Care Home: Wingfield Road Care Home

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What the care home does well A person centred approach to care has been embraced by the home that puts the person at the core of everything they do. People said they were involved with key workers to develop person centred plans that expressed their personal wishes and desires. Guidance is provided for staff so that they can understand how people like their personal care and support for activities to be carried out. People said they like going to college and day centres. One person enjoyed looking after chickens at the home and hoped to have a job looking after chickens on a farm. Information is presented in formats which people can understand using photographs, symbols and text as well as making audio versions available. Staff have access to training and refresher courses providing them with the knowledge and skills to support people. People are involved in the quality assurance system completing surveys and taking part in Craegmoor`s `Your Voice` Forums. What has improved since the last inspection? The home had been issued with three requirements that were all met. The ceiling in the lounge had been redecorated and made good. Documents required before appointing staff were in place and any gaps in employment history were being explored. Evidence was provided that Protection of Vulnerable adult (pova first) checks had been completed and original Criminal Records Bureau (CRB) certificates were in place. What the care home could do better: If medication is secondary dispensed into other containers, when people go on social leave, procedures must be put in place and followed by staff to ensure that errors do not occur. A flood in the bathroom had damaged the ceiling in the hallway and although some work had been done to repair this, further redecoration was needed. The registered manager and deputy manager addressed a number of issues immediately such as labelling of creams and liquids, recording of restrictions and keeping copies of birth certificates. These are identified in the body of the report. Fire procedures need to be reviewed to make sure that people are safe from harm overnight. This may involve a full evacuation if there is a fire in the home. CARE HOME ADULTS 18-65 Sunflower Villa 22 Wingfield Road Trowbridge Wiltshire BA14 9ED Lead Inspector Lynne Bennett Key Unannounced Inspection 9 and 10 September 2008 10:00 th th Sunflower Villa DS0000028443.V364803.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 Sunflower Villa DS0000028443.V364803.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. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunflower Villa Address 22 Wingfield Road Trowbridge Wiltshire BA14 9ED 01225 762043 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) sunflower.villa@craegmoor.co.uk www.craegmoor. Co.uk Parkcare Homes Ltd Mrs Nicola Jane Gardner Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2006 Brief Description of the Service: Sunflower Villa provides care and accommodation for up to six adults with learning disabilities. The home is operated by a subsidiary of Craegmoor Healthcare, a private sector organisation with four registered care homes within Wiltshire. The service has been open for just over ten years, initially under different ownership. The home provides long-term placements, and the current people living at the home have lived there for several years. The property is in a residential area of Trowbridge. A range of amenities are available in the town itself. Larger centres, such as Bath and Bristol, are within reasonable travelling distance. The home is a three storey semi-detached property. All people have single bedrooms, one of which is on the ground floor. The living room and dining room are also downstairs, along with the staff office and sleep-in room. Toilets are available on all three floors. The ground floor has a shower, and the two upper floors both have bathrooms. The home also has a pleasant enclosed garden at the rear. Fees charged for care and accommodation range between £954 and £1187 per week, depending upon the assessed needs of each person living in the home. Information about the home is available in written form, and can also be supplied in picture or audio versions if required. CSCI inspection reports can be seen in the home, and the manager has also developed a folder of relevant information about the Commission. Interested people are also directed to the websites for both Craegmoor and the CSCI. Sunflower Villa DS0000028443.V364803.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 inspection took place in September 2008 and included two visits to the home by one inspector. An Annual Service Review had been completed for the home in June 2008 and information supplied for this review was used for this inspection, this included the Annual Quality Assurance Assessment (AQAA) and surveys from five people living in the home, three relatives and three healthcare professionals. The registered manager completed the AQAA providing information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). We (The Commission for Social Care Inspection) spent time with four people living in the home, talking to them and observing the care provided. We talked to three staff about the support they provide. The registered manager was present throughout. A range of documents were examined including care plans, medication and financial records, health and safety systems and quality assurance audits. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: A person centred approach to care has been embraced by the home that puts the person at the core of everything they do. People said they were involved with key workers to develop person centred plans that expressed their personal wishes and desires. Guidance is provided for staff so that they can understand how people like their personal care and support for activities to be carried out. People said they like going to college and day centres. One person enjoyed looking after chickens at the home and hoped to have a job looking after chickens on a farm. Information is presented in formats which people can understand using photographs, symbols and text as well as making audio versions available. Staff have access to training and refresher courses providing them with the knowledge and skills to support people. People are involved in the quality assurance system completing surveys and taking part in Craegmoor’s ‘Your Voice’ Forums. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 6 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. Sunflower Villa DS0000028443.V364803.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 Sunflower Villa DS0000028443.V364803.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory admission arrangements are in place that include an assessment of people’s needs. Ongoing re-assessment of people will ensure that the service is continuing to meet their changing needs. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed this year and three care plans contained current information about the service they receive and the costs of the service to them. The Service User Guide had been produced in a format appropriate to people’s needs using a mixture of text, photograph and symbol. The AQAA stated that people wishing to move into the home would also be given a copy of ‘Moving into Sunflower Villa’. The home had no new admissions. On files examined people had a current assessment of needs completed by the home. Discussions with the registered manager confirmed that the changing needs of people living within the home were being monitored and that they were being supported to stay at the home wherever possible. Where people had asked to look for alternative accommodation they were being supported to do this, and their decisions whether to move or stay were respected. In this instance the person decided not to move from the home. Sunflower Villa DS0000028443.V364803.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A person centred approach to care planning provides the opportunity for people to take control of their lives. People’s needs are being assessed and they are being supported to makes decisions about their lifestyles. Risks are being managed safeguarding them from possible harm. EVIDENCE: The care for three people was case tracked, which involved reading their care plans, talking to them and staff about the support provided and examining other documents related to their care. People had a person centred plan in place that was clearly based on their assessment of need, which was being reviewed on a regular basis. Key workers noted in daily dairies when evaluation of care plans had been completed and some people had recorded this on evaluation records in care plans. People were also having annual reviews with their placing authority and copies of their current care plans and reviews were on their files. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 10 Care plans were in place for a range of holistic needs covering people’s emotional, physical, intellectual and social wishes and desires. These had prompts for staff to link with specific care plans or risk assessments. People living in the home were signing the plans. The registered manager said that people were totally involved in this process and care plans were read through to them and they signed only after this had been done. An additional care plan on one file stated, “each page was read back to … to make sure he fully agrees and understands what has been written.” It also stated that the plans provided, “a true account of my daily life and support needs.” People living in the home confirmed they had been involved and that their key workers had supported them to express their wishes and needs. Clear guidance was provided for people with autistic spectrum disorder and others who liked routine. The way in which they liked to be supported with personal care or activities was clearly recorded providing staff with step-bystep direction to ensure a consistent approach and to minimise anxiety or distress. Staff were observed putting this into practice with positive effect. Communication profiles were in place describing people’s preferred form of communication. These also indicated what people’s behaviour or body language may indicate about their feelings or emotions if they were unable to express these. Staff had a good understanding of the people living in the home and how to interpret their non-verbal behaviour. Good use was made around the home of photographs, symbols and text providing people with information about activities, meals and staff on duty. The registered manager confirmed that people have access to information about local advocacy. Two people living at the home were actively involved in Wiltshire People First attending meetings on a regular basis. They were also involved in Craegmoor’s ‘Your Voice’ Divisional Forums. Most restrictions had been identified in people’s care plans and the appropriate risk assessments or protocols were in place providing evidence of the rationale for these. The registered manager and staff confirmed that restricted access to cupboards, a fridge and to the front and rear doors were to safeguard people from possible harm. No documentation could be found to explain why the front and rear doors were locked. This was immediately put in place by the registered manager with consideration of the implications of the Deprivation of Liberty Act to be implemented in 2009. She was advised to review these restrictions at annual reviews. Risk assessments had been developed from hazards identified in care plans and provided staff with guidance about how to minimise risks. These were being regularly reviewed. Sunflower Villa DS0000028443.V364803.