Care Home: Woodview

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What the care home does well Woodview provides a good standard of personal and health care support for the people who use the service. The staff team are knowledgeable about the people who use the service and were observed to be relaxed, friendly and professional with service users at all times. Within the home people who use the service have the opportunity to participate in a wide range of activities. Clients are treated equally and their diverse needs are catered for. The people who use the service said they enjoy their stays at the home. Comments made by relatives in their questionnaires were: `the staff have a good understanding of my daughter`; `my son enjoys the visits`; `staff support and look after each persons needs well`; `they make our son feel secure and happy when he is there`; and `there is a warm and friendly atmosphere`. What has improved since the last inspection? 50% of staff now have a NVQ2 or above in care; a pool table and computer have been purchased for the use of people who use the service; all new staff attend the `New Approach` training programme; and the quality monitoring systems and induction process for new staff have been improved. What the care home could do better: Improve the opportunities for people who use the service to access facilities and activities in the community; staff to receive regular supervision and annual appraisals in order that support and professional guidance can be provided, and training and development needs be identified; a copy of the report in respect of the satisfaction questionnaires to be available in the home to people who use the service and their relatives; procedures for emergency admissions to be developed to assist staff when the manager is not on duty; a formal reviewing process is put in place in order that the care plans are formally reviewed at regular intervals, say once a year, with the people who use the service and their relatives; develop communication guidelines for all the people who use the service; all the bedrooms to have a DVD for people who use the service to use if they wish; a new bath to be installed to minimise the risk of back injuries to staff; more frequent and regular staff meetings to take place; all staff to be given the opportunity to attend training to improve their understanding of autism and communication skills; staff training profiles to be kept up to date in order to easily identify staffs` training needs; ensure all staff know how to fit the urinary sheath on the person who uses the service correctly; and risk assessments of people who use the service to be reviewed on a regular basis rather than `when necessary` to ensure they are up to date and reflect current needs. CARE HOME ADULTS 18-65 Woodview 97 Wantage Road Didcot Oxfordshire OX11 8TY Lead Inspector Robert Dawes Unannounced Inspection 6 and 17th December 2007 10:15 th DS0000013149.V353249.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 DS0000013149.V353249.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. DS0000013149.V353249.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodview Address 97 Wantage Road Didcot Oxfordshire OX11 8TY 01235 814939 01235 814939 eileen.hodgkinson@new-support.org.uk www.new-support.org.uk New Support Options Ltd 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) Mrs Eileen Hodgkinson Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places DS0000013149.V353249.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 5 8th August 2006 Date of last inspection Brief Description of the Service: Woodview is a respite service for up to five adults with learning disabilities. It was first registered in 1998. The home is a modern bungalow, part of a purpose built complex, situated within a community hospital site close to local amenities in Didcot, Oxfordshire. The building is owned and maintained by Advance Housing and Support Ltd. The home provides respite care to relieve families of their care responsibilities, as well as providing emergency placements. The service is run and managed by New Support Options, a not-for-profit organisation established in 1989, part of the New Dimensions Group based in Theale in Berkshire. New Support Options Ltd has a wealth of experience in providing services for those with learning disabilities and operates in West Berkshire, Hampshire, Surrey and Norfolk in addition to Oxfordshire. Places at the service are block purchased by Social and Community Services. The service is open 360 days a year but closes for five days over Christmas. The number of nights allocated depends on the assessed priority. An individual can have up to a maximum of 30 nights a year. This could be increased in exceptional circumstances. One of the five spaces is allocated for emergencies. The fees for this service average out at £977.00 per person per week. DS0000013149.V353249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit, which took place during the days of the 6th and 17th December 2007. The Annual Quality Assurance Assessment, two people who use the services’ questionnaires and nine relatives’ questionnaires were returned to the inspector before the site visit. These, together with the site visit, were the main sources of information for the key inspection. During the site visit the inspector interviewed the manager and two members of staff; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. One person who uses the service spoke to the inspector. Twenty four standards were assessed during the site visit of which twenty one were met and three were nearly met. Three requirements and ten recommendations were made. What the service does well: Woodview provides a good standard of personal and health care support for the people who use the service. The staff team are knowledgeable about the people who use the service and were observed to be relaxed, friendly and professional with service users at all times. Within the home people who use the service have the opportunity to participate in a wide range of activities. Clients are treated equally and their diverse needs are catered for. The people who use the service said they enjoy their stays at the home. Comments made by relatives in their questionnaires were: ‘the staff have a good understanding of my daughter’; ‘my son enjoys the visits’; ‘staff support and look after each persons needs well’; ‘they make our son feel secure and happy when he is there’; and ‘there is a warm and friendly atmosphere’. DS0000013149.V353249.