Care Home: Urmston House

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What the care home does well The information made available about this home and their assessment processes would ensure that any person who lives here, would receive the care and support that they need. Robust assessment and care planning processes ensure that each person who lives in this home will receive an individually prepared plan of care and support. They are supported to take risks as part of their chosen lifestyle. People who live in this home can expect to follow a lifestyle of their choosing and participate in a range of fulfilling activities. Specific dietary needs are well managed. The people who live in this home are well supported to meet their physical and emotional health needs, they are monitored effectively and action is taken promptly when any changes occur. Medication systems are safe. The people who live in this home can be assured that they will be listened to and safeguarded from harm, because of the homes policies and procedures. The people who live in this home have comfortable and safe surroundings that have been adapted to meet their individual specific needs. Improvements have been made to the overall safety of the home. The people who live in this home will be cared for by staff who are skilled and competent, and who will be able to meet their individual and specific needs. This home is well managed and run in the best interest of the people who live here. It is safe and the welfare of the people is promoted and safeguarded. What has improved since the last inspection? What the care home could do better: The home must always ensure that new staff are appropriately supervised, at all times, and should follow safe vetting and recruitment guidance concerning those who have commenced work prior the CRB disclosure being received. The home must ensure that they comply with the requirements of the Regulatory Reform (Fire Safety) Order 2005. The home must undertake regular checks of the fire alarm system, fire fighting equipment and emergency lighting system and maintain records accordingly. This will ensure that everything remains in working order. CARE HOME ADULTS 18-65 Urmston House Hareclive Road Hartcliffe Bristol BS13 0LU Lead Inspector Vanessa Carter Key Unannounced Inspection 21st December 2007 09:30 Urmston House DS0000020367.V347234.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 Urmston House DS0000020367.V347234.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. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Urmston House Address Hareclive Road Hartcliffe Bristol BS13 0LU 0117 9642616 0117 9642662 urmstonmanager@shaw.co.uk 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) Shaw Healthcare (Specialist Services ) Ltd Miss Carolyn Jane Booth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing Notice dated 13/09/2000 applies Manager must be a RN on parts 5 or 14 of the NMC register Date of last inspection 27th September 2006 Brief Description of the Service: Urmston House is a purpose built residential care home registered with the Commission for Social Care Inspection to provide nursing care for 5 people with a learning disability in the age range 18 to 65 years. The home is owned and operated by Shaw HealthCare (Specialist Services) Ltd, a subsidiary of Shaw Homes, and was established to provide person centred care for adults with special needs in the community. The property is situated in a residential suburb of Bristol with local shops and amenities close by. Accommodation is arranged over two floors. The upper floor of the accommodation is office and staff facilities. There are five single bedrooms, all with en-suite bathrooms, and kitchen facilities. Each room has individual access to the garden area. Communal facilities include a lounge, snooze /therapy room, and a hot tub room. The home provides nursing care for five people with complex health and communication needs. The cost of placement in this home would need to be discussed with Shaw Healthcare and the manager and would be individually determined. Fee levels are dependent upon assessed needs. Information about what the home has to offer are detailed in the homes statement of purpose and service users guide. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over one day. Evidence to form the report has also been gathered from a number of other sources:• Information provided by the Home Manager in the Annual Quality Assurance Assessment (AQAA) • Talking with the Home Manager • Talking with some of the registered nurses and care staff • Observations of staff practices and their interaction with the residents • A tour of the home • Case Tracking the care of a number of residents • Looking at some of the homes records • Information supplied by a healthcare professional who regularly visits the home No CSCI surveys were returned from staff or the people who live in the home What the service does well: The information made available about this home and their assessment processes would ensure that any person who lives here, would receive the care and support that they need. Robust assessment and care planning processes ensure that each person who lives in this home will receive an individually prepared plan of care and support. They are supported to take risks as part of their chosen lifestyle. People who live in this home can expect to follow a lifestyle of their choosing and participate in a range of fulfilling activities. Specific dietary needs are well managed. The people who live in this home are well supported to meet their physical and emotional health needs, they are monitored effectively and action is taken promptly when any changes occur. Medication systems are safe. The people who live in this home can be assured that they will be listened to and safeguarded from harm, because of the homes policies and procedures. The people who live in this home have comfortable and safe surroundings that have been adapted to meet their individual specific needs. Improvements have been made to the overall safety of the home. The people who live in this home will be cared for by staff who are skilled and competent, and who will be able to meet their individual and specific needs. