Inspection on 15/05/08 for David`s House

This is the latest available inspection report for this service, carried out on 15th May 2008.

CSCI found this care home to be providing an Excellent 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.

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Orchard House Nursing Home

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Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE David`s House Pool Road Harrow Middlesex HA1 3YH Lead Inspector Tony Lawrence Key Unannounced Inspection 15th May 2008 11:00 X10015.doc Version 1.40 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 David`s House DS0000070916.V363933.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 Older People. 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. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service David`s House Address Pool Road Harrow Middlesex HA1 3YH 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) 01332 296200 davidshouse@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Sherin Hart Care Home 30 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (30) of places David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places: 30) 2. Dementia - Code DE (maximum number of places: 30) The maximum number of service users who can be accommodated is: 30 Date of last inspection Brief Description of the Service: David’s House is a care home providing personal care and accommodation for up to 30 older men and women. There were no vacancies when we completed this inspection. The registered provider of services at the home changed from Stadium Housing Association Limited to Methodist Homes for the Aged (MHA) in December 2007. The home has been operating since 1988. It is located within a residential area of Harrow, to the south of the town centre. It is about ten minutes walk from local amenities, and fifteen minutes walk from Harrow town centre. Bus routes are close by and there is private parking for around six cars at the front of the home. The building is purpose built across three floors. Access is by passenger lift or stairs. The top floor is only for management and staff use. All bedrooms are fully furnished and all have en-suite toilet facilities. The home has two bathrooms equipped with assisted baths and two accessible shower rooms. There are spacious dining rooms with kitchenette, and a separate but linked lounge area on each floor. There are additional private lounges and a dining area for residents’ use on the first floor. A conservatory on the ground floor leads to the medium-sized back garden. The weekly fees for the home range from £585 to £671. David`s House DS0000070916.V363933.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 3 stars. This means the people who use this service experience Excellent quality outcomes. This unannounced key inspection took place on Thursday 15th May 2008 from 11:00 – 17:00. We spent time talking with people who live in the home, their relatives, staff on duty and the home’s manager and deputy manager. We also checked care records kept in the home and saw all communal areas and some residents’ bedrooms. The manager sent us an Annual Quality Assurance Assessment (AQAA) and we have used information from this to write this report. 26 residents, 5 relatives and 7 staff working in the home also sent us 38 confidential surveys and their comments are included in this report. We would like to thank the residents, relatives, manager and staff who spent time telling us about the services provided in the home. The acting manager told us that the fees for the home range from £585 to £671. What the service does well: 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. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. People living in the home experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a service user’s guide. The guide details what the prospective residents can expect. EVIDENCE: ‘As a direct result of surveys, discussions, comments and complaints, we have recently improved our statement of purpose and resident guides’. (Extract from MHA’s Annual Quality Assurance Assessment – AQAA). During this visit we saw that the provider’s Statement of Purpose is displayed on the notice board in the home’s hallway. We saw that this included all of the information needed to meet these Standards. Residents and their relatives told us that they had been given copies of the Residents’ Guide and had found this information helpful. All 26 residents who returned confidential David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 8 questionnaires told us that they had received enough information before moving into the home to enable them to make a decision. The manager told us that all residents receive a comprehensive Residential Care Agreement covering all the terms and conditions of living in the home, including a full breakdown of fees. 23 of the 26 residents who returned confidential questionnaires told us that they or their relatives had received a contract when they moved into the home. During this visit we checked the care plan files for three people living in the home. We saw that all three files included a full assessment of each person’s care needs, completed by a senior member of staff from David’s House. The assessments covered all areas of each person’s personal and health care needs and how these would be met in the home. The Manager told us that the home does not provide an intermediate care service and Standard 6 does not apply. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People living in the home experience Excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive effective personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. EVIDENCE: ‘Excellent care given by staff’. (Comment from a resident’s survey). ‘We are all happy with the care and support given’. resident’s survey). ‘There’s always someone to listen if I want to talk’. resident’s survey). (Comment from a (Comment from a ‘I get all the information about the needs of our residents in the care plan and in our zone meetings and handovers’. (Comment from a staff survey). David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 10 ‘All residents have an individual Support Plan which is comprehensive, bespoke and in addition to any Care Plan provided by a placing authority. Support Plans are based on an initial Domiciliary Assessment and we encourage residents and their families to have direct involvement in the development of the plan, write up their Personal Profile and sign the Support Plan’. (Extract from MHA’s Annual Quality Assurance Assessment – AQAA). During this visit we checked the care plan files for three people who live at David’s House. We saw that all three files included a care plan that had been regularly reviewed and covered all aspects of the resident’s personal and health care needs. We felt that the home’s care planning systems were very ‘person centred’. Plans were written in the resident’s voice and emphasised people’s preferences in how they were supported by staff to meet their care needs. The care plans were divided into a number of outcome areas, covering all aspects of personal and health care. We felt that the plans included excellent guidance for staff on the standards of care that were needed to provide good outcomes for residents. This guidance had been well used by staff to develop individual’s care plans, in consultation with the resident and their relatives. Residents and their relatives who spoke with us during this visit told us that staff in the home make sure that each person’s care needs are met in full, in ways that they choose and prefer. Care plans reflected people’s preferences about aspects of their daily lives, including times they get up, food, drink and personal care preferences. Residents told us that staff always respected their choices and preferences and we saw many examples of this happening during our visit. 3 of the 5 relatives who returned confidential questionnaires told us that the home ‘always’ meets the care needs of their relative. 2 relatives told us that residents’ care needs were ‘usually’ met. 5 of the 7 staff who returned confidential questionnaires told us that they were ‘always’ given up to date information about the care needs of residents. 2 staff did not answer this question. The care plans we saw during this visit included excellent information about each person’s health care needs and how these should be met. Again, we felt that the information was presented in a very ‘person- centred’ way and there was clear evidence that residents were involved in planning their own care and support. All three files included detailed records of the person’s contact with health care professionals, including GP’s, chiropodists and District Nurses. We saw that the home uses the Boots Monitored Dosage System (MDS) for the management of all prescribed medication brought into the home. All medication was securely stored in appropriate cabinets in the home’s medical room. We checked the Medication Administration Record (MAR) sheets for David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 11 residents living on the ground floor. The MAR sheets were well completed by staff and we saw no errors or omissions in these records. Residents and their relatives told us that staff always treat people with respect. Residents said that staff always respect their privacy, enabling them to make choices about where they spend their time and how they are supported. The care plans we saw all included details about the resident’s wishes regarding end of life care and resuscitation. These sensitive issues had been discussed with residents and their relatives and their wishes were clearly and prominently recorded. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People living in the home experience Excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, appropriate to their peer group, in both the home and the community. Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. Routines are very flexible and residents can make choices in major areas of their life. EVIDENCE: ‘There’s always something to do’. (Comment from a resident’s survey). ‘I enjoy the exercise groups on Mondays and Wednesdays and the cake making sessions’. (Comment from a resident). ‘The home has a full and varied activity programme running 7 days a week; a yearly programme is scheduled with suggestions from residents. All residents David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 13 have the opportunity to exercise their choice in relation to routines of daily living. We assess residents social needs and interests and document these in individual support plans’. (Extract from MHA’s Annual Quality Assurance Assessment – AQAA). ‘The food is very good – and there’s plenty of it’! (Comment from a resident). ‘I like the food and there is always plenty of choice’. resident). (Comment from a ‘The meals seem to be of the highest standard’. (Comment from a relative’s survey). During this visit we saw that the home’s programme of weekly activities was prominently displayed around the home. The Manager told us that most activities are co-ordinated by the Deputy Manager and run by the home’s team of care staff. The programme included skittles, music quizzes, film nights, bingo, baking and visits from the Pat-a-Dog scheme. In addition, the home pays for tutors to visit and run art and exercise classes each week. We also met the Chair of the Friends of David’s House, a volunteer support group. She told us that the group organises a range of activities, such as monthly bingo sessions, knitting and gardening club. The group also organises parties and a Summer Fete. During this visit the staff ran a music quiz on the ground floor in the morning and on the first floor after lunch. A tutor also ran an art session on the first floor in the morning. We saw that residents on both floors greatly enjoyed the music quiz and care staff ran both sessions very enthusiastically. On the ground floor, one person entertained other residents, staff, visitors and the Inspector with songs that she had been prompted to remember by the quiz. All 26 residents who returned confidential questionnaires told us that the home organised activities they could take part in. The care plans we saw included details of each person’s life history, including information about significant people, dates, jobs and leisure interests. Relatives told us that staff spent time with them and their relatives to build up and record each person’s life story. The care plans also included contact details of each person’s relatives, friends and other significant people. Relatives told us that staff were very good at supporting resident to keep in touch. Staff also told us that they knew the arrangements for contacting each person’s relatives. In one case, staff and the resident’s relatives had agreed regular times when relatives would phone the home to reduce the person’s anxiety. