Care Home: The Drive

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What the care home does well Staff members support residents to participate in a range of social and recreational activities in the local community. Good efforts have been made to enlist the support of colleagues within the local Community learning Disability Team including Speech and Language Therapy Sensory care and Physiotherapy and Occupational Therapy. Residents are provided with a varied nutritious diet. Staff members ensure residents have access to appropriate health care professionals. The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional. What has improved since the last inspection? The manager was newly appointed at the previous inspection and has made commendable efforts to improve the service provided. Two of three requirements made previously were complied with, these related to record keeping and a safety hazard identified. The third requirement is restated following a poor response from some placing authorities regarding the need for contracts for residents. What the care home could do better: Six requirements were made arising from this inspection: The Registered Person must draw up a contract with each resident and both the registered manager and resident/advocate should sign a copy of this. Restated Requirement, previous timescale of 16/03/07 was not met. A copy of the complaints procedure must be made available in a more userfriendly format for residents. The brown painted panelling and skirting boards in the entrance area and corridors must be repainted in order to provide a more conducive environment for residents. Access from the patio to the dining room was difficult for residents with physical disabilities and must be improved by the provision of a non- slip ramp. The kitchen units are in need of replacement and the worn work surfaces that might constitute a health hazard and must therefore be upgraded.All staff members must be annually updated in Moving and Handling and Fire Prevention. Seven recommendations were made arising from this inspection: It was recommended that the manager advises in writing that it is a legal requirement for placing authorities to provided contracts for individual placements and these be returned to the home as soon as possible. It was recommended that the home retain their own notes of reviews pending their completion and receipt by placing authorities. Also that monthly review notes by care staff within the home are clearly dated and signed by the author. It was recommended that the home employ a second shift leader and the post is made permanent and recruited as soon as possible. It was recommended that all staff members be annually updated in safeguarding Adults training. An annual survey of the views of visiting professionals in respect of the service provided by the home should be implemented as soon as practicable. It was recommended that fire drills conducted clearly indicate that all nighttime care staff members are evidenced as having taken part at least two times per annum and the times of drills be recorded. A recommendation was also made regarding an aspect of the medication system. CARE HOME ADULTS 18-65 The Drive 17 The Drive Sidcup Kent DA14 4ER Lead Inspector Keith Izzard Key Unannounced Inspection 28th January 2008 10.30 DS0000006811.V345666.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 DS0000006811.V345666.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. DS0000006811.V345666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Drive Address 17 The Drive Sidcup Kent DA14 4ER 020 8309 0440 020 8309 1532 thedriverh@aol.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) The Drive Care Homes Ltd Vanessa Elizabeth Donovan Care Home 12 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places DS0000006811.V345666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. I place registered for service user category LD(E) for named service user only. 11th May 2006 Date of last inspection Brief Description of the Service: The Drive offers a permanent home for up to twelve adults who have a severe or profound learning disability with associated and complex needs. Complex needs include mobility needs, arising from sensory deprivation, communication needs or behaviour that challenges. The home is located in a residential area within walking distance of the local town and public transport. The Home has it’s own transport which is used to provide opportunities outside of the Home. Staff support is provided 24 hours a day. Opportunities for leisure and occupation are provided by the Home and some service users attend a day service provided by their sponsoring authority. This is determined by the assessment of need and in negotiation with the commissioning authority. DS0000006811.V345666.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 that the people who use this service experience good quality outcomes. The site visit for this key unannounced inspection was completed over one day on 28th January 2008. Three members of staff the manager and deputy manager assisted the Inspector in a constructive and helpful manner. All the residents were seen. The service was last inspected on 23/01/07, a random inspection to follow up on compliance with the requirements made at the previous key unannounced inspection conducted on 11/05/06. The inspection included a review of information received about the service, a tour of the premises, examining records, including care plans, talking to and observing residents’ interaction with members of the staff team. There was a happy and positive atmosphere in the home on the day of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach and care of residents. A good response was received to CSCI questionnaires sent out, four returns from relatives, four from staff members and four from visiting professionals were all complimentary about the service provided, by the home. What the service does well: Staff members support residents to participate in a range of social and recreational activities in the local community. Good efforts have been made to enlist the support of colleagues within the local Community learning Disability Team including Speech and Language Therapy Sensory care and Physiotherapy and Occupational Therapy. Residents are provided with a varied nutritious diet. Staff members ensure