Care Home: The Thomas More Project

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What the care home does well The service users we spoke with and those who responded by survey said they are able to choose how to spend their day and they are treated well by staff who listen to them and act on what they say. The relatives who responded by survey said the home does meet the needs of each individual and provides the care and support they expect. The health professionals who responded by survey said service users` needs are well met, their privacy and dignity respected and they are supported to live the life they choose. The staff members we spoke with said they enjoyed working in the home, feel well supported in their roles and are committed to providing a good quality service to each person who lives in the home. The environment is homely and comfortable for people to live in. What has improved since the last inspection? We noted that each of the improvements we asked for following the last Key Inspection have been made by the home. The `Essential Lifestyle Plans` for service users have now been reviewed and improved. This helps to ensure each person`s support needs are clearly identified and staff know how to meet them. Each individual`s care plan now clearly explains the reasons for any restrictions which are in place. Service users have signed to say they agree with them, wherever possible, and this helps to promote a safe and accountable service. The policies and procedures relating to the recruitment of new staff have now been improved. This promotes the welfare and safety of service users. Staff are now provided with training which enables them to meet current and changing needs of the people who live in the home. Service user`s views are now incorporated in both the annual quality review and the future plans of the home. Medication administration within the home has now been improved. This helps to promote the welfare and safety of service users. Regular auditing visits are now being conducted each month. This helps to promote a safe and accountable service for each person who lives or works in the home. CARE HOME ADULTS 18-65 The Thomas More Project Thomas More House 33 Fallodon Way Henleaze Bristol BS9 4HX Lead Inspector David Smith Key Unannounced Inspection 15th February 2008 10:30 The Thomas More Project DS0000026652.V356610.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 Thomas More Project DS0000026652.V356610.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 Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Thomas More Project Address Thomas More House 33 Fallodon Way Henleaze Bristol BS9 4HX 0117 9629899 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) Thomas More Project Mrs Janet Smith Care Home 11 Category(ies) of Learning disability (11), Physical disability (1) registration, with number of places The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate persons aged between 30 and 70 years. Date of last inspection 6th March 2007 Brief Description of the Service: Thomas More, 33 Fallodon Way, is registered with The Commission for Social Care Inspection as a care home for 11 people. The house is purpose built, blends in well with its surroundings and is situated in a quiet residential area. The house is a two-storey building with single bedrooms on both floors and several communal areas for the clients to access. The garden is well sized and easily accessible from the house. It is close to local facilities and amenities and has its own transport to support clients in accessing community facilities. Clients are encouraged to participate in their local community and remain in contact with their relatives and friends. The Thomas More Project DS0000026652.V356610.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 an unannounced visit to the home as part of a Key Inspection of this service. The review of evidence and pre-inspection planning involved reviewing the report of the last Key Inspection carried out in March 2007 and the service history, which details all contact with the home including notifications of significant events which they have reported to us. We (the CSCI) provided the home with their Annual Quality Assurance Assessment (known as an AQAA, pronounced as ‘aqua’) and a range of survey forms for service users, their relatives, carers, advocates and health professionals, prior to our visit. The AQAA was completed and returned, together with twenty-one surveys. We gathered additional information during this visit through informal discussions with service users, the Registered Manager and other staff members. Interaction and communication between staff and service users was also observed. Care plans and associated records were examined together with Risk Assessments, complaints procedures, medication administration, menu plans, staff personnel and training records and health and safety records. We also viewed all communal areas of the home and some of the service user’s own rooms. What the service does well: The service users we spoke with and those who responded by survey said they are able to choose how to spend their day and they are treated well by staff who listen to them and act on what they say. The relatives who responded by survey said the home does meet the needs of each individual and provides the care and support they expect. The health professionals who responded by survey said service users’ needs are well met, their privacy and dignity respected and they are supported to live the life they choose. The staff members we spoke with said they enjoyed working in the home, feel well supported in their roles and are committed to providing a good quality service to each person who lives in the home. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 6 The environment is homely and comfortable for people to live in. What has improved since the last inspection? What they could do better: Each care plan must continue to be regularly reviewed and a clear record of the review process must be maintained. This would ensure each person is provided with support which meets their current needs. Staff must be provided with regular supervision to support them in providing a good quality service to each person who lives in the home. The home should also consider recording informal support sessions offered to staff as part of the improvement in supervising them. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 7 The home must ensure that all potential risks to each person who lives or works in the home are assessed and eliminated or reduced where possible. This will promote the welfare and safety of service users and the staff team. Our contact details should be amended on each individual’s complaints procedure to ensure they are provided with up to date information should they wish to make a complaint. Each meeting with service users should be recorded to better evidence that they are being supported to determine their own service and make informed decisions. 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 Thomas More Project DS0000026652.V356610.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 The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have access to detailed information in order to make informed choices about whether to use this service. Each service user knows their needs and aspirations will be assessed and met by the home. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a Statement of Purpose, which contains comprehensive information about the home and service it is able to provide. This was last updated in January 2008. The home has one vacancy, which they are currently trying to fill. The organisation has a comprehensive assessment tool, which is used to determine the support needs of each prospective service user. The Manager would generally complete this assessment and obtain as much historical information as she can. This would help to decide if this home would be a suitable place for them to live. The transition to the home is tailored to the individual who moves in, however service users do generally visit or stay at the home prior to moving in permanently. The service users we spoke with and those who responded by survey said they were asked if they wanted to move into the home and did receive enough information to decide if it was the right place for them to live. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that the service provided to each individual takes into account their changing needs and personal goals, supported by both written information in care plans and risk assessments which are subject to ongoing review. EVIDENCE: We examined three service user’s care plans during our visit. These plans use a ‘person centred’ format known as ‘Essential Lifestyle Planning’ (ELP), contain photos or picture symbols and are written in plain English to make them easy to understand. Each plan is written in an individual way and covers key areas of support people require, such as personal care, healthcare, eating and drinking and how they wish to spend their leisure time. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 12 Some areas of these care plans have been reviewed and improved since we last visited. For example, communication guidelines are now much clearer and explain how some individuals may make their needs known through the use of ‘Makaton’ sign language, gestures, vocal sounds and the way they behave. During our visit staff appeared confident in communicating with service users, either through speech, the use of ‘makaton’ signs or by interpreting vocal sounds or gestures. Staff did provide choices, but let each person make their own decisions. Individuals spoken with and those who responded by survey said they did make decisions about what they would like to do each day and felt that they generally do the things they choose. One relative who responded by survey said the home “provides my (relative) with a small, caring environment in which they can express themselves”. Some service users do have restrictions as part of their care plan, which are designed to promote their safety and to help manage some behaviours. There are now clearer guidelines in place for these and service users are encouraged to sign to say they understand and agree with them, wherever this is possible. Each care plan we examined contained details of the last review attended by the service user, a representative from their Funding Authority, staff from the home and family members, if this is appropriate. The Funding Authority has provided each person with a copy of their review notes however some of these reviews were last conducted in 2006, so they do not appear to be up to date. Each care plan should also be reviewed ‘in-house’ between the formal reviews described above. These reviews are not being carried out consistently and the Manager told me that this type of review, which often includes staff from service users’ day care placements, have become much harder to organise. The home operates a keyworking system whereby each service user has a named member of staff who plays a key role in co-ordinating the services they receive. Keyworkers complete a monthly summary which details each key event that month and the home may wish to consider simply extending this system to ensure care plans are kept up to date between formal reviews. I did discuss this with the Manager who felt this would be useful and relatively easy to implement. There are person centred Risk Assessments in place for service users, which support individuals to take risks as part of an independent lifestyle and form part of their ‘ELP’. Most of these are out of date, as they were written in early 2007 and have not been reviewed since then. Some are in an old risk assessment format, no longer used by the home. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual has opportunities and appropriate support to access leisure and educational facilities both locally and in the wider community including day trips and visits to family and friends. Each person’s rights and responsibilities are recognised in their daily lives. A healthy and balanced diet for each individual is promoted. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users are supported to attend day centres and local colleges. Other facilities are used in the community such as the local library, fitness centres, pubs, cinemas and shops. The records we examined showed that service users are going out regularly. On the day of our visit a number of service users were attending their regular day services and others were supported to access the community with staff. The home has a member of staff employed as a Day Care Co-ordinator. This member of staff explained their role is to oversee life skills support provided to the people who live in the home, their college courses and accompany them on trips to the community. The people who live in the home enjoy a number of activities such as photography, cookery, arts, crafts and one individual has recently started making their own jewellery. Each service user is also supported to choose, arrange and attend a holiday. Some choose to go abroad while others have their holidays in this country. The service users we spoke with and those who responded by survey said they were able to choose how to spend their day and generally were able to do the things they wished to do. Service users are supported to maintain close contact with their families and friends. Some regularly visit their families and visitors are welcomed to the home. Relatives who responded by survey said the home does help their relative keep in touch and they are kept up to date regarding important issues. One family said “our (relative) is extremely well cared for in every respect” and another said “the care home is excellent”. The home supports individuals to develop friendships and personal relationships. We did note that the home does access health professionals to ensure service users and offered appropriate support and staff members are provided with clear guidance in this area. Observation during our visit and discussion with both service users and staff shows that each person who lives in the home is treated with respect and dignity. Each person is seen as an individual and treated as such. The health professionals who responded by survey said the home does support people to live the life they choose, respects individual’s privacy and dignity and is good at meeting individual’s differing needs. One professional said they “are very pleased with the care given”. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 15 The menus show that each individual is offered a choice of healthy and nutritious food. Service users continue to be encouraged to choose the food they would like to be included on the menu at their regular house meetings. Their general likes, dislikes or dietary needs are known by the staff. Individuals generally eat their meals in the dining room, which overlooks the front garden. We joined a number of service users for lunch and found this to be very relaxed and informal. Service users appeared to enjoy their meals and were very relaxed in the company of staff. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 16 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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in their preferred manner and their personal and healthcare support needs are well met. The policy and procedures relating to administration of medication ensures service users’ welfare and safety. The ageing, illness or death of a service user would be handled with respect and as an individual would wish. EVIDENCE: The care documentation in place for service users provides clear guidance for staff on how they should support those living at the home with their personal care. The care plans we examined show that service users are registered with a local GP, dentist, optician and chiropodist. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 17 Other specialist services are accessed when an identified need arises. Care records show the home is supported by Psychologists and other relevant health care professionals. Contact with each professional is recorded and forms part of each person’s care plan. There is a core of experienced staff who have a good knowledge of service users’ healthcare needs. Any changes, which may cause staff concern, are noted and acted upon. It remains evident that the management and staff spoken with are sensitive to the personal, healthcare and emotional needs of those living in the home. The health professionals who responded by survey said the home meets each person’s health care needs, seeks their advice and acts upon this to manage and improve individual’s health care. One professional said the home’s “standards are very high”. The home uses a Monitored Dosage System of medicine administration. This system is now well managed. Medication is stored securely in locked cabinets on the ground floor of the home. The care plans explain what medication each person takes and how it is to be administered. The medication records contain the home’s medication policy, a recent photograph of each service user, details of their medication, the times of administration and a list of staff signatures together with a sample of the initials they use on these records. Each service user’s medication record was correctly completed, signed by staff with no gaps evident in the records. The home’s record keeping relating to ‘homely remedies’ (such as painkillers) has improved since our last visit. We examined records and checked the stock levels of some of the medication kept in the home, which were all correct. The health professionals who responded by survey said the home does support individuals to administer their own medication and manages it correctly where this is not possible. Each individual’s care plan describes their wishes relating to ageing and their death. These include their religious beliefs and their preferred funeral arrangements. One individual who lived in the home sadly passed away last year. Their family said they “cannot thank the home enough for all the support they gave to (our relative) and to us”. They described the service as “wonderful”. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 18 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Clear policies and procedures are in place in order to protect service users from the likelihood of abuse, neglect and self-harm. EVIDENCE: The home has a formal Complaints Policy, an Adult Protection Policy and a Whistle Blowing Policy, which staff can use in confidence to raise any issue or concern they have regarding the service. We examined the home’s complaints log. This contains a copy of the home’s policy and a record of complaints, which shows there have been none recorded since our last visit to the home. We have not received any concerns or complaints direct regarding the Thomas More Project. The service users we spoke with and those who responded by survey said they knew who to speak to if they were unhappy, knew how to complain and confirmed that they felt safe living at the home. They felt that staff did listen to them and acted on what they said. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 19 Each service user has their own complaints procedure as part of their ‘ELP’. Our contact details are not up to date in this document and they should be amended as soon as possible to ensure each person has correct information should they wish to complain. Individuals can continue to use the house meetings to raise any concerns they have, together with discussions they have with their Keyworkers. Most relatives who responded by survey said they knew how to make a complaint, although one family said they did not have any details of the formal complaints procedure. Both relatives and health professionals felt the home had responded appropriately if they had raised any concerns about the care provided by the home. All staff are provided with training in relation to the Protection of Vulnerable Adults and are subject to ‘enhanced’ Criminal Record Bureau disclosures (known as ‘CRB’s) before they start work in the home. Some people who live in the home may become distressed or present behaviours which may be perceived as challenging the service provided. These individual’s care plans have details of known trigger points and the appropriate defusing techniques. The staff we spoke with said they felt that the staff team responded consistently to this type of behaviour and it is generally easy to help defuse. The home maintains clear records of all accidents and incidents and notifies us of any significant event which occurs. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Thomas More Project provides a homely, comfortable and safe environment for service users to live in. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Thomas More Project is a purpose built property, which blends in well with its surroundings and is situated in a quiet residential area. The house is a two-storey building with single bedrooms on both floors and several communal areas which individuals are free to use. The garden is well sized and easily accessible from the house. It is close to local facilities and amenities and has its own transport to support service users in accessing community facilities. We viewed all of the communal areas, along with some of the service user’s rooms. All areas of the home were very clean and tidy and furnishings and fittings are of a good quality. The house is tastefully decorated and the housing association, Knightstone, will shortly redecorate the communal areas which will improve these for the people who live in the home. Each person’s bedroom has been decorated and furnished to make it personal to them. There were lots or personal effects, pictures and photographs which added to this. Service users are encouraged to help with the cleaning of their bedrooms as part of their ‘life skills’, but staff are responsible for the general cleaning. The home was found to be clean and hygienic on the day of the visit. The service users who responded by survey said the home is ‘always’ kept ‘fresh and clean’. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 22 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): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clarity of staff roles and responsibilities along with staff training and supervision are designed to provide a consistent approach to the support of staff and service users. The home’s recruitment policy promotes both service users’ rights and their safety. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 23 EVIDENCE: There remains a core of well-established staff with varying abilities who are skilled and experienced to meet the needs of those living in the home. Some members of the staff team have their own areas of responsibility, such as overseeing fire safety within the home. Staff members spoken with said that the staff team is open, honest and supportive. They felt well supported by the manager and were able to discuss issues in an open and honest way. Staff were observed interacting well with service users and those spoken with demonstrated a good understanding of the support needs of each person who lives in the home. Service users spoken with said they liked the staff team and were well supported by them. Each service user who responded by survey said they are treated well by staff that listen to them and act on what they say. The staff team continues to meet regularly. Staff spoken with said they find these meetings useful and are able to discuss any issues they wish as these can be added to the agenda. If staff are not able to attend, they read the minutes to ensure they remain up to date. We examined the personnel records of some newer staff members. These show that the home has now improved its recruitment practice as the revised application form now asks prospective employees for a full employment history and the standard request for references now establishes the validity of the referees. Other documents contained in these files include documents to confirm the identity of staff and their eligibility to work in the UK and medical questionnaires. (The details of Enhanced Disclosures from the Criminal Records Bureau are discussed earlier within this report). Staff are provided with a variety of training opportunities. The records we examined show that staff have had training in First Aid, Adult Protection, Food Hygiene, Health and Safety, Fire Safety and Infection Control. Staff are also provided with more specialist training to enable them to meet the current and changing needs of service users. This training includes understanding Autism, Dementia and how to support people who have a Learning Disability. Staff are encouraged to work towards a National Vocational Qualification (known as an ‘NVQ’). Two staff members said they had recently started their awards. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 24 Relatives who responded by survey said they felt the staff did have the right skills and experience to look after people properly. Health professionals who responded by survey said the staff team do have the right skills and experience to support service users. The home is committed to providing staff with regular, formal supervision. It is clear from discussions with staff and examination of supervision records that these have become infrequent. The Manager is aware that this issue needs to be addressed and hopes that the recruitment of a new Deputy Manager, to replace the member of staff who left in October 2007, will help resume regular supervision meetings for all staff. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 25 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, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well-run and service users benefit from the ethos, leadership and management approach of the home. Service users views are sought in relation to the monitoring and review of the service provided by the home. Each person’s rights and best interests are promoted by the home’s record keeping and the organisations’ policies and procedures. The health, safety and welfare of people living in the home is generally promoted and protected. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Registered Manager, Mrs.Smith, was present throughout this visit and supported the inspection process fully. She has worked at The Thomas More Project for a number of years and has a good knowledge of the people who live in the home. She has attained City and Guilds Foundation in Care Management, NVQ Level 4 Registered Managers Award and is a qualified NVQ Assessor. She undertakes additional periodic training to maintain her knowledge and update her skills and level of competence. Through my discussions with Mrs. Smith it is clear the management approach remains open and positive, with a clear sense of direction and leadership. These discussions also confirmed the commitment to the development and improvement of the service, where this is possible. This includes the action taken to meet each of the requirements and recommendations from our last inspection report. Staff spoken with found the Manager to be approachable and supportive. One relative said “the Manager is exceptionally caring and competent”. The home conducted a Quality Review in November 2007. This involved surveying service users and their relatives to gain their views of the service, together with a check on the quality of record keeping in the home. The views of service users are also sought during the regular house meetings and at other times, such as when supporting individuals to choose college courses or holidays, although at present the home does not record these meetings they should consider this. There are efficient management systems and structures in place to ensure the home runs effectively. The quality of record keeping in the home is generally good, with all records required during our visit easy to access and stored securely when not in use. The home has a number of policies and procedures, which are designed to ensure it complies with the law and remains aware of good practice guidelines. Full details of each policy were provided by the Manager as part of the AQAA she completed for us as part of this Key Inspection process. The monthly auditing of the service has now resumed and we examined copies of the auditing reports during our visit. These cover a number of areas and have been completed consistently since our last inspection. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 27 There are recording systems in place to support Health and Safety within the home, which are being used consistently. Fire safety procedures are excellent. A comprehensive Risk Assessment has been carried out by an external consultant, there are regular fire drills which both service users and staff members take part in and the alarm system and fire fighting equipment is tested regularly. Staff attended Fire Safety training in April 2007 and one member of staff has completed training as a ‘Fire Warden’. There are a number of general Risk Assessments in place to ensure the welfare of service users and staff. However, as with the person centre assessments described earlier in this report, these general assessments are out of date and some remain in the old format. These must be revised and then kept up to date. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 2 3 The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 29 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(1) 15(2) Requirement Timescale for action To ensure service users receive a safe and responsive service, the reviewing and updating of care plans must be completed and a clear record of all review processes must be maintained. 15/05/08 All people living or working in the home must have any potential risks to them assessed and recorded. This will promote their welfare and safety. To ensure staff are supported to provide a good quality service they must be provided with appropriate supervision. 2. YA9 13(4) 15/04/08 3. YA36 18(2) 15/02/08 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 YA22 Good Practice Recommendations Each service user should be provided with up to date DS0000026652.V356610.R01.S.doc Version 5.2 Page 30 The Thomas More Project 2. YA36 3. YA39 information should they wish to make a complaint. The home should consider recording informal meetings with staff to better evidence that they are being supported to provide a good quality service to the people who live in the home. The home should consider recording each meeting with service users to better evidence that they are being supported to determine their own service and make informed decisions. The Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Thomas More Project DS0000026652.V356610.R01.S.doc Version 5.2 Page 32 - 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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