Inspection on 14/01/09 for Midway (5)

This is the latest available inspection report for this service, carried out on 14th January 2009.

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

Midway (5) 12/09/05

Midway (5) 07/06/05

Midway (5) 06/09/04

Midway (5) 17/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Midway (5) 5 Midway Walton- on-Thames Surrey KT12 3HY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Joseph Croft     Date: 1 4 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Midway (5) 5 Midway Walton- on-Thames Surrey KT12 3HY 01932253501 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): Welmede Housing Association Ltd The registered provider is responsible for running the service Name of registered manager (if applicable) Mrs Marie Denise Farouk Type of registration: Number of places registered: care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - LD Date of last inspection Brief description of the care home 5 Midway is a care home for 6 adults with learning disabilities, and is located on a private road within walking distance of Walton on Thames town centre. The home is a large detached house with a parking area to the front of the building and a large secluded garden to the rear. All the bedrooms are single occupancy and there are bathroom and toilet facilities on each floor. On the ground floor there is a large sitting Care Homes for Adults (18-65 years) Page 4 of 29 6 Over 65 0 Brief description of the care home room, a separate dining room, a large fitted kitchen and a well equipped utility room. Midway provides homely and comfortable accommodation for the residents. Welmede Housing Association is the registered proprietor of the home. Staff are no longer employed by the North Surrey Primary Care Trust, they were transferred to Welmede Housing Association on the 1st April 2008. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for the service is Two stars. This means the people who use this service experience good quality outcomes. The Commission For Social Care Inspection (CSCI) (us, we) undertook an unannounced site visit to the service on the 14th January 2009 using the Inspecting for Better Lives (IBL) process. The site visit was undertaken by Regulation Inspector Mr Joe Croft and took seven hours, commencing at 10:00 and concluding at 17:00. The registered manager was on compassionate leave, however, the shift leader and deputy manager assisted throughout the site visit. Two telephone conversations took place with the registered manager when she returned to work. The inspection process included a tour of the premises, direct observation of practice, Care Homes for Adults (18-65 years) Page 6 of 29 sampling of medication records, care plans, risk assessments and health action plans. Discussions took place with the deputy manager, shift leader and two members of staff. Due to the complex needs and communication difficulties we were only able to have a limited conversation with one resident with staff support. This resident was able to convey that they like living at the home, the activities they do and the food they eat. They stated that they like the staff. Staff were observed interacting with residents in an appropriate manner, were aware of residents communication needs, and called them by their preferred names. Surveys were sent to residents, staff and health care professionals. At the time of writing this report we had not received any completed surveys. The inspector would like to thank the deputy manager, staff and residents for their cooperation during the site visit. The last key inspection was undertaken on the 18th January 2007. Weekly fees charged are 1389 pounds. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service, and their representatives, are provided with the information needed to enable them to make a choice in regard to the home meeting their needs. Prospective residents individual aspirations and needs would be assessed before they were offered a place at the home. Evidence: The home has a Statement of Purpose that included information in regard to the philosophy of the home, daily activities, a description of Welmede Housing Association Ltd, staff working at the home, moving in and annual fees. The Service User Guide includes information in regard to health care support, license agreement, the complaints procedure and a copy of the last key inspection report. Photographs are included in both these documents. It was not possible to evidence when these documents were last reviewed and a good practice recommendation has been made in regard to this. Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: The Deputy manager told us that the current six residents have been living at the home for at least twelve years, therefore the home has not had any new admissions. We were told that the manager would follow the organisations policy in regard to moving into the home. Assessment of needs would be obtained from the funding authorities and the manager would also undertake an assessment to ensure the home could meet their needs. Prospective residents would be invited and encouraged to visit the home, which may include over night stays, meeting the current residents and staff, and viewing their bedrooms. The Annual Quality Assurance Assessment (AQAA) completed by the manager did not include any information in regard to the Statement of Purpose, Service User Guide or Needs Assessments. The AQAA was discussed with the manager during a telephone conversation on the day after the site visit, and comments in regard to this have been made under the Conduct and Management of The Home section in this report. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have care plans and risk assessments in place that ensure their needs can be met. Evidence: Two care files were sampled during the site visit. Each file had an assessment in regard to personal and health care needs of the resident. Care plans are produced from these assessments and include information in regard to personal hygiene, dressing, eating and drinking, social behaviour, privacy and physical health and safety. Evidence was viewed that these have been reviewed on a three monthly basis. However, one was last reviewed in August 2008. The deputy manager told us this was because the home was due to commence using Person Centred Plans (PCP), and training in regard to this should have been completed in 2008 but, due to an accident, the trainer was unable to fulfil this obligation. This was confirmed during discussions with the registered manager and staff. All staff at the home are to receive training in regard to PCP on the 26th of January 2009. Each care plan sampled included goals and Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: objectives and was signed by the key worker. The reason why the resident was unable to sign the care plan was