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 6 This home is well managed and run in the best interest of the people who live here. It is safe and the welfare of the people is promoted and safeguarded. 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. Urmston House DS0000020367.V347234.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 Urmston House DS0000020367.V347234.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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information made available about this home and their assessment processes would ensure that any person who lives here, would receive the care and support that they need. EVIDENCE: The homes Statement of Purpose was reviewed and updated in March 2007 and provides the correct information about the home and what it has to offer. It sets out the management structure and staffing arrangements and includes the homes complaints procedure. The service users guide has now been issued to the people who live in the home, however is not in an appropriate format. Staff are in the process of transferring the information on to a CD and this will then be issued to everybody. This will be more useful as the people who live in the home all have visual impairments. All five people who live in the home have done so since October 2000 and therefore as part of the inspection process it was not possible to look at preadmission assessment processes. The home does however have a comprehensive assessment tool that is used to gather information and forms the basis for the care planning process. All of the people who live in the home have had a complete re-assessment of their care needs by both the funding local authority and the home, in order to ensure that service delivery remains appropriate. Urmston House DS0000020367.V347234.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust assessment and care planning processes ensure that each person who lives in this home will receive an individually prepared plan of care and support. They are supported to take risks as part of their chosen lifestyle. EVIDENCE: In order to determine how the home plans to meet the specific care and support needs for each individual, the “Support Profiles” for two of the five people who live in the home were examined. The home uses a person centred approach to planning service provision. They have put together a very comprehensive life history for each person that includes personal information and family support, likes and dislikes, personal care needs and the specific things that are required to “improve the quality of my life”. The plans covered the usual daily routines and for one person stated “needs a structured daily routine”. There was information recorded about healthcare needs, specific eating and drinking needs, and details regarding sleeping and resting. The communication plan stated that behaviour was used to Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 10 communicate and “if they do this it may mean this”. The plan was very well prepared and was obviously based upon an extensive knowledge of the person. The plan for the other person was equally as detailed and informative. There was evidence that the person has an advocate involved in the reviewing process. Both plans had been regularly reviewed and updated as necessary. Concerns have previously been raised regarding the use of the homes ‘Locked Door Policy (LDP)’ and since the last inspection the home have undertaken a great deal of work in clarifying the policy and ensuring that it is only used as a last resort. This work has been undertaken in conjunction with CSCI and the consultant psychiatrist. One agreement made was that CSCI would always be notified when the procedure was used, via a regulation 37 form – the last occasion was in August 2007 and other home records supported this fact. The use of this policy has only been agreed through an assessment process, with three of the five people who live in the home and the documentation was looked at for one person. The policy is used with this person as part of a behaviour management strategy and only when other strategies have been followed. When the policy is followed a behaviour management form is completed. The home has additional monitoring processes in place to ensure that the use of the LDP was appropriate in all cases. The people who live in this home continue to be supported to take risks as part of living a supported independent lifestyle. Risk assessments are completed and the level of risk is determined, and control measures recorded. Tasks or activities would only be undertaken if “the benefits from taking this risk outweigh the possible consequences”. A good example of this would be for one person who likes to use the garden and out door spaces, despite having no vision. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 11 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. People who live in this home can expect to follow a lifestyle of their choosing and participate in a range of fulfilling activities. Specific dietary needs are well managed. EVIDENCE: Four of the five people who live in the home were around during the inspection however one was not available as was physically unwell. Each person has an ‘opportunity plan’ that lists the types of activities that they like to participate in and the goals they would like to achieve. For one person this plan was about increasing their level of mobility, whilst for another it was about trying new activities. Some of the people receive day care support a number of times a week from an external day care provider. For others, support workers from Urmston House will take them out in the mini bus. Photographs of outings to the beach and of birthday celebrations, and discussions with the staff and the manager evidenced that each person has an individual plan of social activity. In respects of holidays, these are only arranged when they are beneficial. One Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 12 person has recently had a holiday at Centre Parcs, whilst for another the plan is for them to have day trips arranged every other week. The people who live in the home can listen to music, watch television or films either in their own apartments or in the communal lounge. Aromatherapy and Indian Head massage is also provided in this home, and for one person this is reported to be very beneficial. Some people attend a club on a Wednesday. On this inspection meal time arrangements were not observed and discussion was only had with the manager, and one other staff member. The menu is flexible and takes account of individual preferences and dietary requirements. One persons support profile listed the types of food they can eat, those that can be eaten in moderation and those that shouldn’t be eaten. It is evident that the staff team have a great deal of knowledge of each person’s likes and dislikes, meaning that each person will receive a good nutritious diet. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 13 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home are well supported to meet their physical and emotional health needs, they are monitored effectively and action is taken promptly when any changes occur. Medication systems are safe. EVIDENCE: The support profiles and behaviour support profiles for two people who live at the home and observations made during the course of the inspection provided evidence that personal support and intimate care is provided with the persons preferences recorded as an integral part of the care provision. Guidance in respects to personal care requirements, hygiene and intimate care needs, clothing, hairstyles and preferred daily routines are recorded and staff explained the importance of having a very structured daily routine for one person. During the course of the inspection observations were made of staff interacting with three of the people and it was clear that the views, wishes and choices of that person were listened to and acted upon. One person wanted to follow their usual daily routine therefore staff arranged that maintenance people visiting the home, used an alternative entrance, so as not to disrupt the person. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 14 Each person who lives at the home is allocated a team of support workers and a team leader, and it was evident from records reviewed that staff within the team advocate on behalf of the person in respect of views, choices and needs. At least one of the people has been allocated an Independent Mental Capacity Advocate (IMCA). This has been arranged to assist in the process of consenting towards medical treatment. For each person a Health Profile is recorded – a timeline details any significant healthcare events in the person’s life, and information is recorded about agreements between the home and the GP or the psychiatrist. The home has systems in place to monitoring each person’s well being, and records evidenced that any concerns about health changes were addressed promptly. Support and guidance from other professionals is ought where necessary. One healthcare completed a CSCI survey form and wrote “we work well together. The staff know the residents well which is essential as my visits to the home are brief”. Individual support is provided for residents to attend all health care appointments, and a detailed account is made to ensure consistency of care and to communicate information to all staff. The registered nurses undertake the administration of all medicines, as none of the people are able to retain responsibility for self-medication. The home has safe systems in place for the ordering, receipt, storage, administration and disposal of medications. An audit of some medication administration records (MAR sheets) was carried out and they were found to be up to date and accurate. Some of the people have medications that they do not need to take on a regular basis (referred to as PRN medications) and the home has procedures in place to check and monitor stock levels. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 15 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. The people who live in this home can be assured that they will be listened to and safeguarded from harm, because of the homes policies and procedures. EVIDENCE: The home has a detailed complaints procedure and this is included in their statement of purpose and the service users guide. Once this guide has been transferred on to a compact disc, the people who live in the home will have better information about how to make a complaint or raise concerns. In the meantime, the home has an “Easy read Complaints Form”, but the improvements they have already put in motion will enhance their complaints process. One of the support workers confirmed that they were involved in this piece of work. Each person is allocated a key worker who will co-ordinate and deliver the individual’s care and support, and would ensure that any complaints or concerns get handled appropriately. Discussions with staff members during the course of the inspection evidenced that they know when each person is upset and if behaviours change, what this is likely to mean. Team leaders will advocate on behalf of the person they are supporting resident and make their views known. Records reviewed indicated that staff members promoted individual needs and choices. Independent advocacy arrangements have been made for at least one of the current people who live in the home. The homes policy and procedure regarding the reporting of alleged incidents of abuse, or any other safeguarding issues is comprehensive and detailed. Guidance for staff is up to date and reflects the local authority protocols in place. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 16 Shaw Healthcare have an expectation that all staff will complete adult protection training (POVA) and those staff spoken with during the course of the inspection confirmed that they had attended “in-house” training. Examination of the homes training matrix evidenced that all bar one newly recruited staff member had completed the training. One of the team leaders has completed a ‘training for trainers’ course and leads these training sessions. In addition the manager and the deputy have attended the Bristol City Council POVA for managers training. All staff spoken with during the course of the inspection, demonstrated a good awareness of protection issues and their responsibility in safeguarding those they care for. Since the last inspection there has been one safeguarding issue that was referred to the local authority and investigated. The home had delayed reporting the incident, but once this was done had taken the appropriate disciplinary action, and arranged for staff to attend refresher POVA training. None of the people who live in the home were harmed from this incident however the potential for harm to have occurred was present. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 17 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, 26, 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in this home have comfortable and safe surroundings that have been adapted to meet their individual specific needs. Improvements have been made to the overall safety of the home. EVIDENCE: Urmston House is a purpose built care home registered to provide nursing care for 5 people. The home is owned and operated by Shaw HealthCare (Specialist Services) Ltd, and was established to provide person centred care for adults with special needs in the community. The home is accessible for wheelchair users and adaptations are in place to meet the needs of each of the people who live in the home. Particular attention has been paid to adaptations for visual impaired people with the installation of orientation aids and different textured surfaces. All windows and external doors are connected to the alarm system. The property is situated in the residential suburb of Hartcliffe, South Bristol. Local shops and community amenities are situated close by. The accommodation is arranged over two floors. The home manager’s office and Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 18 staff facilities are located on the upper floor. There are five single bedrooms, all with en-suite bathrooms, and kitchen facilities. Each room has its own individual access to the communal garden area. CCTV cameras monitor the entrance of the home and security lighting has been installed to the rear of the home since the last inspection, thereby improving the safety for both the people who live in the home and the staff. A tour of the home was made at the start of the inspection, to include all communal areas, some of the individual bedrooms, the laundry and kitchen and the garden area to the rear of the property. The accommodation was found to be clean, tidy and well furnished. Each resident has an individual apartment located on the ground floor. The apartments consist of en-suite bathing or showering room and a kitchenette, with individual access to the garden. The main door in to each apartment is lockable. Only some of the apartments were viewed on this inspection visit however previously all rooms were noted to have been personalised and adapted to meet the needs of the person accommodated. The decor and furnishing in those rooms seen, was in good condition, and the apartments were clean and homely reflecting individual style and taste. In addition to each of the apartments, there is one communal toilet room, a bathroom with Jacuzzi and a hot tub room. These last two rooms have been decorated since the last inspection and provide a pleasant and calming atmosphere. The sensory room is now usable and no longer used as a storage area. The home was clean, tidy and well furnished. The home was odour free because regular cleaning and good standards of hygiene ensure that any unpleasant odours are dealt with promptly. The domestic assistant was on duty at the time of the inspection Each person has their own small garden area. This is adjacent to, and accessible from, their room. Raised flowerbeds, plants, trellis and garden furniture to suit individual needs and choices have been purchased. One resident has a garden- hammock; another has an area of decking made up of different tactile materials. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 19 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 people who live in this home will be cared for by staff who are skilled and competent, and who will be able to meet their individual and specific needs. EVIDENCE: All staff are provided with a job description, therefore they are aware of their role and that of others. Support workers work under the guidance of a registered nurse, who will be on duty and in charge of each shift. Those support workers and registered nurses that were spoken with during the course of the inspection demonstrated a very good understanding and knowledge of the people they are supporting. Support staff are expected to work within the General Social Care Council (GSCC) code of conduct and registered nurses, within the Nurse and Midwifery Council (NMC) code. Support workers were observed to be liaising with the nurses regarding aspects of a persons care. Staff training records, and the homes computerised training matrix, evidenced that support staff and registered nurses receive mandatory training manual handling, fire, risk assessment, health & safety, food hygiene, COSHH, infection control and POVA. New staff will complete a four-day induction course and will initially be mentored by a senior member of staff. All staff will Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 20 have to complete a six-month probationary period after starting work and their work performance and conduct will be monitored during this period. These measures will ensure that the people who live in this home, are cared for by competent staff. In addition to the mandatory training, there was evidence that staff have received ‘Values training’ – covering equality and diversity issues, ‘positive response training’, and that some staff from each team will attend training in nutrition and healthy eating. Five support staff have already achieved an NVQ Level 2 in care (33 ) and a further five are in the process of completing the award (66 )training or have just completed training and wish to progress. Evidence confirmed that supervision in the past year including one person