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 14 Residents and relatives told us that people were supported with their personal finances, where this was needed. The Manager also told us that the home has details of local advocacy services and residents would be supported to selfrefer if necessary. Residents told us that they were encouraged to bring items of furniture and other personal belongings into the home. All the residents’ rooms we saw during this visit were highly individual and very well personalised. We saw that the home’s four-weekly menu is displayed around the home. The Manager also spent time during our visit developing the summer menu that will be introduced shortly. Some residents told us that they greatly enjoyed the food, while others said they were generally satisfied. We saw that the home’s dining rooms were bright and spacious and provided attractive areas for residents to eat meals communally. Some residents told us that they preferred to eat some meals in their rooms and added that staff always respected their choices. 23 residents who returned confidential questionnaires told us that they ‘always’ enjoyed the food that is provided at David’s House. 3 residents told us that they ‘usually’ enjoyed the food. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People living in the home experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Residents and others involved with the service say that they are happy with the service provided, feel safe and well supported by an organisation that has their protection and safety as a priority. EVIDENCE: ‘Do I feel safe here? I’ve never felt safer anywhere else’. (Comment from a resident). ‘It’s so reassuring, knowing that I don’t have to worry if Dad is safe. I know the staff will call me straight away if ever there’s anything I need to know’. (Comment from a relative). ‘There’s always someone to speak to if we’re not happy, we’re not afraid to ask’! (Comment from a resident’s survey). ‘The complaints procedure was in the paperwork we received and it’s on the MHA website as well’. (Comment from a relative’s survey). ‘Complaints are responded to as fully as appropriate within 15 working days. We always apologise for mistakes or bad practice, and take action to remedy David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 16 things. Our aim is to satsify the complainant as quickly as possible, but where we do not they are given the information to take the matter further. Our published procedure gives details of the local CSCI office’. (Extract from MHA’s Annual Quality Assurance Assessment – AQAA). During this visit we saw that the home’s complaints policy and procedures were displayed on notice boards around the home. We also saw that there was information widely available about MHA’s safeguarding adults policy and procedures, including a whistle blowing policy for staff. The Manager told us that the whistle-blowing policy has 2 confidential freephone 24 hour phone lines (one for staff, and one for residents) both run by external agencies. The Manager told us that there had been one formal complaint since our last inspection and this was resolved using the home’s procedures. The Manager also told us that there had been no safeguarding adults referrals or investigations since our last visit. All 26 residents who returned confidential questionnaires told us that they knew who to speak to if they were not happy. All 26 people also said that they knew how to make a complaint and six people added that they had never needed to complain about anything. We saw that the home had a copy of the local authority’s Safeguarding Adults policy and procedures in the main office for staff reference. Staff told us that they would report any concerns they had about residents’ welfare to the home’s Team Leaders, Manager or Deputy Manager. The Manager and staff confirmed that staff are trained in abuse awareness and attend the Local Authority Adult Protection Teams training. Staff also told us that they have regular 1:1 supervision with senior staff and safeguarding issues are discussed during these sessions. We spoke with most of the staff on duty during this visit and they all demonstrated a good understanding of the home’s safeguarding procedures. All were aware of the provider’s confidential whistle-blowing phone lines for residents and staff. We saw that a quality assurance survey was completed by the home in 20072008. 25 residents completed surveys. 24 people said they felt complaints would be taken seriously and all 25 people said that they felt safe in the home. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. People living in the home experience Excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. The environment is fully able to meet the changing needs of people, along with their cultural and specialist care needs. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment are designed to fit within the homely environment. EVIDENCE: ‘I love my room and having my things around me’. resident). (Comment from a ‘The home is exceptionally clean’. (Comment from a resident’s survey). David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 18 ‘The home is cleaned beautifully at all times’. survey). (Comment from a resident’s ‘They provide a friendly, clean, welcoming environment that is apparent as soon as you walk in the door, no matter what time of the day you visit. There has never been an occasion when the rooms and facilities have been less than spotless’. (Comment from a relative’s survey). ‘We have introduced a comprehensive self-assessment (Standards and Values) carried out by an independent and experienced manager which includes a detailed inspection of the premises and environment, and focuses on the outcomes and experience of residents. MHA has further delegated capital spending to Home Managers to enable prompter repairs and developments’. (Extract from MHA’s Annual Quality Assurance Assessment – AQAA). The Manager told us that David’s House opened in 1988. The home is located within a residential area of Harrow, to the south of the town centre. It is about ten minutes walk from local amenities, and fifteen minutes walk from Harrow town centre. Bus routes are close by and there is private parking for around six cars at the front of the home. The building is purpose built and is fully accessible across three floors. Access is by passenger lift or stairs. The top floor is only for management and staff use. All bedrooms are fully furnished and all have en-suite toilet facilities. The home has two bathrooms equipped with assisted baths and two accessible shower rooms. There are spacious dining rooms with kitchenettes, and a separate but linked lounge area on each floor. There are additional private lounges and a dining area for residents’ use on the first floor. A conservatory on the ground floor leads to the medium-sized back garden. During this visit we saw all communal parts of the home, bath and shower rooms and some residents’ bedrooms with their permission. We felt that the home offers excellent standards of communal and private accommodation. The residents’ bedrooms we saw were highly individual, well decorated and comfortably furnished. Residents told us that they were very happy with their rooms. Communal lounges were spacious, bright and comfortably furnished, with attractive dining areas. The bath and shower rooms were well equipped and had been made very welcoming facilities for residents’ use, with all rooms having plants, candles, pictures and radios / CD players. We saw there was a well-kept garden with garden chairs, tables and sunshades. Residents told us that they enjoyed sitting in the garden when the weather allowed. During this visit all parts of the home that we saw were clean, pleasant and hygienic. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People living in the home experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents told us they have confidence in the staff who care for them. Accurate job descriptions clearly define the roles and responsibilities of staff. All staff receive relevant training that is focussed on delivering improved outcomes for residents. The home’s recruitment procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. EVIDENCE: ‘They could do with more staff, the girls are very busy all the time’. (Comment from a resident’s survey). ‘The staff are lovely – they’ll do anything for you’. resident). (Comment from a ‘The staff care for and look after my Mother exceptionally well. In all areas of her care I feel they take really good care of her’. (Comment from a relative’s survey). ‘The staff on the whole are very good but there should be more care workers so that they have time to spend with each resident. They are always so busy, David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 20 there is too much paperwork and not enough conversing with residents’. (Comment from a relative’s survey). ‘Our ratio of NVQ qualified care staff is currently 72 , which will rise to 88 once the staff currently in training complete the qualification. We have a comprehensive recruitment manual which sets out clear guidelines. We are very careful to make all the necessary checks on potential staff and ensure they are suitable for employment. Once employed, they all receive detailed contracts and the GSCC code of conduct. All staff are properly inducted through a programme in line with the Skills for Care Foundation guidelines. Additional mandatory and developmental training is also provided and an allowance of at least 5 days per person made in the staffing budget’. (Extract from MHA’s Annual Quality Assurance Assessment – AQAA). When we arrived for this inspection, the home’s Manager and Deputy Manager were on duty with one Team Leader. Two care staff were supporting people living on the ground floor and three care staff were working with people living on the first floor. During the day we saw that staff on both floors worked well together to meet residents’ care needs. Information given to us by the Manager in the home’s AQAA is evidence that the home has achieved the standard of a minimum of 50 care staff qualified to National Vocational Qualification (NVQ) Level 2. During this visit we checked the staff personnel files for three people working in the home. We saw that all three files included an application form, two written references, proof of identity, proof of eligibility to work in the UK and confirmation of Criminal Records Bureau checks. The files included all the information needed to make sure that staff are suitable to work with vulnerable adults. 7 staff who returned confidential questionnaires all told us that the home had taken up employment checks before they started work. We spent time during this visit talking with four staff who work in the home. Staff were very positive about their jobs and they told us that the home provides good induction training and regular refresher training on essential skills. All 7 staff who returned confidentrial questionnaires told us that their induction training had covered everything they needed to know to do their job. All 7 staff also said that they were given training that was relevant to their roles and kept them up to date with new ways of working. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. People living in the home experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities, and works to continuously improve services. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. EVIDENCE: The home’s registered manager told us that she is a qualified nurse who has 24 years experience of working in social care in local authority and independent sector services. She has completed the National Vocational Qualification (NVQ) Level 4 registered manager’s award and has been David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 22 registered by the Commission as a fit person to manage the home. We felt that the Manager and her team had worked well to support staff with the introduction of new policies and procedures, following MHA’s acquisition of the home in December 2007. The Manager completed and returned to us an Annual Quality Assurance Assessment (AQAA). The AQAA was detailed and is evidence that the manager and provider know what needs to be done to further improve already excellent standards of care in the home. Residents and their relatives told us that they felt involved in the running of the home. People said that staff asked for their views and respected them. Relatives mentioned the Friends group and the support they provided for people living in the home. We saw that a quality assurance survey had been completed in 2007-2008. Residents and other people connected with the home completed surveys and the results were collated to provide an overview of people’s views on the services they received. During this visit we checked a variety of care records kept in the home, including care plans, risk assessments, staff personnel files and medication records. We felt that records were up to date and well maintained and standards of record keeping in the home were good. We saw that records of health and safety checks were up to date and no health and safety issues were noted during our visit. David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 4 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 David`s House DS0000070916.V363933.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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