Inspection on 12/02/08 for 16 Godwyne Road

This is the latest available inspection report for this service, carried out on 12th February 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

16 Godwyne Road 12/12/05

16 Godwyne Road 20/06/05

16 Godwyne Road 30/11/04

16 Godwyne Road 24/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 16 Godwyne Road 16 Godwyne Road Dover Kent CT16 1SW Lead Inspector Chris Woolf Unannounced Inspection 12th February 2008 09:50 16 Godwyne Road DS0000023285.V357744.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 16 Godwyne Road DS0000023285.V357744.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. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 Godwyne Road Address 16 Godwyne Road Dover Kent CT16 1SW 01304 201714 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) petemay@ireland.com Mr Peter John May Mr Peter John May Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2007 Brief Description of the Service: Godwyne Road, is a large semi-detached period residence, occupying a corner plot in a residential area of Dover. The home is located on a hillside overlooking the town and has views of Dover castle. It is within walking distance of local bus routes, leisure facilities, shops, pubs and restaurants. Some on-street parking is available. The home provides support and accommodation for up to 10 residents with a learning disability. Although registered for 10, at the time of this inspection there were only 8 residents living in the home. Accommodation ranges over four floors with access to all levels is via two staircases to the front and rear of the building. This means that all residents must have reasonable mobility to be able to negotiate stairs. Most bedrooms are used for single occupancy, with one shared bedroom located on the top floor. There are sufficient shared communal washing facilities for the existing number of service users; and staff have their own toilet and wash facilities. Communal space includes an activities/dining room and kitchen on the lower level and a main lounge on the first floor. There is also a separate laundry area. The home benefits from a good-sized rear garden mainly laid to lawn, which can be accessed from the laundry area. There is some garden seating and furniture for residents use. Two double gates are located to the side and end of the garden, which are kept shut. The current mixed sex user group are aged between 45 and 78 years of age. The home operates a key worker system. The present owner also undertakes the day-to-day operational management of the home. The current fees for the service at the time of the visit range from £562.86 to £620.98 per week. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide 16 Godwyne Road DS0000023285.V357744.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 information for this report has been gained from the information that we have received, or asked for, since the last key inspection. This included the annual quality assurance assessment (AQAA) that was sent to us by the service. Surveys returned to us by 4 residents, 3 relatives, and 3 members of staff. We also made a site visit to the service that lasted 6 hours. The site visit was unannounced. This means that neither the residents nor the staff knew that we were coming. During the site visit we talked with all of the residents, some in passing and some for a longer period. We also talked to the staff on duty and to the manager and deputy manager. We had a tour of the building. Our observations included seeing how staff and residents interacted; medication being administered; and lunch being served. We also looked at a variety of records including care plans, staff files and medication records. The people who live in this home prefer to be called ‘residents’ and this is the term used to describe them throughout the report. Where the term ‘we’ is used this refers to The Commission for Social Care Inspection. What the service does well: There is a friendly, family atmosphere in the home with a friendly staff team and positive management. Family comment cards included they do well by, ‘Promoting a family atmosphere and respect for all concerned’ and ‘As this is a small home, it feels like a family when you walk in. I was impressed by the attitude of the staff also the clients its mutual respect and concern for each other’. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 6 Residents are encouraged to develop and maintain their independence. The home encourages good communication at all levels, which is supported by a variety of positive communication methods. Residents on the day of the site visit and on comment cards said, ‘I like it here’, ‘I like the people’, and “I like it here best”. A staff member said, “It’s a home from home. Its pleasant to be here”. Family comment cards included, ‘My son xxx has been at 16 Godwyn for some years in the care of Mr. P. May. I am very happy about his care. I visit whenever I can and what means most of all xxx is always clean, well dressed and enjoying life to the full’, and ‘I don’t think it can improve. It’s top grade’, What has improved since the last inspection? What they could do better: 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 7 The home needs to inform us of all events that affect the welfare of the residents. 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. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed and they are able to have a series of trial visits to ensure that the home can meet their needs. EVIDENCE: There have been no new admissions to the home since the last inspection. However, when prospective residents are identified the home has comprehensive procedures in place for assessment. This assessment is to ensure is to ensure that the home will be able to meet all of the prospective residents physical, mental, psychological, and equality and diversity needs. At the time of the initial meeting the resident is given a pictorial guide which includes photographs of existing residents, staff, the proposed bedroom, bathroom, significant other rooms, the front of the house, the garden, and places of local interest. A series of trial visits take place to ensure that the home is right for the resident and that the person fits in with the existing residents. Placements are not confirmed until the resident has lived in the home for 3 months and a meeting has been held with the resident, their family 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 10 and their placement officer to ensure that this is the correct place for the resident. A staff comment card included, ‘All of the needs that our clients have are being met to our best knowledge’. Although the home is registered for adults (18-65) and all new admissions will be within this age group, this is a ‘home for life’. Once a resident becomes 65 they can remain in the home, for as long as the home are able to meet their needs. The homes statement of purpose and service user guide is currently being updated to reflect this. Each resident is issued with and signs a contract/terms and conditions with the home. These contracts are drawn up in pictorial form to make them easier for the resident to understand. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s individual needs and choices are recorded in their care plans and are supported by the staff. Residents are able to make decisions about all aspects of their lives and are supported to take responsible risks. EVIDENCE: A comprehensive, person centred care plan is in place for each resident. Care plans are continually developing to take account of the needs of the residents and changes in good practice. The amount of detail in the care plan gives support staff sufficient information to enable them to support each individual in the way they prefer. Key-workers sit with each resident every 4-8 weeks to review the care plan and the resident completes and signs a summary sheet 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 12 with smilie faces to indicate their views. In addition to the care plans, individual flash cards have been produced with details of each resident’s daily needs. These cards are issued daily to the staff member who is responsible for the resident and are used as an aide-memoir throughout the day. Staff comment cards included, ‘Our deputy manageress is very hot on the care plans and leads the way to keeping all staff up to date with new information about the care plans’, and ‘All the information that we need to know are always being passed on by management’. Residents are supported to make decisions about all aspects of their lives. Each resident has a communications board in their room to which they apply pictures each day to show their choice of what they wish to do. Staff support the residents in completing the communications board in the mornings, and talk to the residents about what went well at the end of the day. The staff use NVQ performance criteria as working standards, these emphasises the prime requirement of involving clients in all decision-making whenever possible. Residents’ meetings are held a minimum of twice a week to gain feedback from the residents as to their wishes, feelings and choices. A staff member said, “I like to communicate with the residents and link them and the world, and I like to get them to communicate with each other”. Residents are supported to take responsible risks in their lives. Individual risk assessments, to identify and minimise any risk, are in place in the care plans for all areas where such risks have been identified. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead the lifestyle they prefer, with opportunities for activities inside and outside the home. They are encouraged to maintain contact with family and friends; and enjoy a healthy and balanced diet EVIDENCE: Residents who had been in long term intuitional care have been encouraged and supported by the home to take ownership for their lives, to make decisions, and to become more independent. They have been aided in this by the use of communication aids, and the assistance of Speech and Language therapists. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 14 Residents who choose attend an Education Centre or a Resource Centre, where they have an alternative network of friend and colleagues, and where they undertake personal and social development activities including model making/craft session, art and sewing. Following the closure of one adult education class visits to the home by an ex-teacher have been organised to run Art Development classes for the residents who this closure affected. In house activities include occupational therapy activities, interactive tabletop activities, relaxation, music and movement sessions, and soft indoor ball games. During the last year the home has updated its occupational therapy equipment to include a comprehensive range of musical and percussion instruments. Some residents have sensory and/or aromatherapy sessions, and some have physiotherapy exercises. In addition residents are encouraged to assist with the cooking and with preparation of their own drinks and snacks. External activities include horse riding, visits to town for personal shopping or cups of tea, visits to the hairdresser, attendance at two different discos, and sessions of reflexology in Dover. During the last year health walks have been introduced into the activities programme. Residents who wish are supported to attend the local church. Currently there are residents with different faith needs but the home would support these if there were a need. The home supports residents to maintain links with their family and friends. Relative comment cards included ‘I have frequent contact by telephone or visits’, ‘The care home often phone so my son can speak to me, any time he wants to, even if it was in the night’ and ‘They always ring my mother, sister or myself once a week without fail’. One resident, whose family live at distance is taken home to see them every 3 weeks by a volunteer, who is an ex-member of staff. Other residents have regular contact with their relatives, either receiving visits or going to visit them at home. Two residents have regular visits from Mencap ‘befrienders’. If a resident should wish to develop a more intimate relationship this would be supported by the home. Daily routines in the home are very flexible. Residents are encouraged to be independent and to clean their own rooms, make their own drinks and snacks, and help with cooking the meals supported by staff. Residents said, “I am going to clean my room”, and “Making a cup of tea”. Currently no resident has a key to their own room but the manager is investigating suitable locks to enable residents to keep their rooms locked if they so wish and to have their own keys subject to risk assessment. Meals in the home are well cooked and attractively. All foods are prepared using healthy living guidelines of low fat, low sugar and high fibre. A new dedicated cook has been employed for 5 days a week and this has led to more consistent quality in midday meals, and a more flexible menu choice. Support staff organise the cooking at weekends. Residents are encouraged to help with cooking, laying tables, and clearing away. They also choose what they want to 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 15 eat at each mealtime. Mealtimes were observed to be a happy relaxed and sociable experience. A resident said, “Its nice” (lunch). Resident comment cards included, ‘I make my own sandwiches’, and ‘I can choose my food’ Staff commented, “The residents help with the cooking”, “The cook is fantastic, the food is always nice”, and “Residents have an input into the menu”. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are supported by the home and they are encouraged to visit health care professionals as and when required. EVIDENCE: The home has taken the time to find out each residents preferences in personal care and support, and these preferences are respected and reflected in their Care Plan. Communication of residents needs and wishes, and their ability to make choices, has been enhanced by the introduction of communication boards which are used daily to help in decision-making and understanding. Personal care is supported in private and in the one shared room there are curtains to ensure this privacy is maintained. Residents choose their own times of getting up and going to bed. They also choose what they will wear each day. Where professional assessment shows that it is necessary residents are assisted to use aids provided to maximise their 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 17 independence. A resident said, “I do my exercises”. Each resident is allocated a key-worker. Relative comment cards included, ‘I am very satisfied with his care’, and the home are good at ‘Looking after its residents’. Key workers are responsible for ensuring that regular health checks take place by optician, dentist, doctor or podiatrist as appropriate. Key workers also alert the management and colleagues about any problems that develop with their resident. The home keeps a record of all visits to or from health care professionals. The home has sound policies and procedures for the receipt, storage, administration and disposal of medication. All staff that assist with medication have received training. A file has been produced listing the different drugs for each resident together with visual identification details and details of possible side effects. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives know that their concerns and complaints will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The home a clear complaints policy and a copy is on display. No complaints have been received by the home since the last inspection, neither have any complaints been sent to the Commission. Comment cards received from both residents and visitors confirmed that they know who to speak to if they have a complaint or concern, some mentioning individual members of staff or management. One visitors comment card stated, ‘I’ve never needed to raise any concerns’. At least once a week staff and residents hold an ‘Ideas, Feelings and Choices’ meeting. This is an opportunity for residents to express how they feel about life in the Home generally, and if they have any concerns. It also gives them an opportunity to choose things such as colours for decoration. Where a resident’s communication skills are more limited their actions and gestures are observed and taken note of. All staff have received training in the protection of vulnerable adults. Those spoken to confirmed that they would know what to do if they suspected abuse. All members of staff have been checked against the Protection of Vulnerable 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 19 Adults register. Where problematic behaviours of residents have been identified, a Behavioral Procedure is written in their Care Plan and followed by all staff to ensure consistency of approach. This has been found to help reduce the severity and negative effects of such behaviour, and is designed to reduce the impact on fellow residents as far as possible. A robust system is in place to keep accounts of residents financial transactions. When key-workers take residents out to spend money each transaction is individually recorded, and receipts to match the expenditure, are kept and attached to the accounting sheets. Residents have their own building society account and their allowances are credited directly into the account. Resident’s financial records are checked and audited by their Care Manager during the annual review, and a record signed in the resident’s file to confirm this has been completed. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment with rooms personalised to meet their own needs and preferences. EVIDENCE: The home is set out over four floors with stair access to all areas. This means that only residents with a reasonable degree of mobility can be accommodated. There are two stairways to every level giving a better chance of escape in the case of a fire. The home is homely, and comfortable. There is a garden available for residents use but the wall and fences in one corner need rebuilding following wind damage. Since the last inspection the landing and lobby area on level 2 have been redecorated to increase reflected light. Level 1 hallway, stairs and landing have been redecorated, and the lounge 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 21 curtains have been renewed. Lighting in the dining room has been improved to ensure sufficient light for occupational therapy activities. A new dishwasher has been fitted in the kitchen, and the two fridges have been replaced with new ones. There are some areas when maintenance work is still required but these have been identified by the home and are listed in their development plan. The handyman/gardener visits twice a week and deals effectively with the homes maintenance needs. He has worked for the home for many years. Residents have personalised their rooms to their own taste. One resident spoken with confirmed that she had chosen the colour for her walls, she said, “I choose colours”. A resident comment card included, ‘I like my new room’. The one ‘shared room’ in the home has privacy curtains fitted. One room does not have a sink but this has been risk assessed and agreed with the link inspector, and there is a bathroom close at hand. All bedrooms are fitted with lockable cupboards for residents to keep their own belongings safe. The home has a dining room/activities room, a lounge, and a small sitting area on the level 2 landing. The furnishings in all communal areas meet the needs of the residents. Appropriate policies and procedures are in place to maintain good hygiene and to control the spread of infection. The home is kept clean and has no unpleasant odours. The cleaner/carer has been employed by the home for many years and knows the residents well. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a trained, competent and friendly staff team. EVIDENCE: The home employs staff in sufficient numbers to meet the needs of the residents. During staff recruitment periods there have been occasional lapses but these have now been resolved. Staff comment cards stated, ‘Its not ideal when there are only 2 support workers on a shift, especially at weekends when we also have to be cook and cleaner as well. But it is mostly 3 staff (support workers)’, and ‘ There might be a time when we have some people leaving and the hours needed are being covered by the other staff but new staff are soon employed’. The manager agreed to ensure that there is always at least 3 staff on the morning shift at weekends. All new members of staff joining the home have induction training. The manager has taken the Skills for Care induction and developed this further so 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 23 that the evidence is more easily transferable to the knowledge base for NVQ Level 2. He is currently in the process of further upgrading this. A staff member said, “I did an induction in the office and then completed a booklet which went towards my NVQ”. Currently 6 of the 15 support staff are trained to NVQ Level 2 or above. However a further 4 staff are doing this training and when they have completed their course there will be 66 of the staff trained. Staff commented, “I have NVQ 2”, and “I have NVQ 3”. All staff are issued with the General Social Care Council Code of Conduct when they first start work in the home. A staff comment card stated, ‘Every aspect of job explained in full’. The home has sound recruitment processes that include reference to its equality and diversity policies. All staff have checks against the Criminal Records Bureau records, and the Protection of Vulnerable Adults register, and all have 2 references. Staff comment cards stated, ‘I started work at Godwyn Road 7 years ago, I don’t believe I had a CRB check done for quite sometime after. But my references were checked’, and ‘The whole procedure of interview and taking care of documents, CRB etc is well monitored’. There is a positive training ethos in the home. Staff are either up to date with, or training is planned for, mandatory training. Staff are trained in Adult Protection. All staff that deal with medication receive training. Support staff are trained to administer Rectal Diazapam. One member of staff is a moving and handling trainer and gives regular updates to all staff. Staff said, “I have training and support”, “I have done training to do exercises with the residents”, and “We have four seniors who share the training for new staff”. A staff comment card included, ‘Most important we have the support and training to carry out our work to the highest level possible’. Staff receive regular support and supervision from the management. Staff comment cards said, ‘Its supposed to be every 4 weeks but I’d say it doesn’t actually happen that often. But I would say on a personal level, I’ve found both people in the management team very supportive when I’ve needed them to be’, and ‘The management is very open minded and ready for any new ideas and suggestions. They will meet with us to discuss our work performance and progress at work as well as opportunities for promotions’. The deputy manager confirmed that supervisions take place every 4-8 weeks. Residents’ comments and comment cards regarding staff included “xxx is my mate”, and ‘Manager and everyone is kind to me’. A family comment card stated, ‘I think the staff are great and they always make me very welcome and get on well with xxxx’. General comments from staff included, “I’m happy here. I enjoy it”, “I am given quite a bit of autonomy”, and “I love it, there is such a good feeling in the home”. 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. The health, safety and welfare of residents and staff are protected. EVIDENCE: The manager and deputy manager are both qualified and competent to run the home. They have been working together for almost 18 years giving an air of stability and reliability to the residents. The manager is highly motivated in the provision of a good care service, and has a close personal and professional involvement with both residents and staff. A relative comment card stated, 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 25 ‘We have a good relationship with the manager/owner of the home’. A staff member said, “I definitely get support from the management. They treat us with respect. We are all one team, and they listen”. The home has a homely, friendly and welcoming atmosphere and this welcome is displayed by management, staff and residents. The Home’s ethos is to promote independence, diversity and individuality to reverse the process of institutionalisation that had occurred during the time various residents have spent in long-term institutions. The home has improved its Quality Assurance systems during the past year. Questionnaires are sent to residents, families, care managers, and visiting professionals. The manager is now considering including staff in these surveys and producing an analysis of the various results. Staff complete a Quality Assurance Checklist twice daily. Daily Care Plan Recording Sheets are used as an important component of the quality assurance system. The cleaner/support worker also has her own weekly quality assurance checklist. Residents meetings are held at least twice a week. Staff meetings are held regularly. The home has a development plan where planned improvements to the service are detailed. In addition to the homes own quality assurance they completed an annual quality assurance assessment (AQAA) that we requested. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The form was well completed with comprehensive information, and was returned to us in advance of the date requested. The home’s Health & Safety policies and procedures protect the health, safety and welfare of residents and staff. Staff all undertake the mandatory health & safety related training. The in house recording of accidents and incidents is good but the home do not always notify us of events that affect the welfare of residents. A recommendation is made regarding this. 16 Godwyne Road DS0000023285.V357744.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 3 4 3 5 3 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 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 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X 16 Godwyne Road DS0000023285.V357744.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1 Refer to Standard YA42 Good Practice Recommendations The home should inform the Commission for Social Care Inspection of all events that affect the well being of the residents. In as much as they should complete and send the appropriate Regulation 37 notifications. 16 Godwyne Road DS0000023285.V357744.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. Extracts may not be used or reproduced without the express permission of CSCI 16 Godwyne Road DS0000023285.V357744.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. 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