who had not received any supervision since they started working in the home. The staff team consists of the manager, the deputy manager, registered nurses, support workers and ancillary staff. The nurse and support workers cover both day and night duties on a rota’d basis. During the day there is one registered nurse plus four support workers and during the night, one nurse plus two support workers. Records seen confirmed these arrangements. The home has in the past found it necessary to use agency staff to fill vacant shifts however have recently recruited one new team leader and three support staff. A further team leader will start once recruitment checks have been completed. The recruitment processes that the home follows were examined during part of the inspection and three staff files were looked at. Potential workers are expected to complete a full application form, attend for interview and provide evidence of medical fitness and qualifications. Two satisfactory written references, POVAfirst list and a CRB (Criminal Records Bureau) disclosure complete this process and evidence safe recruiting and vetting procedures. Workers may be commenced after it is determined that they have not been placed on the POVA list but prior to the return of a CRB and in these instances, the worker must always be supervised by a senior member of staff. Each staff member will have a yearly appraisal where his or her training and development needs are discussed. The manager will carry complete these but staff supervision is undertaken by the senior staff team. The team leaders and the deputy manager will supervise a group of support workers and the manager will supervise all team leaders and the deputy. The manager oversees all and will ‘sign off’ all written records. Team meetings for the whole staff group are scheduled on a monthly basis and written records confirmed the arrangements. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is well managed and run in the best interest of the people who live here. It is safe and the welfare of the people is promoted and safeguarded. EVIDENCE: The registered manager, Carolyn Booth returned from secondment to another care home care earlier in the year and has, since her return, ensured that the shortfalls referred to in the last inspection report have been addressed. She is a registered 1st level nurse and is in the process of completing the Registered Managers Award (RMA). The deputy manager is also completing this. With the return of the home manager it is evident that the difficulties that the staff team were having at the last inspection, have been resolved. Staff spoken with during the inspection were complimentary about the management approach and the open style of working. They felt they were listened to and their views and opinions were valued. It is evident that with the return of the manager, the home has regained leadership and a sense of direction. As part Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 22 of the inspection visit, the staff handover session was observed in order to confirm the communication systems used between shifts. The handover was very detailed and generated healthy and informative discussion between the staff teams. The Shaw Healthcare area manager visits the home on a monthly basis and carries out an audit of the service – a “Regulation 26” report is written and a copy submitted to CSCI. Care planning documentation and each persons ‘opportunity plan’ is regularly reviewed and updated where necessary, to ensure they remain a true reflection of current needs and aspirations. There are systems in place for ensuring that the health & safety of people who live in the home and staff is maintained. CSCI are notified via regulation 37 forms regarding any significant events that affect the health or safety of the people that live in the home or staff. This includes those occasions when the locked door policy has been used or when staff are hurt as a result of a person’s challenging behaviour. All staff receive manual handling training as part or induction and on-going refresher training although on the whole do not need to lift or move the people who live in the home. Staff receive all the relevant health and safety training and this is listed in the staffing section. The fire logbook was examined and showed that the relevant checks on the fire alarm system, fire doors and fire fighting equipment, and the testing of the emergency lighting, is not being consistently carried out. This has already been picked up during the last area manager’s visit. The manager explained that to address this shortfall a back-up person has been identified to fill-in when the designated worker with health & safety responsibility, is on leave. The last fire drill took place the previous week and these are held on a regular basis. All staff work day and night shifts and therefore have at least three monthly fire awareness training. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 23 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 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 3 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 X 3 3 3 X X 3 X Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 24 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 YA34 Regulation 19(11)a Requirement The home must ensure that new staff appointed following a POVA check but before CRB disclosure is received, are appropriately supervised at all times. The home must ensure that they comply with the requirements of the Regulatory Reform (Fire Safety) Order 2005. Timescale for action 21/01/08 2. YA42 23(4)a, c. 21/01/08 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 YA42 Good Practice Recommendations The home must undertake regular checks of the fire alarm system, fire fighting equipment and emergency lighting system and maintain records accordingly. This will ensure that everything remains in working order. Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 25 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 Urmston House DS0000020367.V347234.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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