residents have access to appropriate health care professionals. DS0000006811.V345666.R01.S.doc Version 5.2 Page 6 The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional. What has improved since the last inspection? What they could do better: Six requirements were made arising from this inspection: The Registered Person must draw up a contract with each resident and both the registered manager and resident/advocate should sign a copy of this. Restated Requirement, previous timescale of 16/03/07 was not met. A copy of the complaints procedure must be made available in a more userfriendly format for residents. The brown painted panelling and skirting boards in the entrance area and corridors must be repainted in order to provide a more conducive environment for residents. Access from the patio to the dining room was difficult for residents with physical disabilities and must be improved by the provision of a non- slip ramp. The kitchen units are in need of replacement and the worn work surfaces that might constitute a health hazard and must therefore be upgraded. DS0000006811.V345666.R01.S.doc Version 5.2 Page 7 All staff members must be annually updated in Moving and Handling and Fire Prevention. Seven recommendations were made arising from this inspection: It was recommended that the manager advises in writing that it is a legal requirement for placing authorities to provided contracts for individual placements and these be returned to the home as soon as possible. It was recommended that the home retain their own notes of reviews pending their completion and receipt by placing authorities. Also that monthly review notes by care staff within the home are clearly dated and signed by the author. It was recommended that the home employ a second shift leader and the post is made permanent and recruited as soon as possible. It was recommended that all staff members be annually updated in safeguarding Adults training. An annual survey of the views of visiting professionals in respect of the service provided by the home should be implemented as soon as practicable. It was recommended that fire drills conducted clearly indicate that all nighttime care staff members are evidenced as having taken part at least two times per annum and the times of drills be recorded. A recommendation was also made regarding an aspect of the medication system. 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. DS0000006811.V345666.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 DS0000006811.V345666.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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents were comprehensively assessed. Contracts for some residents were still outstanding and must be provided as soon as possible. EVIDENCE: Standard 2 The care files and records for three residents were examined in detail and this showed that good attention had been paid to obtaining comprehensive information prior to admission to the home. The individual needs of residents had been assessed and accurate care plans developed from the assessments of need, in those files examined. Standard 5 Following a previous requirement made it was noted that individual contracts for residents had not been fully set up and the manager was awaiting responses from the placing authorities to comply with this Standard. The manager was advised that written requests for placing authority contracts should be sent as soon as possible. It was recommended that the individual placing authorities be advised that it is a legal requirement for these contracts DS0000006811.V345666.R01.S.doc Version 5.2 Page 10 to be retained within the home. It was noted from the records that verbal requests for the completion of contracts had already been instigated by the manager, but without a response so far. See Restated Requirement 1 & Recommendation 1 DS0000006811.V345666.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): 67&9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments viewed were up to date, comprehensive and reviewed on a regular basis and showed that residents were involved and family or representatives and professionals involved had been invited. Residents were involved in decisions about them, supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality. EVIDENCE: Standard 6. Three care files and individual plans were examined in respect of the residents who were case tracked. Individual plans were comprehensive and involved both service users and their representatives, including family or advocates and other professionals involved. These plans are regularly reviewed with outcomes DS0000006811.V345666.R01.S.doc Version 5.2 Page 12 clearly stated and agreed by all participants. Records seen were comprehensive and up to date and records included appropriate risk assessments. Where risks were identified procedures and care plans reflected how these were being managed. It was recommended that the home retain their own notes of reviews pending their completion and receipt by placing authorities. Also that monthly review notes by care staff within the home are clearly dated and signed by the author. See Recommendation 2 Standard 7 Residents are encouraged to make decisions wherever possible in respect of activities, food, domestic tasks, the décor and layout of their rooms, their personal appearance and clothes they choose to wear. All residents’ rooms were seen and all were highly personalised and residents chose their preferred colour scheme. Residents are encouraged to take part in the preparation of meals, make drinks and snacks for themselves dependant on their abilities and to assist in the compilation of the menu thereby participate in the weekly shopping. The manager stated that further work is planned by staff members to increase the participation of residents in planning a weekly menu. Staff members and residents have benefited from input by a local Speech and Language Therapist in respect to developing objects of reference and other ways of enabling residents to communicate more fully their individual wishes and choices in relation to eating menu choices and activities to be made available. Standard 9 Independence is promoted where possible. Risk assessments were available in the resident’s care files we examined and are readily accessible by all staff members. Any restrictions placed are minimal these are recorded in the care plan and would be for the safety and welfare of residents, for example not going out of the home unaccompanied. Evidence was available from the residents’ records examined and from discussion with two residents, who were able to communicate, that they are enabled to express choice in what they do and did not feel that any restrictions were placed upon them. DS0000006811.V345666.R01.S.doc Version 5.2 Page 13 DS0000006811.V345666.R01.S.doc Version 5.2 Page 14 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): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social needs of the residents. