, and risk assessments relating to fire safety have been completed. A service user confirmed that they were familiar with the procedures for fire evacuation and the record show that staff have been involved in fire drills. General risk assessments have been completed and are subject to review. While there is overall evidence of improvement in some areas since the last inspection the manager agreed that some area remain a “work in progress.” Shamu DS0000064026.V369362.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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 2 X X 3 x Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA32 Regulation 13(3) Requirement The manager must ensure that all staff have received infection control training. Timescale for action 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The manager should ensure that the fees and costs of the service are included in the service user guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. The manager should ensure person centred guidance should be offered to all staff. The new person centred planning system should be fully implemented and service users should be fully involved with this. The manager should ensure that medication records are accurately maintained. This will reduce the risk to service DS0000064026.V369362.R01.S.doc Version 5.2 Page 27 2. 3. YA6 YA6 4. YA20 Shamu users. 5. YA21 To consider the subject of ageing, death and dying and establish individual wishes. This will ensure that the people using the service and/or their families’ wishes are followed in this event. To continue to undertake a programme of refurbishment and redecoration to ensure that the people using the service live in more pleasant surroundings. To ensure that 50 of the care team are trained to NVQ level 2. The organisation should continue to regularly review the staffing levels to reflect the needs of the people using the service. The manager should ensure that all staff have attended safeguarding training to ensure that they know how to recognise and report suspected abuse. The manager should produce an annual development plan based upon the outcomes of quality audits, to demonstrate how the service intends to improve. 6. YA24 7. 8. YA32 YA33 9. 10. YA32 YA39 Shamu DS0000064026.V369362.R01.S.doc Version 5.2 Page 28 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. 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