Care Home: Wendorian

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What the care home does well What has improved since the last inspection? No requirements were made following the last inspection. What the care home could do better: CARE HOME ADULTS 18-65 Wendorian Cracknore Hard Lane Marchwood Southampton Hampshire SO40 4UT Lead Inspector Sue Kinch Unannounced Inspection 25 March 2008 10:30 th Wendorian DS0000060604.V359532.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 Wendorian DS0000060604.V359532.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. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wendorian Address Cracknore Hard Lane Marchwood Southampton Hampshire SO40 4UT 02380 867557 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) wendorian@ukonline.co.uk Wessex Regional Care Ltd Mrs Lisa Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th November 2006 Brief Description of the Service: Wendorian currently provides accommodation and support for four people who have learning disabilities and may also present behaviour that is challenging to service providers. It is situated in Marchwood, a short distance from local shops. All people living in the home are provided with single rooms, one of which has en-suite facilities. The home also has a lounge with dining area, a recently redecorated conservatory, a kitchen and a laundry room. There are sufficient bathroom and toilet facilities. The garden to the rear of the property has seating available and there is a wooden building at the end of the garden which service users use as a computer room. An office and a sleep over room are available for staff. The registered manager stated at the visit that the current fees for the home ranged from £1352 to £1579 per week and were based on individual needs. Wendorian DS0000060604.V359532.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 inspection consisted of a review of the file held at The Commission for Social Care Inspection (the Commission) local office and of an Annual Quality Assurance Assessment (AQAA) document completed and sent in by the manager before the inspection visit. The visit took six hours. Detailed conversations were held with two residents. Separate discussions were held with two staff members and the manager who was on annual leave but attended the inspection in the afternoon. Parts of the physical environment were looked at and a sample of documents and records required to be in the home were viewed. Responses were received to surveys sent out before the inspection. They were received from 3 residents, 10 staff, 1 relative, a health professional and an advocate. What the service does well: People using the service are confident that they will be listened to by staff and management, and consulted about the support that they receive. There are some restrictions in place based on individual needs and these are as a result of planning and discussion also involving external professionals. They are confident that they will have support with social, emotional and health needs. One professional said ‘they do provide an individualised service and are able to manage complex behaviours- they have a very positive view of people with learning disabilities.’ Care plans and risk assessment are reviewed regularly and people living at the home are aware of the contents of them and speak of discussing them regularly with the staff. They say that they have support to find things to do in and out of the home and staff support is provided when they need it. Staff members are aware of residents rights and their in promoting decisionmaking. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 6 People living at Wendorian like the choices that they have about food and the opportunity to be involved in food preparation. People living in the home are encouraged to voice their views individually or in meetings and feel able to raise concerns and know they will be addressed. The environment is pleasant, maintenance is regular and people can influence the décor. People living in the home receive support from staff who are trained, guided and supervised by a manager considered to be supportive and approachable. Systems in the home are well managed. 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. Wendorian DS0000060604.V359532.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 Wendorian DS0000060604.V359532.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Systems are in place to assess needs and aspirations of people wishing to live at the home before admission. EVIDENCE: At the last inspection it was found that people living in the home had been provided with information about the home and contracts. Pre-admission assessments were seen for the three people living in the home indicated that all aspects of care needs had been assessed. The admission process was found to be satisfactory. At this visit there had not been any new admissions to the home but one person had moved back in having had experience at another. Care and support was discussed with that person and evidence of a recent review and revision of care plan was in place. One of the people living in the home spoke about the spare room and that the home could admit another person. The person was aware that an admission was being considered but said that only a relative of the new person had visited so far. They said that they fully expected that people living in the home would be included in discussions about any admissions. This was in line with Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 9 other comments received throughout the inspection about people living in the home feeling listened to. In the AQAA the manager said that systems are in place to assess the needs of people by visiting and consulting a variety of people before deciding on an admission and that work towards supporting an existing resident to move into supported living ‘ demonstrates ongoing assessment and support for service users as to the services capacity to best meet their needs and strive towards their aspirations.’ She said that this process is involving the care manager and an advocate. The manager said that the service user guide had been reviewed and this was viewed and included some pictures. However she said that work is taking place to make the information more accesible to the people living in the home and will be providing some of the information in a recorded format. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in their care planning and feel the plans in place reflect their personal goals and changing needs. Service users are supported to make decisions about their lives, to take risks as part of an independent lifestyle and feel they are consulted on and participate in all aspects of life at the home. EVIDENCE: Each person has a securely held, detailed care plan folder. Respecting the views of the people living in the home, the staff consulted people before sharing folders with us. One was looked at whilst talking about the care received with person using the service. A second was looked at separately and then elements discussed with the person. They said that they know about the care plans and the range of information that was written in them and have contributed and feel consulted. They are encouraged to sign their care plans and those viewed had been updated recently. One person said that the staff Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 11 read through it with them and was aware of the sections looked at during the visit. We looked for a sample of information in care plans relating to some of the issues raised (such as use of the community, behaviours, agreements, mental health, social and recreational support and budgets and these were recorded with support needed. Staff said, that they are kept up to date with information about people living in the home. People living in the home say they feel consulted and listened to and one said that they felt that staff ‘know what to do’ and felt treated like an individual. One person said ‘I am happy here’. Another said its ‘one of the best homes I have been in’. The files contain evidence of regular and recent Care Programme Approach reviews and people knew about the frequency of them and are involved in the process. The manager said that all risk assessments and restrictions are discussed at these reviews. Care plans include elements of risk relating to individuals over a range of activities and where sampled restrictions (such as going out with staff or alone at certain times) have been recorded, agreements made and guidance is also in the care plan. Examples were discussed with people living in the home who agreed with the plans. Restrictions were reported by the manager to be agreed with relevant professionals involved. One person living in the home said that there were regular meetings to discuss these issues. A review of one risk issue was identified as needed during the inspection visit and this is reported on in the complaints and adult protection section of this report. Wendorian DS0000060604.V359532.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Wendorian are supported to be active and involved in a range of activities and relationships in the community and at home with varying levels of support based on assessed need and the promotion of rights. They are also supported to choose a healthy diet and prepare meals, which they enjoy. EVIDENCE: At the start of the inspection visit two people were out independently in the community. Access in this way has been assessed with the use of risk assessments in the care planning process and an individual approach is taken with each person living in the home. People spoken with were happy with their arrangements and during the inspection it was noted that phone contact was made by a staff member with someone who was out as required in the care plan. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 13 In the Aqaa the manager referred to people using the service doing various things in the day. One goes to a work placement, another to a voluntary work placement at a horticulture social enterprise after an initial college course, another is volunteering in a charity shop and general visits are made to a snooker club. Feedback from people living in the home included agreement that where possible they are supported to use the community independently and that the home also arranges activities that they can take part in. External activities commented on included the some of the work and courses above and regular trips to football, the cinema, and going to town. One person said that he had enough to do and went out most days with staff support, which was available. On the day of the visit he had chosen to go out in the afternoon. Another person said that staff were working to increase the range of things that he was involved in. Evidence of support given with activities is recorded in the daily recording. Each person has their own room, which they have been able to individualise and these have a range of equipment for recreational use such as televisions, music centres and an exercise bike based on individual choice. One person also spoke about access to the computer room in the garden. Help is given with maintaining relationships and friendships and one person spoke about meeting friends at work, being able to invite them over and, another person spoke of having visitors. They both also spoke of help from staff with emotional needs and one gave an example of support to go and visit a cemetery. Other professionals were also referred to for providing support with relationships. A relative said that the home always helps their relative to keep in touch. Regular residents meetings are also held in the home. People do feel that they have a say in the home and that they are listened to and discussions with staff showed a respect of the rights of the people living at Wendorian. One person living in the home said ‘ you’re free to do what you want - within limits- I’m happy with it’. In the three surveys from the people living in the home all said that they can make decisions about what to do each day including at the weekend. People living in the home are involved in the running of the home and rotas for cooking and cleaning are on the kitchen wall. These were discussed together with a member of staff and someone who lives there. They said that they have been agreed although not everyone likes them. Another person said that they had suggested changing the washing up rota, which had been changed. All agreed that there is some flexibility and some people prefer some tasks to others, but people are encouraged to take part. If people don’ t keep to it others do it or staff do it. Responsibility is also encouraged in care of rooms, laundry and the shared areas of the home. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 14 The home has a menu plan based on the wishes of the people living in there. These are now planned weekly instead of monthly to increase choice. A member of staff was food shopping on the morning of the inspection. People living at Wendorian are involved but not on this occasion and they also purchase items at the local shops. Food provided was discussed with one person who said that: they liked the food provided, (which included fresh fruit and vegetables,) that there was variety and choice and that you could have something else if you did not want the food on the menu. Wendorian DS0000060604.V359532.