recorded. Other information included spiritual needs, weekly activities, preference in regard to their personal care needs and their likes and dislikes. Each care file viewed included risk assessments and a manual handling risk assessment. One file had a behaviour assessment that was last reviewed in 2004. The manager told us that the objectives of this assessment have been accomplished and it is no longer required. The manager was advised to record this on the assessment. The care files sampled had a photograph of the resident and a personal information sheet that included the residents next of kin, GP details and other personal information pertaining to the resident. During discussions the deputy manager and staff told us that staff support residents to make decisions for themselves such as the choice of menu, clothes they wish to wear and activities and they want to partake in. This was evidenced during the site visit, in particular one resident conveyed that they wanted to go for a walk, another resident had chosen to spend time on their own in their bedroom watching their television. Due to the residents complex needs and communication difficulties we were not able to have discussions with all people who use the service. However, we were able to have a limited discussion with one resident who conveyed that they like living at the home. The AQAA informs that care plans are in place and residents have key workers with whom they have built up trust. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are encouraged by staff to participate in a range of activities. A balanced diet is provided for residents. Evidence: Residents continue to have access to the local amenities, and attend day centres as appropriate to their needs and ability. Activities attended at the day centres include reflexology, art and exercises. The home has a list of the weekly activities residents take part in, this is displayed in the office. Each resident has an activity list in his or her care file. During discussions one resident told us they like the activities they do. Activities provided include bingo, attending a local Mencap club, swimming and snoozlum. During discussions staff told us that they take residents to theatre productions and had Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: recently been to see a pantomime at the Woking theatre. Residents are supported to access the local community, and go shopping and have meals out at the fast food outlets. On the day of the site visit residents had left to attend bingo. Staff told us that they took all the residents on a weeks holiday to Jersey in October last year. We were shown photographs of this and other activities that residents take part in. It was evident by their response that residents had enjoyed their holidays and celebrating birthdays, Christmas and Halloween. Two residents currently attend church services every Sunday with staff support. The deputy manager told us that the home has an open door policy for family and visitors. During discussions staff told us that they have transported residents to their family homes for visits. Residents receive their own mail and staff support them with their telephone calls. The menu for the week of the site visit was viewed. Meals included fresh meat, fish, pasta, fresh vegetables and fruit. Staff told us that residents are supported to make choices about the menu during their monthly resident meetings. Fresh fruit was freely available on the day of the site visit. The lunch was observed to be a relaxed unhurried occasion with all three members of staff sitting at the table with residents and having the meal with them. Staff told us that all staff on duty have their meals with the residents. Care plans viewed included information in regard to residents diets, and informed staff of the support that may be required. One resident told us that they like the food provided at the home. The AQAA informed that all residents participate fully in activities that suit their needs, allowing them choices. However, there was no information in regard to family contact or meals provided. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Physical and health care is offered in such a way as to ensure residents personal, physical and health care needs are met. People who use the service are protected by the homes storage and administration of medication procedures. Evidence: Staff continue to attend to residents preferred method of care assistance, and this was recorded in the care plans sampled. During discussions staff told us that they attend to the personal care of residents in the privacy of bedrooms and bathrooms, and ensure residents are appropriately covered when attending to these needs. Residents are encouraged to be as independent as possible. As stated previously, residents likes and dislikes are recorded in the care plans, this also includes information in regard to the level of support required with their personal care needs. Staff told us that they knock on bedrooms doors before entering and call residents by their preferred names. During the site visit it was clear that staff knew the individual Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: residents well, including their likes and dislikes. Staff stated they are able to recognise the moods of residents through their body language and facial expressions. Residents would convey to staff if they were unwell or feeling sad. Care files sampled include health action plans that record medical appointments, and include the reason for the appointments, the diagnosis and medication prescribed. It was clear from discussions with staff, and records maintained, that residents have access to all the National Health Services that included GP appointments, dentist, and specialist appointments as and when required. Staff told us that residents attend the local GP surgery for medical appointments, and that annual health checks are undertaken. Residents weights are regularly checked and were recorded in the two care files sampled. Staff told us that one resident has a fear of going to the dentist, however, this had not been recorded under their likes and dislikes in their care plans. A good practice recommendation has been made that residents phobias should also be recorded in their care plans. The home follows the organisations Medical Policy and Procedure that was last reviewed in October 2007. The local pharmacist provides the Medication Administration Record (MARs) sheets and training to staff working at the home. Evidence was viewed that all staff had attended the local pharmacist training programme to enable care workers to safely administer medication in care homes. Staff had also attended training in regard to the use of rectal diazepam. Staff told us that it was extremely rare to use this medication. No resident is currently taking a