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. DS0000013149.V353249.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 DS0000013149.V353249.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): Number 2. People who use the service experience good quality outcomes in this area. Prospective clients’ individual aspirations and needs are assessed. The home should develop procedures for emergency admissions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a detailed admission policy and procedure in place. Comprehensive assessments are undertaken before any person receives planned respite care. The home accepts people for emergency respite care. There were no emergency admissions procedures to guide staff when the manager is not on duty. DS0000013149.V353249.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): Numbers 6, 7 and 9. People who use the service experience good quality outcomes in this area. People who use the service are encouraged to lead as independent a life as possible and make decisions about what they do and how they are cared for. The care plans reflect their diverse needs but should be reviewed in a more formal way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All files seen contained detailed individual care plans. Every person who uses the service has a key worker who is responsible for keeping the records up to date and reviewing the care plans. The key worker up dates the care plans after reviews take place at day services or social services departments; and through informal discussions with the people who use the service and their relatives. However there is no formal reviewing process to ensure that the changing needs of the people who use the service is reflected in the care plan, i.e. the care plans specifically for the DS0000013149.V353249.R01.S.doc Version 5.2 Page 10 respite care being formally reviewed at regular intervals, say once a year, with the people who use the service and their relatives. Records of people who use the services’ meetings showed they are involved in making decisions about their time spent in the home. Several of the people who use the service have significant communication difficulties. ‘Communicate with me’ guidelines have been developed for these people. The manager said she would like all people who use the service to have communication guidelines. In response to the question in the people who use the services’ questionnaire ‘do you make decisions about what you do each day?’ one replied ‘always’ and the other replied ‘sometimes’. In response to the questions in the relatives’ questionnaire ‘do you get enough information about the care home to help you make decisions?’ and ‘does the care service support people to live the life they choose?’ all the relatives replied either ‘always’ or ‘usually’. People who use the service are encouraged and enabled to be as independent as possible. People who use the service were observed making their own drinks and meals in the kitchen. Appropriate risk assessments are in place. DS0000013149.V353249.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): Numbers 12, 13, 15, 16 and 17. People who use the service experience adequate quality outcomes in this area. People who use the service take part in a wide range of appropriate activities in the home, which reflect their diverse needs. They access facilities and activities in the local community but their choice is significantly restricted by the shortage of drivers, the home’s vehicle not being adapted for wheelchair users, the limited activity budget and only two staff being on duty in the evenings and at weekends. They are enabled to keep in touch with their families and friends; their rights are respected and responsibilities recognised in their daily lives; and are offered a healthy diet and enjoy their meals. The organisation is promoting diversity and equality in the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the week the majority of the people who use the service are at day services out of the home. During the evenings and at weekends there are a range of leisure activities from which to choose from, i.e. pool table, computer, DS0000013149.V353249.R01.S.doc Version 5.2 Page 12 arts and crafts, TV, DVDs, making films and music. Not all rooms have DVDs and although they can be moved from room to room it was recommended that all the rooms should have a DVD for people who use the service to use if they wish. People who use the service go to facilities and activities in the community such as cinemas, pubs and bowling. On the day of the inspection two people who use the service were going to a local pantomime. However the opportunity for going out is restricted by the shortage of drivers, the home’s vehicle not be adapted for wheelchair users, the activity budget being equivalent to £17 per person per year and only two staff being on duty in the evenings and at weekends. If one person needs two staff to assist with his/her care this means that no one can go out of the home. At a review that was held because a person who uses the service was selfharming during a weekend stay, one of the contributory factors for his selfharming was because he could not go out. A relative commented in a questionnaire ‘I am sure they would be able to do more if they had extra staff and extra finances but under their present circumstances they do an excellent job’. In response to the question in the people who use the services’ questionnaire ‘do you make decisions about what you do each day?’ one replied ‘always’ and the other replied ‘sometimes’. The organisation is promoting diversity and equality by appointing a diversity lead person; publishing a diversity newsletter; providing ‘diversity and equality training opportunities for staff; and ensuring people who use the services’ cultural needs are addressed. People who use the service are encouraged and enabled to keep in regular contact with relatives. The home has a sexuality and relationships policy. In response to the questions in the relatives’ questionnaire, ‘does the home help you keep in touch with your relative?’ the relatives replied positively. People who use the service were observed to have unrestricted movement around the home, except other people’s bedrooms. People who use the service can choose to be alone. People who use the service help with simple tasks around the house such as helping prepare meals, laying tables and assisting with health and safety checks. The philosophy of the home is that the people who use the service choose what they wish to do. DS0000013149.V353249.R01.S.doc Version 5.2 Page 13 A very positive and respectful interaction between staff and people who use the service was observed. In response to the question in the people who use the services’ questionnaire ‘can you do what you want to do during the day, in the evening and at the weekend?’ both replied ‘yes’. In response to the question in the relatives’ questionnaire ‘does the care service support people to live the life they choose?’ all replied positively. Menus reflect people who use the services’ likes and dislikes. If they don’t like the meals they can have an alternative. People who have long stays contribute to the menus. One person who uses the service emails what he wants to eat before he arrives for respite. Dietary and cultural needs are catered for. Meal times are flexible. People who use the service can eat their meals in their rooms. People who use the service are encouraged and supported to assist with the preparation of meals. DS0000013149.V353249.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): Numbers 18, 19 and 20. People who use the service experience good quality outcomes in this area. People who use the service receive personal support in the way they prefer and require; and their physical and emotional health needs are well met. Service users are protected by the home’s medication procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service receive personal support in the way they choose. Care plans contain guidelines covering all aspects of a persons’ care needs. People who use the service can get up and go to bed when they choose. Female guests only receive personal care from female members of staff. Several people who use the service are emailed before they have respite informing them which staff will be on duty. One person who uses the service told the inspector she would ‘let them know if she wasn’t being cared for properly’. In response to the question in the relatives’ questionnaire ‘does the care home give the support or care to your relative that you expect or agreed?’ the relatives all replied positively. DS0000013149.V353249.R01.S.doc Version 5.2 Page 15 As the people who use the service spend a relatively short period of the year in the home they or their carers are primarily responsible for their physical and emotional health. However, staff monitor peoples health and any problems are identified and addressed, i.e. during the inspection a member of staff noticed a person who uses the service might have had problems with her teeth; and a local psychology service was contacted, with the parents permission, to modify a persons’ tendency to self harm when stressed and anxious. Behavioural guidelines are developed by the psychology service for people who use the service where necessary. Staff are receiving training to assist a person who uses the service insert contact lenses onto her eyes. In response to the question in the relatives’ questionnaire ‘do you feel that the care home meets the needs of your relative?’ seven replied positively and one negatively. The relative who replied negatively commented ‘our son needs total personal care. We have been to the home on numerous occasions and shown staff the procedure for applying urinary sheaths. The staff are struggling to get to grips with this. Matters are still unsatisfactory and our son’s needs are not being met. Staff need more training’. The manager acknowledged the problem. She said staff are receiving training from a District Nurse and they are endeavouring to apply the urinary sheath correctly. Appropriate medication policies and procedures are in place. Sufficient staff have received medication training to cover all shifts. The medication for each person who uses the service is kept in a lockable cabinet in their rooms. No person who uses the service administers medication without some assistance. Appropriate risk assessments are developed. Two members of staff administer the medication and sign the records. The administration records were in order. A pharmacist visited the home in July 2007 to inspect the storage, administration and disposal of the medication. No recommendations were made. DS0000013149.V353249.R01.S.doc Version 5.2 Page 16 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): Numbers 22 and 23. People who use the service experience good quality outcomes in this area. The majority of people who use the service feel their views are listened to and acted on; and are protected from abuse. The manager and staff team are working hard to resolve the complaint about the personal care issue of a particular person who uses the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place. People who use the service are given complaints procedures in easy read formats. No complaints to the Commission have been made since the last inspection. In response to the question in the relatives’ questionnaire ‘do you know how to make a complaint?’ all the relatives replied ‘yes’. In response to the question in the relatives’ questionnaire ‘has the care service responded appropriately if you or the person receiving the service has raised a concern about their care?’ five relatives replied ‘always’ or ‘usually’ and one replied ‘sometimes’, commenting ‘we have liaised with the care service but still the problem persists and is no closer to being resolved’. This comment related to a personal care problem referred to in the ‘Personal and Healthcare Support’ section. In response to the people who use the services’ questionnaires ‘do you know who to speak to if you are not happy?’ and ‘do you know how to make a complaint?’ both replied ‘yes’. DS0000013149.V353249.R01.S.doc Version 5.2 Page 17 Staff have received safeguarding younger adults training. An appropriate safeguarding younger adults policy and procedures are in place. No allegations of abuse have been made to the Commission since the last inspection. An allegation to the home of physical abuse was responded to appropriately. The manager informed the inspector that no person who uses the service is subject to physical intervention guidelines. A physical restraint policy and procedures are in place. People who use the service can look after their own personal money if they choose and have the use of lockable facilities in their rooms. The manager keeps the money of people who use the service who do not want to look after their own money in individual wallets and in a secure facility. Records are kept of all transactions and they are audited annually. DS0000013149.V353249.R01.S.doc Version 5.2 Page 18 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): Numbers 24 and 30. People who use the service experience good quality outcomes in this area. The home is comfortable, safe and well maintained. The home is clean and hygienic. To protect the health and safety of staff the bath should be replaced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is spacious; well furnished and decorated; comfortable; and well maintained. In April 2007 an Occupational Therapist assessed that the height of the bath posed a health and safety risk to staff when they assisted people who use the service in and out of the bath. A member of staff recorded in the accident book that she suffered back pains as a result of bending down to assist a person who uses the service in the bath. The home was clean and hygienic on the day of the inspection. In response to the question in the people who use the service s’ questionnaire ‘is the home fresh and clean?’ both relied ‘yes’. DS0000013149.V353249.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): Numbers 32, 33, 34, 35 and 36. People who use the service experience good quality outcomes in this area. An effective, competent and qualified staff team who receive a broad range of training support the people who use the service fairly, without discrimination and in a caring manner. The home operates a thorough recruitment procedure. The home should operate a more flexible duty rota and offer all staff training in understanding autism, which would raise the level of care even more. Staff need to receive regular and more frequent supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interviewed demonstrated a good understanding of the conditions and needs of the service users. Relaxed and positive relationships were observed between staff and people who use the service. 50 of staff now have a NVQ 2 or above in care. In response to the question in the people who use the services’ questionnaire ‘do staff treat you well?’ and ‘do the carers listen and action what you say?’ DS0000013149.V353249.R01.S.doc Version 5.2 Page 20 both replied ‘yes’. One person who uses the service commented ‘I enjoy it there’. In response to the questions in the relatives’ questionnaire ‘do you feel that the care home meets the needs of your relative?’, ‘does the care home give the support or care to your relative that you expect or agreed?’, ‘does the care service meet the different needs of people?’ and ‘do the care staff have the right skills and experience to look after people properly?’ the replies were very positive. Comments made by relatives were ‘the staff have a good understanding of my daughter’ ‘my son enjoys the visits’; ‘staff support and look after each persons needs well’; ‘they make our son feel secure and happy when he is there’ and ‘there is a warm and friendly atmosphere’. There was one negative comment, which concerned the personal care of a person who uses the service. This was referred to in the ‘Personal and Healthcare Support’ section. The manager, eight full time support staff and one part time support staff work in the home. Regular agency staff are employed at night. Two members of staff are on duty during the day and evenings. One waking member of staff is employed at night unless the needs of the people who use the service dictate more night staff have to be on duty. The inspector was surprised to find that during the week two or even three support staff can be on duty during the day when there could be one or no people who use the service in the home. Given the problems taking people who use the service out to activities in the community it seemed a very inflexible working rota. The number of staff on duty is sufficient to support people who use the services’ needs while in the home but not to go to activities in the community that they would like to attend. There has been only one recorded staff meeting this year. Recruitment records are kept at the