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with support to meet their varying health and emotional needs in a supportive and enabling environment. The home’s policies and procedures ensure the safe administration of service users’ medication and promote their independence. EVIDENCE: People said that support is available as needed and they are able to make decisions about their daily routines. Where support is needed for personal care this is documented although a staff member said most people are independent in self-caring tasks. They said support is based on needs, and mostly consists of prompting. In the surveys one staff member said that they thought people living at the home could have better support with personal hygiene. People living at the home said that they get all the support that they need at the inspection visit. People living in the home also said that they receive the care and support they need with health. Those spoken with said that there is good support with Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 16 physical and emotional health. Examples were provided of how the staff have helped with specific issues including involving external professionals when needed. They gave examples of external professionals involved showing that psychiatric, psychological and specialist nursing support is received. One person said that staff provide enough help with emotional needs and another that ‘staff are always there to talk to’. There is also a key worker system in place to assist with this. Care plans include the issues, needs and action needed to meet health needs and risks are assessed. As reported in the section in individual needs and choices people with mental health problems required to have Care programme Approach (CPA) reviews are having them within the required timescales. People using the service said they are supported with general health monitoring and appointments. One person said these had happened regularly. Independence is encouraged and another person said that they make their own health appointments unless unwell and staff will attend appointments and provide support if needed Self-medication is encouraged but some of this partial and medication is administered. Risk assessments for involvement in self-medication are in place. Medication is held securely but individually for each person and records are held of administration. A staff member and someone living in the home showed us how individual help is given with medication that is privately administered or assisted with. Records are held of administration. Staff training records were viewed at the last inspection. Wendorian DS0000060604.V359532.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ views are listened to and acted upon and systems are in place to aid protection but steps are needed to review whether staff training and a planned physical intervention is needed for one person living in the home to ensure that the appropriate support strategy is in place for that person. EVIDENCE: The home has a complaints procedure, which is provided in the Service Users’ Guide that has been provided in a format that people living in the home can understand. They provided verbal and written information to say that they know who to speak to if they are not happy and know who to complain to. Systems are in place for people to have opportunities to talk with staff regularly. One person said ‘staff are always there to talk’ and said that complaints were responded to ‘pretty quickly’ and that they were happy with the solutions. Another said that they could talk to the staff manager or others if they were not happy. That person also said that staff listen. In the Aqaa the manager said people are encouraged to raise concerns or complaints and that there had been sixteen complaints since the last inspection. At the inspection visit we looked at the logbook to view a sample of entries. These were recorded and some details were given about when these were addressed. These were not fully detailed but the manager said that they could be cross-referenced to the files of the people living in the home. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 18 The training records held in the home included evidence that staff members are trained in abuse awareness and this was discussed with a member of staff who confirmed that they had received some training. The person was able to give examples of the type of abuse that can occur and was aware of the need to act on it if suspicious. Staff also showed a strong awareness of the rights of people living in the home. In the written survey all ten responses from staff indicated they knew what to do if the people living in the home had concerns. Since the last inspection one incident of unplanned restraint was reported to the Commission under regulation 37. This was discussed with the manager. Not all staff have been trained in restraint, as it is not in any of the care plans. However, a review of the use of restraint following such incidents including an assessment of the risk of it being used again or whether an agreed strategy is required, has not been carried out. The manager agreed that this would be completed with relevant professionals. Wendorian DS0000060604.V359532.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): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home enjoy pleasant, hygienic surroundings that they contribute to keeping clean. EVIDENCE: Areas of the home viewed included all shared areas, the garden and two bedrooms. The home was clean and people living in the home say they look after it with staff help. Staff agree and it is their job to do it if the people living the home are unable to or don’t help on certain days. In the surveys one person said that it was only clean sometimes but on the day of the visit it was clean and people living in the home spoken with said that it is always fresh and clean. Areas viewed were mostly decorated to a good standard and in the bedrooms viewed there was evidence of lots of personal belongings. In the AQAA the manager had reported ongoing improvements in last twelve months including a Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 20 ‘redecorated kitchen, office, downstairs bathroom, stairs, landing and hall way.’ Staff and people living in the home spoke of the redecoration of the conservatory, since the last inspection, which they liked. They spoke of plans to redecorate the first floor toilet, which has peeling wallpaper, but were not aware of plans to redecorate the lounge/diner, which has some paint peeling above the radiator and some stains on the carpet. The manager however, was aware of the need to address this. People also have access to a medium sized garden with space for a vegetable patch, which one of the people living in the home says they will be growing vegetables in as the weather improves. In the Aqaa the manager said that maintainance issues are attended to promptly and tracked through the home’s purchase order system. At the visit staff and people living in the home confirmed that things are fixed as necessary and that everything in the house was working. There is an infection control policy for the home and in the AQAA the manager said that ten staff had been trained. Staff spoken with said that they were provided with training, protective gloves and aprons. Hand washing equipment is provided in toilet areas. A laundry is available for general use and people living in the home have full access to it. Each person has a day when they can have priority use of the facilities but one person said that could still do washing on any day. Wendorian DS0000060604.V359532.