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): 11,12,13,14,15.16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritious diet and their diverse needs are catered for. EVIDENCE: People’s religious beliefs were identified in their care plans and there was evidence that the home had discussed with them whether one person would like to go to the local Roman Catholic Church, or invite the priest to visit. In their survey responses people told us that they make decisions about what to do each day and can do what they want during the day and evening. One person told us some of the things they do including going on holiday, going to college, gardening and day trips. Another person said that they liked going to Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 12 their day service and enjoyed always having the weekend out with their mother. People had activity schedules produced in a mixture of text, photograph and symbol. Notice boards around the home also provided information about what people were doing that day and who would be supporting them. During the visits people were observed being supported to go to the local college and a day centre. One person had decided to try college for the first time and was successfully supported by staff. One person had a job one afternoon a week and another person had an interview for a new job. Staff described how they try to give people informed choice and where people indicate they do not want to try an activity, they respect this but also make sure that there were opportunities to reconsider at a later date. For instance one person had not been on holiday for a number of years but after discussion with staff indicated they would like to try a holiday next year. This was being arranged with them during one of the visits. In another instance one person chooses to spend much of their time in their room. They liked to have daily newspapers and access to magazines that were observed being provided. However prior to the visits they had been out with staff on two occasions for a drive in the car. Staff were heard discussing with them whether they would like to do this again. People were using local facilities such as shops, pubs and the cinema. They were able to walk or use the home’s transport. One person had recently bought some chickens and was being supported to look after them. They and others in the home were taking great delight from the fresh supply of eggs. This person had chosen to occasionally share these with others living in the home. People also had gold fish and tropical fish that were kept in the lounge for all to enjoy. Daily records provided evidence that people were being supported to participate in a range of activities both inside and outside of the home. Notices in the dining room provided information about forthcoming events. These were produced using photographs and text. People said they had regular house meetings and minutes of these had been produced. The registered manager stated that these were read through to people before being typed. People were observed helping around the home with cleaning, laundry, shopping and cooking. One person said they enjoyed helping to keep the house clean and liked peeling the potatoes. Contact sheets were being maintained keeping a record of visits or telephone calls to family and friends. Daily records also indicated when people had been in touch. One person said they liked to go home to see their relatives. Another person was expecting a parent to visit whilst we were there. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 13 The menus for the home were developed with people living there and reflected their likes and dislikes. Alternatives to the main meal were being provided when requested and noted on a separate record. The registered manager stated that people were involved with the shopping for the home over the internet, giving them a visual prompt to what was available as well as shopping on a day to day basis as needed. During the visits freshly cooked meals were prepared using fresh vegetables. People were observed snacking on fresh fruit. One person had diabetes that was controlled through their diet. Guidelines were in place providing staff with information about the diet to be provided. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and wellbeing are being met helping them to stay well. Suggested improvements in the administration of medication were immediately implemented to safeguard people from the risk of error or possible harm. EVIDENCE: The way in which people would like to be supported with their personal care needs was identified in their care plans. Each person’s likes and dislikes were recorded. Any particular products they liked to use, or their preferred routines were noted. Staff spoken with had a good understanding of these. Although staff meeting minutes indicated that staff had discussed the gender of care staff supporting people with their personal care needs, this was not recorded in their care plans. One person had diabetes and their care plans omitted to provide clear information about their foot care. A new care plan was put in place during the visits. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 15 People living in the home had health plans providing information about their individual health and medication needs. Individual records were also being kept for each appointment with a healthcare professional which included the reason for and outcome of the appointment. There was evidence that people were being supported to have regular appointments with a range of healthcare professionals. One person did not like to go out to the dentist and so arrangements were made for the dentist to come to them at the home. Feedback from healthcare professionals told us that the home works in partnership with them and consults them appropriately. They were satisfied with the overall care provided to the people who live in the home. One commented that the home needed to work with people in a more person centred way, while another said ‘the team do a lot of proactive work with individuals…it is all person centred.’ There was evidence of regular consultation with the Community Team for People with Learning Disabilities and staff confirmed referrals had been made to the team for additional support with a particular issue. A range of monitoring forms were in place and observed to be completed by staff. For people who had epilepsy there were risk assessments and protocols in place, including for the use of a listening and monitoring device. There was clear guidance for support needed when using the shower or bathing. Protocols were also in place for the use of ‘as required’ medication. Systems for the administration of medication were examined and found to be mostly satisfactory. Staff confirmed that they had completed training in the safe handling of medication and that they have regular competency audits. Copies of these assessments were seen. At the time of the visits handwritten entries on the medication administration record had not been countersigned although staff indicated this was the normal practice. This was done at the time of the visit. Staff explained that stock was kept as a minimum and any