Controlled Drug, and none are able to self-administer their medication. The MARs sheets were viewed during the site visit. Where possible these are countersigned by another member of staff. MARs sheets were appropriately maintained, however it was noted that one signature had inadvertently been signed in the wrong place, this was immediately corrected. Medication was appropriately stored in a locked medical cabinet. Records of medication received and returned to the pharmacy are maintained by staff at the home. The AQAA informs that residents have a choice of who attends to their personal care, and that health checks are regularly carried out. Care Homes for Adults (18-65 years) Page 17 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and their relatives have access to a complaints procedure that enables them to raise concerns. Residents are protected from abuse through the organisations policies and procedures and staff training, however, the organisation must address the issue in regard to charging for staff meals. Evidence: The Commission For Social Care Inspection have not received any concerns, complaints or Safeguarding issues in regard to the home since the last key inspection of 2007. The home follows the organisations Complaints Policy that was last reviewed in September 2007. This included the correct contact details for the Commission for Social Care Inspection and included the timescales for responding to complainants. A copy of this document is included in the Service User Guide, and included pictures and plain English. The AQAA informs that the home has not received any complaints. The home has a complaints and compliments book that would provide all the details as required from a complainant. This book also included many letters and cards of compliments sent to the home by relatives of residents. During discussions staff told us that they are able to tell if residents are unhappy through their body language and moods, and some residents would let them know if Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: they were unhappy. The home has a copy of the recent Surrey Safeguarding Procedures, and staff follows the organisations abuse Policy that was last reviewed in October 2007. The training matrix provided on the day of the site visit provided evidence that all staff had attended training in regard to Safeguarding Adults, however, it was noted that one member of staff last attended this training in 2005. The deputy manager told us that all staff have been booked to attend refresher training in February 2009. Different scenarios in regard to abuse were discussed with staff. They were knowledgeable about the procedures to be followed and were aware that the safeguarding issues must be reported to the local Safeguarding Team. The deputy manager told us that staff do not have power of attorney for residents finances. The home holds small amounts of monies for residents, and these are always checked at every handover shift. The money held for the two residents being case tracked were viewed. The amount held balanced with the records maintained. It was noted that residents are paying for staff when they are having meals out. This was discussed with the manager who stated this was the recent Christmas meal. However, this matter will be referred to the organisation to address in this and all other care homes they are responsible for. The AQAA informs that residents and carers have access to the complaints procedure and know whom to contact if they want to make a complaint. Staff receive training on protecting Vulnerable Adults and all staff have Criminal Record Bureau checks undertaken. Care Homes for Adults (18-65 years) Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The design and layout of the home enables the people who use the service to live in a safe, well maintained and comfortable home. Evidence: A tour of the premises and the sampling of residents bedrooms were undertaken during the site visit. The accommodation is set on two floors. All bedrooms are of single occupancy and there are bathroom and toilet facilities on each floor. The home has been redecorated since the previous key inspection, including the entrance hall, dining room and office, which were requirements made at previous key inspections. The kitchen, first floor bathroom and laundry room have been refurbished. The ground floor bathroom has a hoist, although this is not required as yet, an adjustable bath and a walk in shower. Communal bathrooms and toilets had liquid soap and paper towels. Bedrooms viewed were appropriately decorated, and residents had their personal belongings that included photographs, televisions and stereo players. Bedrooms had furniture of the residents choosing, such as reclining chairs, and were suitable to their needs. There is a communal lounge that has a large television with satellite connection, and new comfortable sofas and seats. There is a separate dining room with a large dining table. Staff told us that all staff on duty have their meals with residents. This was observed at lunchtime during the site visit. This meal was relaxed and Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: unhurried, and residents were making choices about the food they ate and the drinks they required. The dining room table had a tablecloth and matching place mats. On the day of the site visit the home was clean, tidy and free from offensive odours. Staff told us that they take pride in ensuring that cleanliness is maintained. The training matrix provided evidence that all staff had attended training in regard to Infection Control. The AQAA informs that the home provides a safe, homely, comfortable, secure and environment. Care Homes for Adults (18-65 years) Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for staffing are satisfactory. Staff are provided with training required to ensure the residents needs are met. People who use the service are protected by the organisations recruitment policies and procedures. Evidence: The home continues to employ a multi-cultural staff team that includes male and female staff. Staff were observed through the site visit to be appropriately interacting with residents, offering support as and when required. During discussions one resident told us that the staff at the home were nice. The duty rota was viewed during the site visit. This provided evidence that there are three members of staff on duty on the early and late shift, and there is one waking night staff. The deputy manager told us that staff from another nearby Welmede home provides support during the night should it be required. During discussions, the deputy manager and staff told us that they cover staff shortages themselves, and the home does not use agency staff. Welmede have their own bank staff that the home would use when necessary. Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: The AQAA informs that six members of staff plus the manager work at the home. Of the six care staff, four hold the minimum of an NVQ level 2, two are currently undertaking the NVQ level 2, and one member of staff is doing NVQ level 3. Other training undertaken by staff includes epilepsy, rectal diazepam and Control Of Substances Hazardous to Health(COSHH). The deputy manager told us that staff have also attended training in equal opportunities, risk assessments and stress. All staff are offered training courses that are provided by Welmede Housing Association Ltd. The home follows the organisations Recruitment policy that, according to the AQAA, was last reviewed in 2005. Two recruitment files were sampled during the site visit. These included an application form, employment history, photograph, proof of identification, health questionnaires and notes of interviews. One staff file had two written referrences. The other only had one, however, there was an E Mail in this staff file stating that the HR manager from Welmede Housing Association Ltd had spoken to customer services at the Commission for Social Care Inspection in regard to not being able to obtain the referrences. It was recorded on an E Mail that the organisation were advised that if circumstances are beyond our/the candidates control, then we are okay to go ahead with the employment as long as we make relevant notes on the individual files to this effect. The recruitment files sampled were not easy to use and a good practice recommendation has been made that staff recruitment files should include an index that would enable easier access to the information required. The manager holds the key for staff files and another manager from a nearby Welmede home had the authorisation to access these when an inspection was taking place. However, the Criminal Bureau Record (CRB) referrence numbers could not be located. The person accessing these files told us that these are held separate to staff files. During a telephone conversation with the registered manager on the day following the site visit we were advised that all staff had CRBs undertaken, and that the referrence numbers would be forwarded to the Commission for Social Care Inspection. These were received on the 21st January 2009. The deputy manager told us that new staff undergo an induction programme that is in line with the Skills for Care Council. This was confirmed during discussions with two new members of staff who were recently employed to work at the home. Unfortunately neither staff had their induction programmes with them, so we were not able to evidence this during the site visit. Staff told us that they receive formal one to one supervision from the manager every six weeks. The AQAA informs that the home has a well trained staff team with good skills and Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: knowledge. Staff induction is provided and staff have regular supervision meetings and annual appraisals. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. Evidence: The manager has been managing the home since February 2003 and is a Registered Nurse for Mental Health (RMNH). She has the NVQ level 4 and the Registered Managers Award (RMA). The manager was not present during the site visit, however, we had a telephone conversation with the manager on the 15th and 22nd January 2009. The manager told us that during the past twelve months she has attended all the mandatory training as required including Safeguarding Adults and medication. Other training undertaken has included conflict management, interview skills, appraisals, Person Centred Planning and the Control Of Substances Hazardous to Heatlh (COSHH). During discussions staff told us that the manager has an open door style of management and is very supportive to all staff. The home had an Annual Service Review undertaken in June 2008. Part of this process Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: including making telephone contact with the registered manager for confirmation that the requirments made at the previous key inspection had been complied with. At this time the manager confirmed that the requirement made in regard to ascertaining the views of staff and residents representatives had been complied with. During the site visit completed questionnaires were viewed from residents relatives. However, the deputy manager could not locate the staff questionnaires or a summary of the findings of these. During a telephone conversation with the manager on the day after the site visit she reassured us that this had been done, and she would forward a copy of the summary to the Commission for Social Care Inspection. Evidence was seen that residents are having regular residents meetings where they are able to convey their views about the home, the activities and the meals they wish to have. The deputy manager told us that the organisation undertakes monthly Regulation 26 visits and reports are forwarded to the home. These reports were not viewed during this site visit. Evidence of monthly staff meetings were viewed during the site visit. The manager sent the Annual Quality Assurance Assessment to the Commission For Social Care Inspection when we asked for it. Although this document was informative, there were some outcome areas that require further information. This was discussed with the manager and a recommendation has been made that the manager should read the guidelines in regard to completing the AQAA that are on the CSCI web site. The training matrix provided on the day of the site visit provided evidence that all staff working at the home had attended all the mandatory training as required. These included first aid, manual handling, fire, Infection Control and medication. The AQAA informed that annual servicing of equipment used at the home had been undertaken as required by the manufacturers. During the site visit the following records were evidenced: Portable Appliance Testing (PAT), July 2008, general risk assessments , last reviewed December 2007, fire risk assessments, February 2008, health and safety audit August 2008, and the servicing of the hoist was undertaken on the 8th December 2008. The AQAA informs that the home follow the policies and procedures of the organisation. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 4 1 19 34 39 The Statement of Purpose and Service User Guide should include the dates of when they were last reviewed. Residents phobias should also be recorded in their care plans. Staff recruitement files should include an index that would enable easier access to the information required. The manager should read the guidelines in regard to completing the AQAA that are on the Commission for Social Care Inspection web site. Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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