Care Home: The Old Quarries

Similar services:

• 2 Perhaver Park
• The Vicarage
• 7 Hyde Road
• St George`s
• 5 Seafield Road
• Radfords
• Trevaylor Manor

What the care home does well The service provides people with a safe and homely environment to live in and develop their skills. People are supported to identify their goals/needs and develop Person Centred Plans using technology such as computers and videos if they wish. People clearly expressed how much they enjoyed the activities they are involved in on and off site. Medication administration does not put people at unnecessary risks. The organisation has a robust recruitment procedure that ensures people are not put at risk. When staff have been employed they complete a comprehensive inductiontraining programme that is followed by regular training in topics relating to the needs of the people they support.The registered manager has re-assessed a number of peoples needs in relation to the hours they receive. This has enabled additional funding for hours providing people with one to one staffing at different times. What has improved since the last inspection? Peoples personal files are well organised and this enables the reader to find information quickly and easily. Staffing numbers have improved meaning that people are able to complete more of the activities they wish to be involved in. What the care home could do better: Staff must ensure that people`s targets are realistic and that they are specific and not too general. The evidence to show that people`s goals are being achieved is poor and it is impossible to confirm that people`s goals are being achieved in a lot of cases. Staff must regularly review risk assessments to ensure that people are not being put at unnecessary risks. The home must ensure that the cooking arrangements across the site are well organised and the goals of the action plan received by the CSCI are achieved. Staff must ensure that all people`s personal care needs are met and where evidence of this is required they complete the form as expected. CARE HOME ADULTS 18-65 The Old Quarries Rectory Lane Avening Nr Tetbury Glos GL8 8NJ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 5th March 2008 09:00 The Old Quarries DS0000016623.V344680.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 The Old Quarries DS0000016623.V344680.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. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Quarries Address Rectory Lane Avening Nr Tetbury Glos GL8 8NJ 01453 832201 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) www.hft.org.uk Home Farm Trust Mrs Janet June Newbould Care Home 33 Category(ies) of Learning disability (33), Physical disability (3) registration, with number of places The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 33 LD includes 3 LD residents who are also under PD Date of last inspection Brief Description of the Service: The Old Quarries is an old Vicarage House with a number of accommodation facilities within the house or grounds. The home is situated near Tetbury and Nailsworth in Gloucestershire and service users have access to transport that is provided by the Organisation. The service users use the local facilities, supported by staff where appropriate. The site is staffed 24 hours a day, seven days a week. Family and friends are welcome to visit the Old Quarries at any time and service users can meet them in private if they wish to. The service users at the site use a number of Day Services, most service users attend the Day Services that are available on site provided by the Home Farm Trust. Gloucestershire Social Services and local Colleges provide other Day Services. People that may wish to live at the home have access to a service user’s guide and a statement of purpose. The Old Quarries DS0000016623.V344680.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. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The visit to the service took place on a Wednesday. We met with a selection of the people living across the site, along with a number of the staff team. The registered manager was present throughout the day. During the visit we observed the day-to-day lives of people in the different units across the site. Various records were looked at including examples of care plans, healthcare notes, risk assessments, medication charts and staffing information. Shared areas and bedrooms were also checked during the visits. Before the visit to the service they sent us an AQAA (Annual Quality Assurance Assessment) providing information about how the service runs. Written feedback was also obtained from different people with an interest in the home such as family members and healthcare professionals. What the service does well: The service provides people with a safe and homely environment to live in and develop their skills. People are supported to identify their goals/needs and develop Person Centred Plans using technology such as computers and videos if they wish. People clearly expressed how much they enjoyed the activities they are involved in on and off site. Medication administration does not put people at unnecessary risks. The organisation has a robust recruitment procedure that ensures people are not put at risk. When staff have been employed they complete a comprehensive inductiontraining programme that is followed by regular training in topics relating to the needs of the people they support. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 6 The registered manager has re-assessed a number of peoples needs in relation to the hours they receive. This has enabled additional funding for hours providing people with one to one staffing at different times. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. The service’s admission procedure is thorough and minimises the risk of people being admitted to the service whose needs cannot be met. EVIDENCE: There have been no new admissions to the home since the previous inspection was completed. As identified in the CSCI’s AQAA (Annual Quality Assurance Assessment) completed by the registered manager they state that the home has a comprehensive admissions policy. When people have been admitted to the home previously we have seen that the process has been thorough. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living across the site are able top make decisions about their lives and staff support them where it is required. It is impossible to confirm that all people’s current needs are being met as assessments are in need of review. Goal recording and review is poor making it impossible to confirm that people’s goals are being met. People are being put at unnecessary risks due to the poor risk assessments in place. EVIDENCE: The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 10 There are 5 units across the site named Chandler house, Meadow view, the bungalow, Sunset view and the Gallery flat. We visited each unit with the assistant service manager and looked at the care for at least 1 person in each unit. When looking at a person’s care we examined what their assessed needs were, when those needs were reviewed and the steps taken to meet those needs. Across the site we noted that people’s personal files have now been reorganised into a standardised format which makes them a lot easier to use. Before we visited the different units across the site the registered manager explained that they are in the process of implementing a new care computer system named “SPARS” (Support Planning and Recording System). This involves all of the people living across the site being re-assessed and their information being inputted into the new system. Whilst completing the tour if the site we saw that the staff in the units were at different stages of achieving this. All of the personal files seen contained a personal profile, health action plan, a Person Centred Plan (Commonly known as a PCP, this approach empowers people to make changes in their lives, achieve their goals and ensure that resources are in place to meet their future needs), a medication plan, activity timetables, hospital assessments, support plans and a record of progress towards meeting goals. The staff make good use of technology such as computers and video to enable people to create their PCPs. This enables a person to play a pre-recorded presentation at their review. This empowers people to say what they really mean in a “safe” environment. Across the different units we found a number of good practices and some common shortfalls. A good practice being used across the site was staff making use of pictures and symbols for people with communication difficulties. All of health action plans seen stated “You must seek the permission of ****** to read this document”, and this was respected. In addition to this a number of documents were signed by people agreeing to their care needs and plans to meet them. The common shortfalls seen across the site included: • Goals not being reviewed regularly. • Goal recording (progress towards meeting goals) was not being recorded. • People’s goals were too general, for example “for ****** to be able to clean and tidy the kitchen”. • PCP meetings were being held and no goals set. • Personal profiles not being reviewed regularly. • Activity timetables were out of date. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 11 • Risk assessments were limited and had not been reviewed regularly, putting people at unnecessary risks. Each person has a key worker and they are expected to review goals, risks, etc. Each file had a front sheet to identify when reviews had been completed. Some of the files provided evidence of this sheet being completed by the key worker, and the unit team leader. But this was not always the case, and some were found to be inaccurate. A good example of this sheet being used correctly was in the Gallery flat where the unit manager had completed a review of a person’s file, identified shortfalls, met with the key worker to discuss them and the shortfalls had then been addressed. Whilst completing the site visit we made observations of the relationships between staff and people living on the site. All of the relationships seen were positive, respectful and there were clearly some close friendships. A questionnaire completed by 1 person living on the site states “I am treated with dignity and respect by all of the staff”. The AQAA completed by the manager stated they felt an area for improvement over the next 12 months was the standard of recording to become consistent across the site, and that it is reviewed and updated on a regular basis. At the end of the site visit we met with the registered manager to discuss these findings. We were concerned about the potential risks people were being put at, and that in a lot of cases people’s goal documents had not been reviewed in over 6 months. It is poor practice that these documents have not been reviewed regularly and it was impossible to confirm whether people’s current needs were being met and their goals achieved. The service manager gave us assurances that the implementation of the new computer system should solve these problems in the future. We will examine this at the next site visit. It becomes a requirement of this inspection report that the manager ensures that people’s needs are assessed and reviewed at regular intervals. Speaking to people living across the site they were able to confirm that staff supported them to make decisions about their lives. This was also supported by the documentation seen throughout the day. An example of people being able to make decisions about their lives included what activities they take part in. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The wide range of leisure activities and opportunities for people mean they lead active and fulfilling lifestyles. The food provided in the different units was seen to be varied, nutritious and chosen by the people living at the home. EVIDENCE: As mentioned earlier in this report we spoke to a number of people living at the home whilst completing the site visit. During these conversations some were asked what activities they are involved in and whether they enjoyed them. The range of activities people stated they were involved in included: • College. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 13 • Day Services – provided on site. It was explained that these hours are being used flexibly with some people going canoeing and rafting at the weekends. Speaking to people who did this they were really enthusiastic about it. Community Inclusion Group – the day service rents some rooms in the local town of Nailsworth where people are then supported to make use of local facilities. Work placements in the local community as well as one person working in the office on site and another delivering the post across site. Leisure activities – shopping, swimming, walking, horse riding, pub visits, cinema and golf. Various holidays, people gave examples such as going to Cornwall and Torquay with friends. People attend the local Gateway Club regularly. • • • • • Since the previous site visit was completed gardening has become more popular across the site and discussions are underway about purchasing a poly tunnel/green house and developing some raised beds. A random unannounced inspection was completed in June 2007 in response to concerns raised by the staff team about staffing numbers and the effect on activities for people living in the home. Speaking to staff across the site during this site visit it was agreed that staffing numbers have improved and people are completing their activities. Speaking to the registered manager they have been negotiating with local authorities to increase funding across the site. We spoke to a number of people across the site about their activities, and whether they were able to complete them regularly. All of the people spoken to were happy with the service they were receiving and agreed their activities took place regularly and staff were available. People have friends without learning disabilities and the staff provide support where appropriate with personal relationships. Speaking to people living across the site it was clear that there is an expectation for people to be involved in the day to day activities of cooking, cleaning and laundry. This is done to different degrees across the site. Whilst around the site we saw a number of people completing tasks including laundry and cleaning. People’s current religious needs are addressed with a number of people attending the local church regularly. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 14 Before completing this inspection the CSCI received information from members of the staff team raising concerns about cooking across the site. As a result the CSCI asked the provider (HFT) to complete an investigation (see standard 22). Menus seen by us confirmed that a good range of healthy, fresh meals were available to everybody. Visiting the different units across the site showed that snacks are available between meals. When speaking to people across the site they made comments like “I like the food”, “I can choose what I want to eat”, “we have a picture menu that we choose”, “the food is nice”. The AQAA completed by the manager highlights that they have implemented job clubs for people living on the site and that over the next 12 months this will be expanded further. HFT have provided Stroud supported employment with funding for people from the scheme to access it. In addition to this the day services team are looking at the service provided and how changes can be made to facilitate and support community inclusion in the evening and at weekends. These are really positive steps towards further inclusion for people living across the site. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is impossible to confirm that all of the people across the site are having their personal care needs met. It is impossible to confirm that people’s health action plans are accurate and that people’s current needs are met. The service’s medication procedures minimise potential risks to the people living there. EVIDENCE: None of the personal files examined contained any detailed plans to meet people’s personal care needs. Where people do not require specific support with their needs this should still be noted in people’s files. Each unit keeps a record of the personal care completed each day. These sheets highlight whether people have had baths, washed their hair, brushed teeth and cut their fingernails. The majority of the records were completed thoroughly, but there were a number of sheets with gaps that implied people had not done things like brush their teeth for a number of days. The assistant service manager said that this might have been due to staff not signing the sheet. The manager The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 16 must ensure that people’s personal care needs are being met; this becomes a recommendation of this report. All of the files examined contained health action plans; these highlight people’s medical needs. Of the samples examined all contained a good level of information to enable other professionals to meet people’s needs. Unfortunately a number of these actions plans were not dated, signed or showed evidence of review. This made it impossible to tell whether these documents were up to date. It becomes a recommendation of this inspection report that people’s health action plans are reviewed. Medication administration across the site was examined. The organisation has comprehensive policies and procedures that are followed by appropriately trained staff. This minimises potential risks to people living across the site. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that enables people to make a complaint if they are unhappy. Potential risks to people across the site are minimised through the organisation’s policy and training in safeguarding adults. EVIDENCE: The service has a complaints procedure that makes good use of simple language supported by the use of symbols. Previous inspections have provided evidence that all of the people living at the home have been involved in workshops to explain the procedure. We spoke to a number of people, and the consensus of opinion across the site was that if people needed to make a complaint they would be listened to by the staff. Most of the people we spoke with said “I would speak to staff if I was unhappy”. We have examined the policy and procedure regarding protection of vulnerable adults at a previous inspection. It sets the framework for a robust response to any suspicion or evidence of abuse or neglect. Examination of the service’s training records showed that all new staff receive safeguarding adults training as part of their induction and regular updates are available to all staff. In the AQAA the manager states they aim to improve training options/ formats to raise peoples awarness of abuse and whistle blowing. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 18 We sampled records for people’s income and expenditure in each of the units across site. All of the records seen were correct but staff must be watchful of how people’s receipts are numbered and stored. On one occasion it was difficult to work out how much money had been spent, when it had been spent and on what. It becomes a requirement of this report that the service manager reviews the current procedure to ensure that all staff are following it correctly. Since the previous key inspection we have received 2 concerns raised by members of the staff team at the home. This has resulted in a random inspection being completed in June 2007, and the provider being asked (by us) to complete an investigation into the 2nd concern in the week before this site visit was completed. As mentioned previously in this report 1 concern related to staffing numbers, and from available evidence this is being addressed. The 2nd concern related to catering in the units across the site. Findings of the investigation show a number of shortfalls and we were provided with an action plan to address this. We will follow this up at the next site visit. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living across the site benefit from a good standard of accommodation that meets their current needs. EVIDENCE: Across the site the units are decorated to a high standard with all communal areas in the units being personalised by the people living in them. All of the units provide a safe environment. The environment across the site continues to improve. The bedrooms seen during the day of the inspection were decorated to a high standard and personalised by the people that lived in them. People spoken with stated that they liked their bedrooms. On the day of this site visit all areas were seen to be clean and hygienic. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 20 The AQAA states an area for improvement is the services ability to meet the need for specialist needs of people with Dementia/Alzheimer’s across the site to ensure people have the option to remain independent of hospitalisation for as long as is possible. And, in response to needs identified in 4 peoples PCP’s the lodge will be renovated. In addition to this there are plans to redecorate some areas of units and deep clean some of the carpets in communal areas. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The recruitment procedures ensure that potential risks to people being supported by the service are minimised. Staff complete comprehensive training providing them with the necessary skills to meet peoples needs. Staffing figures have improved across the site and this has enabled people’s needs to be met more consistently. EVIDENCE: All staff have job descriptions that clearly identify their roles. HFT provide staff with access to a comprehensive training programme. Records showed staff completing training in subjects including first aid, manual handling, fire safety, food hygiene, safeguarding adults, Person centred planning, health and safety and behaviour management. Records also showed that 27 of the staff team have completed National Vocational Qualification’s (NVQ’s) in health and social care at level 2. Another 7 staff are currently completing the same NVQ. Unit manager across the site The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 22 have either completed NVQ level 4 registered manager’s award or will be completing it as part of their future training. We looked at the recruitment records for 4 staff recruited since the previous inspection was completed. Records showed that the provider’s procedures had been followed and in turn this meant the criteria of these regulations were met. Speaking to 2 staff from different units about the current staffing of the units they work in they stated that this has improved with people now getting the enhanced hours they require. Examples of people using these hours include people receiving 1 to 1 staffing to go shopping, and complete activities including bowling and other leisure activities. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management team’s extensive knowledge of the service should enable them continue the development of the service. The external health and safety audit and the committee that meet regularly go some way to minimising potential risks to people across the site. The service has a quality assurance procedure in place to enable people living across the site to be put at the centre of future developments. EVIDENCE: Since the previous inspection was completed the registered manager has been acting up as the service manager due to the previous manager leaving in March 2007. As a result of this another member of staff has been acting up in the role of manager of the registered care home. Both of these roles have now The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 24 become permanent and as a result the CSCI have received applications for the roles of registered manager and responsible individual. The service manager is currently completing their NVQ level 5 in management, whilst the manager applying to become registered manager has achieved their NVQ level Registered Manager’s Award. The management team for the service have extensive knowledge of the service having worked there for a significant amount of time before starting in their current roles. The AQAA completed by the service manager states that HFT has reviewed its quality assurance system since the previous inspection was completed. The framework has been designed to reflect and relate to the organisations core values and purpose, which is stated as meeting the hopes and needs of people with learning disabilities through: • • • • • • Care Consultation Communication Opportunity Respect Empowerment The system is more person centred and seeks quality outcomes for people. At the next site visit this will be examined to assess the findings and corrective actions taken where required. Part of the quality assurance system examined on this occasion was the monthly unit reports completed by the unit managers. These are submitted to the service manager monthly and enables them to have an overview of what is happening across site. Measuring quality assurance based on the people’s goals and needs being achieved it is impossible to confirm that a quality service is being delivered at present. Speaking to people across the site the concenus of opinion was that people were happy, they felt supported by staff and were able to choose how they lived their lives. Each unit across the site has a COSHH file containing data sheets for the chemicals stored/used in the home. There is a health and safety committee led by the service manager. Each unit across the site has a representative on the committee which meet monthly. The aim of the committee is to discuss health and safety issues and ensure that all regular checks on health and safety across the site are completed. Records seen during this site visit showed that fire safety precautions were being checked regularly. HFT employ a health and The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 25 safety manager and they complete regular audits of the site. Results of those audits are forwarded to the manager and any shortfalls are then addressed. The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 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 X 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 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X 3 X The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement Each person must have an upto-date care management plan that is kept under review. Risk assessments must be completed to support people’s day-to-day activities and all risk assessments must be reviewed regularly. Timescale for action 01/08/08 2. YA9 13(4) b, c 01/05/08 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 YA6 Good Practice Recommendations Future goals could be more specific as a number seen during this visit were very general making it impossible to measure a person’s progress towards achieving them. People’s personal profiles should be updated regularly. Activity timetables should be updated regularly to provide the reader with a clear picture of what the person actually does. DS0000016623.V344680.R01.S.doc Version 5.2 Page 28 2. 3. YA6 YA14 The Old Quarries 4. 5. YA18 YA18 If a person does not require any support with their personal care this should be recorded in their personal file. The manager needs to monitor the personal care needs recording forms for each of the units to ensure that people’s needs are being met. Health action plans should be reviewed to ensure that they accurately reflect people’s current needs. 6. YA19 The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 The Old Quarries DS0000016623.V344680.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!