organisations head office. These records have been assessed during key inspections of other services and found to be compliant with the requirements of the regulations. People who use the service are members of interview panels and have the opportunity to meet prospective members of staff when they visit the home. All new staff undertake an induction training programme including a five day course titled ‘new approach’ which includes topics such as anti-discriminatory practice, values and attitudes and how the organisation expect the people who use the service should be cared for. All staff have received basic training and training in key areas of their work such as safeguarding younger adults, first aid and rectal diazepam. DS0000013149.V353249.R01.S.doc Version 5.2 Page 21 Staff said they would like more in depth training in safeguarding younger adults and understanding autism to improve their response and communication skills. Records showed only two support staff had received autism training. The inspector found it difficult to determine exactly what training staff had undertaken because the training profiles were not up to date. The manager assured the inspector that the majority of staff had received all the necessary training and refresher training took place when required. Staff have not been appropriately supervised. Records showed staff have only received one or two formal supervisions in the last year. Staff have also not received annual appraisals. DS0000013149.V353249.R01.S.doc Version 5.2 Page 22 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): Numbers 37, 39 and 42. People who use the service experience good quality outcomes in this area. People who use the service benefit from a well run home; their views underpin all self-monitoring, review and development by the home; and their health, safety and welfare are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, competent and experienced to run the home. She has been the manager for six years. The manager undertakes periodic training to maintain and update her knowledge and skills. Staff described the manager as being clear in how she wants the clients cared for. A quality assurance and monitoring system operates in the home through regular service users’ meetings taking place; a representative of the organisation visiting the home every month to undertake an inspection of the DS0000013149.V353249.R01.S.doc Version 5.2 Page 23 quality of care being delivered; and relatives and people who use the service completing annual satisfaction questionnaires which are returned to the organisation’s head office. No copy of a report in respect of the survey was in the home nor was there a copy of the annual service plan. The manager assured the inspector a service plan is developed every year and she receives feed back about the satisfaction questionnaires. Records showed all health and safety checks and inspections are up to date and completed as required. Necessary health and safety policies and procedures are in place. The home’s fire risk assessment is up to date. All the service users’ files seen contained risk assessments but were reviewed ‘when necessary’ rather than on a regular basis. All the staff have received the necessary health and safety training including first aid, manual handling and fire awareness. All accidents and significant incidents are recorded. DS0000013149.V353249.R01.S.doc Version 5.2 Page 24 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 2 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 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000013149.V353249.R01.S.doc Version 5.2 Page 25 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 YA13 Regulation 16 Requirement Timescale for action 31/03/08 2. YA36 18 3. YA39 24 People who use the service must have more opportunities to access facilities and activities in the community. Staff must receive regular 29/02/08 supervision and annual appraisals in order that support and professional guidance can be provided, and training and development needs can be identified. A copy of the report in respect of 31/01/08 the satisfaction questionnaires must be available in the home to people who use the service and their relatives. 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. 2. Refer to Standard YA2 YA6 Good Practice Recommendations Procedures for emergency admissions are developed to assist staff when the manager is not on duty. A formal reviewing process is put in place in order that the DS0000013149.V353249.R01.S.doc Version 5.2 Page 26 care plans, specifically for the respite care, are formally reviewed at regular intervals, say once a year, with the people who use the service and their relatives to ensure that the changing needs of the people who use the service is reflected in the care plan. 3. 4. 5. 6 7 YA7 YA14 YA24 YA33 YA35 Develop communication guidelines for all the people who use the service. All the bedrooms should have a DVD for people who use the service to use if they wish. A new bath should be installed to minimise the risk of back injuries to staff. More frequent and regular staff meetings should take place. All staff should be given the opportunity to attend training to improve their understanding of autism and communication skills. Staff training profiles should be kept up to date in order to easily identify staffs’ training needs. A copy of the annual service plan is held in the home in order for the manager to meet the targets set in the plan. Risk assessments of people who use the service should be reviewed on a regular basis rather than ‘when necessary’ to ensure they are up to date and reflect current needs. 8 9 10 YA35 YA39 YA42 DS0000013149.V353249.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection The Oast Hermitage Court Herimtage 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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