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. More evidence is needed in the home to demonstrate that the protection provided by the recruitment procedures for permanent staff in place are also used for all bank/relief staff. People in the home are provided with staff flexibly deployed and provided with training suitable to meet their needs. EVIDENCE: Staff returning surveys have reported that checks such as Criminal Record Bureau checks and references were obtained before employment. We looked at a sample of pre employment checks held for three staff recruited since the last inspection and enough information was provided to indicate that the checks took place before they were employed at the home. However, in one situation although two references were obtained one did not include the previous employer and there was no explanation for this and for another it did not state how long the referee had known the staff member. The manager said that she would discuss these matters with the organisation. Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 22 Although the manager said that there is a system in place to carry out the pre employment checks for bank/relief staff, the home has staff records for only some of them that work at the home. The manager agreed to address this. The manager said that there are plans to increase the involvement of people living in the home in the recruitment process. Current practice was not discussed with anyone else on this occasion. Written and verbal feedback about staff levels was received indicating that there is enough staff to meet people’s needs. Staff and people using the service said that there were always or usually enough staff. One said that there are normally two staff working during the day and sometimes three depending on the support needed by the residents. There are also two staff at night –one awake and one asleep. This was reflected in the sample of rotas viewed. Staff members were positive about the training and support they receive in the home. In written feedback they confirmed that they have up to date training relevant to their role and to meeting the needs of the people living at the home. They confirmed that they have induction, monthly supervision and information is shared between them. They also have a range of regular meetings. One professional said the staff were ‘essentially on the right trackthey need to ensure that all staff are up to speed.’ Evidence is recorded of the training that staff are given and includes a range of health and safety and care issues such as various courses in managing behaviours including breakaway techniques and adult protection. All current staff had received some of this training in the last year. One staff member confirmed that induction had been provided and that a workbook had been completed. The member of staff was about to do training in fire and managing behaviours in the next two days after the inspection and spoke about already having completed some training in aggression and the Mental Capacity Act. The manager reported that three staff had been assessed to National Vocational Qualification (NVQ) level two and above and another five were working on level two. The manager has records of training completed by permanent staff but not bank staff. In the AQAA she talked on increasing staff training in areas such as disability awareness and the Mental Capacity Act. At the inspection the manager said that an external professional had been involved in identifying training needs for staff. Wendorian DS0000060604.V359532.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a well run home with a manager that seeks their views and promotes their health, safety and welfare. EVIDENCE: The registered manager, Lisa Smith, holds a degree in Social and Professional Studies for Learning Disabilities, and the Registered Managers Award and is working towards a Master of Science degree in Applied Psychology of Intellectual Disabilities. Mrs Smith has several years experience in working with people with learning disabilities and registered with the commission as manager of the home in July 2006. In the Aqaa she reported that she is furthering her studies and is engaged in a course in Applied Psychology of Intellectual Disabilities commenced in October 2007. She said she is also Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 24 planned to do more training in physical interventions and updating in first aid. It was noted during the visit that the manager had a good rapport with the people living in the home and staff. All staff said that they had support from her regularly or often and people living there felt they could talk to her. To assist with quality assurance the manager said that a quality assurance audit had been completed. This was viewed and had been completed on 4/10/07. The manager said that the tasks raised had been actioned but this needed to be recorded. She also spoke of a management away day that she had attended looking at the development of the service and that the Service Manager had followed these up through Manager’s Meetings and her supervision. The manager showed that there was an action plan for the home in the records of the away day and said that this information was available to staff. People receiving the service indicated in all feedback that they feel consulted and involved in the decisions about the service provided. They say individual and group meetings for people living in the home help and one person said that he could definitely voice his opinions. In the surveys all staff said that they thought the ways that information is passed between them, people using the service and the manager worked well. The manager said that following the quality assurance audit she intended to develop a service user satisfaction questionnaire internally within the home. At the last inspection the registered manager said that she had reviewed all the home’s policies and procedures in September 2006. In the Aqaa received before this inspection she showed that updates are ongoing. Policies and procedures are in the home for health and safety, staff spoke of some of the training that they have received relation to this and records are held. A sample of records required to be held in the home in evidence of some checks of servicing was sampled. We found that the checks of gas maintenance and electrical wiring had been completed as required. The fire logbook indicated that the fire system had been checked by an external organisation this year. A person living in the home said that the fire bells were checked regularly every Tuesday and had already been completed on the day of our visit. The same person was aware of the staff having training in food hygiene and pointed out the kitchen rules on the wall of the kitchen. These were based on food hygiene regulations. He said that they all use them and he had also Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 25 completed food hygiene training. There is written evidence, in the home, that staff receiving regular training in health and safety issues such as first aid, food and fire training. Wendorian DS0000060604.V359532.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 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 4 x x 3 x Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wendorian DS0000060604.V359532.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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