medication left at the end of the month returned. A returns book was in place. Liquids and creams were not being labelled with the date of opening but again this was completed during the visit. When people go on social leave for a short period of time, staff were secondary dispensing medication into compliance aids for them to take with them. This could lead to error and advice was given about the labelling of these containers. However the team decided that they would take the medication in the containers dispensed by the pharmacy from now on. However if they continue to use a compliance aid they must make sure the following is in place: • A risk assessment alongside a written procedure, this should include which staff are permitted to put medication into a compliance aid, what containers are to be used, how the containers are to be labelled and what other information is to be given DS0000028443.V364803.R01.S.doc Version 5.2 Page 16 Sunflower Villa • a clear record of all staff involved in each stage of the procedure and the actions taken. Sunflower Villa DS0000028443.V364803.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 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to express their concerns and they are confident that they will be listened to. People are safeguarded from possible harm or abuse. EVIDENCE: The home had a complaints policy and procedure which was accessible to people living in the home. One person said that they had made a complaint to the registered manager and others said they would talk to staff if they had concerns. People living in the home had made two complaints in 2007. Copies of these complaints and the outcomes were recorded in the home’s complaints file. It was evident that people feel comfortable broaching concerns about staff with management. These were taken seriously by the home and the organisation resulting in action being taken by Craegmoor under their grievance and disciplinary process. We had not received any complaints. Staff confirmed that they had completed safeguarding training and in discussion they had a good understanding of the protection of people living in the home from possible abuse or harm. They had confidence that the registered manager would challenge poor practice or suspected abuse. Information was displayed in the office about the local Adults at Risk procedures and ‘No Secrets’. Staff had completed training in Crisis Prevention Intervention, a low arousal approach to the management of challenging behaviour. They said they did not Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 18 use physical intervention and that guidance supporting people who may become angry indicated to give space. Records confirmed that this was being followed. Critical event/incident forms were being completed for any incidents and where appropriate we were being informed under Regulation 37. Staff and the registered manager confirmed that where they had concerns about the support needed for people who expressed anger either verbally or physically they involved healthcare professionals from the local Community Team for People with Learning Disabilities. Sunflower Villa DS0000028443.V364803.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 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is personalised reflecting the lifestyles and interests of people living in the home. A safe environment is maintained which would benefit from repair work to the hallway being completed. EVIDENCE: At the time of the visit to the home, it was clean and tidy. An odour noticed on the morning of the first visit quickly disappeared during the day and was not noted at the following visit. People living in the home told us that the home is always fresh and clean. Domestic support was being provided during the week. A maintenance person was employed for day-to-day repairs and the registered manager said that another person was being recruited to help out on a part time basis. Some redecoration was being completed during the visits including repairs to the ceiling in the hall. Flooding in the bathroom above had caused Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 20 this. The risks of this being repeated had been minimised by making sure that taps could be locked. The repairs to the ceiling now need to be completed. People’s rooms were decorated to reflect their interests and lifestyles. People said they had chosen the colour schemes. Artwork by people living in the home and photographs of people on activities, trips and holidays were displayed around communal areas. The grounds to the rear of the property were well maintained. People living in the home were helping the gardener to care for the gardens. Good infection control measures were observed to be in place. Personal protective equipment was provided for staff. Communal toilets and hand washbasins had paper towels and liquid soap. One person said they liked to help disinfect doorknobs and banister rails each day. Sunflower Villa DS0000028443.V364803.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 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Recruitment and selection processes safeguard people from possible harm. EVIDENCE: There had been changes to the staff team that was made up of staff who had worked at the home for sometime and newer members of staff. Both groups said that morale was good and that communication within the staff team ensured consistency of approach and continuity of care. People living in the home indicated, “the staff treat us well and they listen and act on what we say.” Staff were observed in positive and respectful interactions with people living in the home. The DataSet confirmed that 50 of staff had a National Vocational Qualification (NVQ) Award in Health and Social Care. New staff confirmed that they were working through an induction programme that was equivalent to the Skills for Care Standards. A certificate of completion was observed on one Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 22 staff file. The registered manager stated that new staff continued to be supernumerary whilst going through induction that could take up to three months. Staff did not have access to the Learning Disability Qualification. Recruitment and selection files were examined for three members of staff. There was evidence that staff were not being appointed