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Standard 12 Evidence was available from the care files that opportunities are being made available for the personal development of residents. Although owing to the degree of learning disability most of the residents have not been identified as being able to participate in full employment or further education. All residents attend day centre places or college placements for one or two days per week and have an activity plan, this is provided on a daily basis, and ensure outings are possible into the community every day. Examples of alterative activities DS0000006811.V345666.R01.S.doc Version 5.2 Page 15 provided are, Trampoline sessions, Aromatherapy, Sensory sessions Arts and Crafts and Hydrotherapy. Standards 13 &14 Residents are provided with a good level of community outings and activities and the home was assisted in this provision by having regular access to a mini bus and staff available and qualified to drive the vehicle. Records showed that residents were supported to access leisure activities of their own choice and to integrate with the community. A range of outings was noted, for example, visits to cinemas, places of interest, pub lunches, visiting friends and family. An activity programme also highlighted indoor activities such as Board games, bingo, painting and drawing. Residents had recently attended a pantomime “Snow White” and two separate groups of residents had enjoyed a holiday in Blackpool for several days. Standard 15 Staff members actively support and encourage family contact and one resident stays with a relative every weekend. Another resident has regular weekly contact with a relative via a swimming session. Through the various activities and outings provided residents are provided with some opportunity for meeting with other people. Staff members reported that there are no relationships of emotional or relationship significance for any of the residents other than for those with parental involvement. Individual care records and the communication book provided good evidence that staff members communicate regularly with all relatives and this was further supported by returned questionnaires from relatives who praised the efforts made by staff in this respect. This is commendable. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping trips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise, in activities of their own choosing. Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food canned or died foods was seen stored in the home. All residents are encouraged to eat health and nutritional meals, as many would survive on chips and junk food, given the opportunity. A small dining room is pleasantly laid out and was recently redecorated providing a good environment for residents to enjoy their food in a sociable situation. DS0000006811.V345666.R01.S.doc Version 5.2 Page 16 Those members of staff who assist with the preparation of meals had all received appropriate Food Hygiene certificates. DS0000006811.V345666.R01.S.doc Version 5.2 Page 17 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. Residents’ needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Residents are able to choose whether they receive same gender care. Care plans that were seen showed how personal care needs were to be met. Three residents who we spoke to commented that their needs were met in a way that suited them as individuals. Most of the residents in the home would be unable to give feedback about any aspect of the service, however we found no reason to suspect that and residents were unhappy with the service or care provided for them. Both the daily notes and resident meetings indicated that residents were satisfied with the care provided fro them. Daily DS0000006811.V345666.R01.S.doc Version 5.2 Page 18 records were kept to describe the care provided and the activities residents were involved with. Standard 19 Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about resident’s individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. All residents were registered with a local GP and staff supported them to access other medical services such as dental and optical care and various Consultants within the National Health Service. Links were well established with the Community Learning Disability Teams in order to support staff with meeting residents’ needs and evidence was available of regular visits by various members of the team to facilitate this, for example Physiotherapist, Occupational Therapist, Psychologist and Speech and Language Therapy. A CSCI questionnaire completed by the local Speech and Language Therapist was very positive about the care and professionalism of the manager and the developing skills of care staff with whom she was providing ongoing training. Any nursing care needs would be commissioned via the GP from the local District Nursing Service or Community Psychiatric Nurse. Standard 20 None of the residents case have the assessed capacity to manage their own medication and have not expressed any desire to self medicate. The manager stated that should a resident wish to deal with their own medication and this was risk assessed as appropriate, then they would be encouraged to do so, under supervision and appropriate lockable facilities made available. The medication system was examined and was appropriately organised; medication was stored in a locked cabinet and quantities and dosage of medications tallied with the MAR sheets examined. The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist. A query had arisen within the previous inspection regarding documentation required when an invasive procedure might be necessary for some residents, ie the administration of Rectal Diazepam. As this has not now been required for over two years, it was recommended that the manager reviews whether this is now necessary with the GP and CLDT and develops an agreed written protocol regarding consent in the event of medical advice being for continued provision. DS0000006811.V345666.R01.S.doc Version 5.2 Page 19 See Recommendation 3 DS0000006811.V345666.R01.S.doc Version 5.2 Page 20 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. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. No complaints had been made to the provider since the previous inspection. However a complaint had been received directly by the Commission, it was noted that the complaint had no bearing on the care provision for residents and the matter concerned was adequately resolved by the manager. Few residents have the capacity to easily raise concerns and when we spoke to two residents who would be able to do able to do so, they both indicated that they were very happy within the home and had no complaints. A copy of the complaints procedure is clearly displayed in the entrance area, however the manager acknowledged that the complaints procedure must be made available in a more user- friendly format for residents. See Requirement 2 DS0000006811.V345666.R01.S.doc Version 5.2 Page 21 Standard 23 The home had policies and procedures in relation to Safeguarding Adults protection and a whistle blowing policy. One Safeguarding Adults referral had been raised by the home and assessed by the local Safeguarding Team and this was found to be unsubstantiated. We were satisfied that the home had acted in accordance with Safeguarding Adults procedures promptly and that residents were protected from any form of abuse or negligence .The home had a copy of the London Borough of Bexley Safeguarding Adults Procedures and staff members had read the document and signed to verify that they understood it. The homes policy matches the requirements within the local authority procedures. Those staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such a situation. All staff had received POVA training although the manager felt that a couple needed updating and stated this would be scheduled in as soon as possible. Three staff members who were interviewed were confident that both the manager and deputy manager would respond appropriately to any such matter arising and they are approachable, thereby encouraging staff members to discuss any concerns they might have. The financial records pertaining to two residents case tracked were examined and found to be accountable. Good records of expenditure were kept along with receipts and the cash held in the lockable safe tallied with that recorded in the ledger. DS0000006811.V345666.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment that is safe clean and hygienic. The premises were generally homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs and had the specialist equipment he needed to maximise independence. EVIDENCE: Standard 24 The home was clean, bright and comfortable, except the entrance area and corridors that were unnecessarily gloomy because of the prevalence of dark DS0000006811.V345666.R01.S.doc Version 5.2 Page 23 brown painted panelling and skirting boards, these areas must be repainted in order to provide a more conducive environment for residents. See Requirement 3 Residents’ bedrooms were spacious and highly personalised, this is commendable, and there was ample communal space for service users. We noted that there was a patio area to the rear of the building adjacent to the conservatory leading off from the sitting room. This area had the necessary equipment for relaxation in warmer months by the residents and was part of a large but rather featureless garden. In particular it was noted that access from the patio to the dining room was difficult for residents with physical disabilities and must be improved by the provision of a non- slip ramp. See Requirement 4 Standard 30 The Home was clean and tidy on the day of the inspection, and liquid soap and towels was available in the bathrooms and toilets. The kitchen work surfaces were clean and tidy with utensils and equipment appropriately stored. All cleaning materials were locked away and subject to COSHH procedures. However, it was noted that the kitchen units were in need of replacement and that the worn work surfaces might constitute a health hazard and should therefore be upgraded. See Requirement 5 A laundry is situated on the ground floor and equipped with a washing machine and a tumble dryer that were suitable, for purpose. DS0000006811.V345666.R01.S.doc Version 5.2 Page 24 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 training was comprehensive and the required level of staff members qualified to Level 2 NVQ. Residents are supported and cared for by competent and qualified staff members who act as a team to meet their needs. Recruitment practice was satisfactory. EVIDENCE: Standard 32 From observations made of care worker practice and the evidence of training provided for staff the we felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite skills, attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to DS0000006811.V345666.R01.S.doc Version 5.2 Page 25 service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions. The home had achieved the required 50 of care staff members qualified to Level 2 NVQ. The remaining staff members were all working toward this qualification therefore there is every reason to anticipate that this Standard will be maintained. Staffing numbers for home and rotas over a four- week period showed that staffing had been maintained at the required levels and were consistently so. The staffing is a shift leader and four support staff for both am and pm shifts and two waking night- time staff. It was recommended that the home employ a second shift leader and the post is made permanent and recruited as soon as possible. See Recommendation 4 Standard 34 Three personnel files were examined for staff members and recruitment practice was found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. Proof of identity and photos were included on the personnel files and also evidence obtained of the physical and mental fitness of workers had been complied with, CRB and POVA checks completed and references appropriately obtained .Two members of care staff were interviewed and both stated that they had received a thorough recruitment and induction programme when they commenced working for the home. Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for new staff and foundation training following this as well as medication, Autism, Challenging Behaviour, Health and safety and Safeguarding Adults. However, it was noted that not all staff members had been annually updated in moving and Handling and Fire Prevention, these areas are mandatory and must be updated annually. See Requirement 6 It was also recommended that all staff members be annually updated in Safeguarding Adults training. See Recommendation 5 Overall, a comprehensive spread of training had been provided for staff members. A training matrix showed the training scheduled for future provision and assists the manager to identify any gaps existing for the staff team as a whole. DS0000006811.V345666.R01.S.doc Version 5.2 Page 26 DS0000006811.V345666.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run. Quality assurance mechanisms were being developed and surveys of relatives and visiting professionals and others involved with the home were about to be developed. The health and safety of service users was promoted. EVIDENCE: Standard 37 DS0000006811.V345666.R01.S.doc Version 5.2 Page 28 The manager is a very experienced and competent care professional having a comprehensive background in various areas of learning disability and residential health provision. Three staff members and the two service users interviewed were all very positive about the way the home was managed and the support and advice available to them offered by the manager. Questionnaires returned from relatives and a visiting professional all complimented the service provided by the manager. All commented that they would not have any hesitation in approaching her about any concerns either in respect of the welfare of service users or the running of the home. The manager was aware of the need to update her own training and was already included within the overall training matrix. Standard 39 Feedback was received from residents in respect of the running of the home via recorded residents’ meetings. The manager had undertaken an annual survey of residents’ views and the results were seen to be positive. We recommended that a similar survey of the views of visiting professionals be implemented as soon as practicable. See Recommendation 6 The manager stated that she intends to introduce appropriate annual surveys as recommended. The home had received regular monthly monitoring visits as required under Regulation 26 and the reports were available for inspection within the home. Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. Environmental health and fire inspections had also been conducted in the recent past and no concerns were identified. A number of areas were picked at random and checked against the pre inspection questionnaire (AQAA), the information provided, was found to have been accurately recorded. It was recommended that fire drills conducted clearly indicate that all night- time care staff members are evidenced as having taken part at least two times per annum and the times of drills be recorded. See Recommendation 7 DS0000006811.V345666.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 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 2 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 3 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000006811.V345666.R01.S.doc Version 5.2 Page 30 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1)(c) Requirement The Registered Person must draw up a contract with each resident and both the registered manager and resident/advocate should sign a copy of this. Restated Requirement, previous timescale of 16/03/07 not met. A copy of the complaints procedure must be made available in a more user- friendly format for residents. The brown painted panelling and skirting boards in the entrance area and corridors must be repainted in order to provide a more conducive environment for residents. Access from the patio to the dining room was difficult for residents with physical disabilities and must be improved by the provision of a non- slip ramp. The kitchen units are in need of replacement and that the worn work surfaces might constitute a DS0000006811.V345666.R01.S.doc Timescale for action 01/10/08 2 YA22 17 schedule 4 16 & 23 01/10/08 3 YA24 01/12/08 4 YA24 23 01/12/08 5 YA30 23 01/12/08 Version 5.2 Page 31 health hazard and must therefore be upgraded. 6 YA35 18 All staff members must be annually updated in Moving and Handling and Fire Prevention. 01/12/08 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 YA5 Good Practice Recommendations It was recommended that the manager advises in writing that it is a legal requirement for placing authorities to provided contracts for individual placements and these be returned to the home as soon as possible. It was recommended that the home retain their own notes of reviews pending their completion and receipt by placing authorities. Also that monthly review notes by care staff within the home are clearly dated and signed by the author. In respect of the potential administration of Rectal Diazepam, or other invasive procedures it was recommended that the manager reviews whether this is now necessary with both the GP and CLDT and develops an agreed written protocol regarding consent in the event of medical advice being for continued provision. It is recommended that the home employ a second shift leader and the post is made permanent and recruited as soon as possible. It is recommended that all staff members be annually updated in safeguarding Adults training. An annual survey of the views of visiting professionals in respect of the service provided by the home be implemented as soon as practicable. It is recommended that fire drills conducted clearly indicate that all night- time care staff members are DS0000006811.V345666.R01.S.doc Version 5.2 Page 32 2. YA6 3 YA19 4 YA32 5 6 YA35 YA39 7 YA42 evidenced as having taken part at least two times per annum and the times of drills be recorded. DS0000006811.V345666.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000006811.V345666.R01.S.doc Version 5.2 Page 34 - 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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