until a pova first check had been obtained and two satisfactory references were returned. Where an employee had started before the Criminal Records Bureau (CRB) check had been returned a risk assessment was in place. CRB certificates can now be destroyed. The reason for leaving former positions in care was now being obtained from referees. Where there were gaps in employment the registered manager said that these were being explored at interview although more evidence could be provided of this. One record indicated the person had brought up children before working in care for 12 years but did not refer to the gaps in employment history between 1983-1998. An interview pack produced by Craegmoor provided a prompt to check employment history for gaps and if this had been used on this occasion, further evidence would have been provided. This document was in place for another member of staff. Each file contained proof of identity and a current photograph. Copies of birth certificates should not be kept. These were destroyed during the visits. Where people had been employed from abroad there was evidence of a visa including additional evidence that Craegmoor had confirmed clearance for overseas candidates. The registered manager confirmed that people living in the home were being involved in the interview process. Interview records provided evidence of this. Other people were being involved in meeting and greeting people when they came for interview or during visits to the home. A training matrix was provided which confirmed that over 90 of staff had completed first aid, infection control and fire safety training and 100 had completed health and safety, manual handling, Protection of Vulnerable Adults and violence and aggression training. Training had been booked for staff in food hygiene and person centred planning to ensure that all had completed these courses. The registered manager had provided information for staff about Diabetes and Autism. Sunflower Villa DS0000028443.V364803.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 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a manager who has a dynamic and creative approach, and who provides clear direction and leadership. Effective quality assurance systems are in place involving people. A review of fire procedures will ensure that people are being safeguarded from possible harm. EVIDENCE: The registered manager stated in the AQAA that she had 25 years experience of working in care, the Registered Managers Award and NVQ Level 4 in Health and Social Care. She confirmed that her continuing professional development included Equality and Diversity, Person Centred thinking, Employment Law and Investigations. She had positive relationships with people living in the home and they were obviously used to having 1:1 chats with her in the office. During the inspection she showed a willingness to work with us to ensure high Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 24 standards were maintained within the home. Wherever possible changes or amendments were made to the service or documents as we raised concerns. Craegmoor had a robust quality assurance programme in place that involved people living in the home. All had recently completed a survey and were being involved in unannounced Regulation 26 visits to the homes. Two people were actively involved in the organisation’s ‘Your Voice’ Divisional Forum attending meetings with others from the region. A person living in the home showed copies of these minutes to us. They had also been made available on audio CD. The home conducts regular self-assessments into key areas identified by Craegmoor. The audits examined identified actions to be completed and all had achieved over 95 . There was evidence on these documents as the home completed each action. The AQAA stated, “ In the Clinical Governance audit in May 2008 we achieved 98 . We were awarded 5 stars from Environmental Health in March 2007. We were the Area 14 ‘Leading Light’ for Craegmoor Healthcare.” Systems for monitoring health and safety within the home were examined confirming information supplied in the DataSet that regular tests and servicing of equipment and systems were in place. This had been cascaded to staff within the home to monitor with staff nominated to complete these should they be absent. The Fire Risk Assessment referred to people staying in their rooms in the case of fire overnight. It was suggested that the registered manager discussed this with the local fire service in light of the Regulatory Reform (Fire Safety) Order 2005 that refers to a full evacuation of all people living in the home. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 25 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 4 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 4 X X 3 X Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 10/11/08 2. YA24 23(4) 3. YA42 23(4A) Where a compliance aid is used to provide medication to people on social leave, procedures, risk assessments and labelling of the compliance aid must be in place. This is to safeguard people from possible harm due to medication error. Damage to the ceiling needs to 30/11/08 be made good and repairs now completed. This is to ensure the environment is safe and clean. Fire risk assessments must 30/11/08 comply with the Regulatory Reform (Fire Safety) Order in respect of whether people can be left in their rooms at the time of fire. This is to make sure people are safe and not at risk of harm. 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 Good Practice Recommendations DS0000028443.V364803.R01.S.doc Version 5.2 Page 27 Sunflower Villa 1. 2. 3. 4. 5. Standard YA6 YA7 YA18 YA32 YA34 Evidence of regular review/evaluation of care plans should be recorded on the sheets provided for this purpose. Any restrictions that are in place should be reviewed at annual reviews in a multi agency forum. The gender of staff providing people’s personal care should be recorded in their care plans. Staff should have access to the Learning Disability Qualification. Copies of birth certificates should not be kept. Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West 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 Sunflower Villa DS0000028443.V364803.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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