Inspection on 11/03/08 for Osborne House

This is the latest available inspection report for this service, carried out on 11th March 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Osborne House 20/09/06

Osborne House 07/11/05

Osborne House 12/07/05

Osborne House 07/12/04

Osborne House 27/05/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Osborne House 90 Osborne Road Windsor Berkshire SL4 3EN Lead Inspector Kerry Kingston Key Unannounced Inspection 11th March 2008 10:30 Osborne House DS0000011278.V359400.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 Osborne House DS0000011278.V359400.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. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Osborne House Address 90 Osborne Road Windsor Berkshire SL4 3EN 07845 996807 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) malama.pierids@advanceuk.org Advance Housing and Support Ltd Mrs Malama Pieridis Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Osborne House in Windsor is registered to provide accommodation for 9 adults with a range of learning disabilities age between 18 and 65 of both sexes. The home is an old Victorian building, which has been completely renovated. The home is situated close to Windsor town centre and in walking distance of many local amenities. The home has 4 floors and each single bedroom has its own en-suite facilities. There are separate kitchens on each floor in addition to the communal kitchen and lounge. To the rear of the property there is a large garden. The home has wheelchair access throughout including the installation of a lift. There are small balcony areas located on some of the floors. The home is bright and airy throughout. Fees are £742 per week. Osborne House DS0000011278.V359400.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 stars. This means that the people who use the service experience good outcomes. This is a report for the key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 10.30 am and 5.30pm on the 11th March 2008. The information was collected from the Annual Quality Assurance Assessment, a document sent to the service by the Commission for Social care Inspection and completed by the registered manager of the service. Surveys were sent to the residents of the survey, some were completed and returned to the Commission but the information collected from them was not available at the time of writing the report. Discussions with two staff members and the registered Manager took place. Four residents were spoken to individually and two others were spoken to for a short time. Observation of practice and interactions between staff and residents was used as a further source of information throughout the visit. A tour of the home and reviewing residents’ and other records were also used to collect information on the day of the visit. What the service does well: What has improved since the last inspection? Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 6 The written plans, that staff use to make sure they are helping people in the best way, are looked at quite often so that people can be sure they are up-todate. The written plans include what people prefer and how they like to be helped so that everyone knows what they should do everyday to support the people who live in the home. Some residents have new health plans that show staff exactly what they should do to help people to stay as healthy as possible. All of the residents will soon have these plans in their file. The home has a new way of checking that they give people good care and that they are listening to what the residents and other people say about the home. 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. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience adequate quality outcomes in this area. The home ensures people are properly assessed prior to admission but do not have the policies and procedures to ensure that the home fully demonstrates its’ ability to meet those needs. Action is taken if peoples’ needs change and the home is not able to adequately meet them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no admissions since the last inspection. There is one vacancy, due to the person admitted in May 2007, being identified as unsuitable after four months and being moved to an assessment placement. People who live in the home know their assessed and changing needs and the resident who has moved was reviewed regularly when their behaviour suggested that the home was unable to meet their needs. The organisation have a 10 year contract with the local authority, there was a discussion with the manager about her responsibilities with regard to only admitting people that they can meet the needs of and the rights of the local Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 9 authority because of their ‘block booking’ contract. The manager fully understood her legal responsibilities but discussed feeling pressured to take people who she did not feel were suitable. The home does not have a robust admissions procedure that clearly sets out the managers’ responsibilities and it does not have any formal way of recording that the home can meet the assessed needs of prospective residents. This could be an issue in the near future as there is a current vacancy in the home, this does not impact on the current residents as most have been in the home for a number of years. The requirement from the last inspection was met by reviewing all the residents’ needs and the discharge of the person whose needs they could not meet. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. Care planning and reviewing of the care plans is up-to-date, residents know what their assessed and changing needs are, as they are fully involved in the review process. Residents are as involved in decision-making as far as possible and are helped to maintain or increase their independence. The homes’ daily living programmes encourage independence although risk assessment could be further improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for four residents were looked at, all had detailed and up-to-date assessments. One re-assessment resulted in a resident moving to a specialised assessment placement and special measures were adopted to ensure their and others safety while a placement was sought. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 11 Care plans reflect peoples’ changing needs such as those arising from the ageing process, health needs and peoples’ developing interests such as one persons’ growing interest in their background and culture. Reviews are up-to-date and care plans clearly reflect peoples’ current needs. Those who need more intense personal support plans have very detailed plans, which reflect any equality and diversity issues. All care plans are reviewed with the resident and key worker monthly and any changes/issues are noted and acted upon. Residents’ opinions of their care and lifestyle are sought at these monthly meetings. One person has been supported to achieve more independence and is moving to supported living in the near future, care planning and assessments supported this and risk assessments supported the move towards independence. The resident demonstrated that they had knowledge of the impending move. They were aware that they had been working towards more independence over a period of years and had been involved in the decision making for the move. Risk assessments are up-to-date but some could be more detailed and there could be more of them to ensure that people are supported to independence in the safest possible way. There was a discussion with the manager about reviewing other areas that may need risk assessments, mainly practical areas such as presence in the kitchen, currently not identified as a risk because they are only accessed with staff present. One resident has a very detailed risk assessment and programme to enable them to walk to day services independently, this has been completed with support from staff from the Community Team for People with Learning Disabilities. Six residents said that they choose what they want to do and they ‘know what is going on in the house’. Staff were seen giving people choices and asking what they thought. Residents files are presented in an efficient and effective way, with easy to find information and are user friendly in places, the user friendliness of documents is an area of development identified by the manager. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 12 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): 12,13,15,16 and 17. People who use the service experience excellent quality outcomes in this area. The home supports people to lead an interesting and rewarding lifestyle. It helps them to keep contact with family and friends and makes sure that they are an integral part of the local community. The home gives people choice and control over their menus whilst encouraging people to eat in a way, which meets their health needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activity plans for all eight residents were looked at. There is an activity plan in each individuals care plan. The activities plan/programme reflects individual needs such as age, development needs and preferences. Residents have a minimum of four sessions of activities, external to the home. Residents activities programmes are on display in the home so that people can see what they are doing that day. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 13 Programmes include swimming, drama, music and some educational content, as chosen by residents and to enhance their independence programmes and increase/maintain living skills. Residents use local shops, pubs, sports facilities and community groups. The manager said that people are well known in the area and a staff member confirmed that they are well accepted and participate in the community. Residents described their favourite activities and said there were always staff available to support them if necessary. Some residents go out unaccompanied, risk assessments are in place, as necessary. One resident described his membership of a drama group that had won prizes for its’ productions and another described her visits to a community dance group in the evenings. All the residents spoken to said that they had plenty of things to do. The home uses innovative ways to ensure people are enabled to access events on a 1:1 basis by the use of ‘befrienders’ or ‘buddies’ from local organisations. Daily notes confirmed that people participate in numerous activities during the day and are supported to attend various social events in the evenings and at weekends, one person said he had been to a concert at the weekend which he very much enjoyed. All residents are supported to have an annual holiday or long weekends away, whichever is their choice. The provider contributes to the cost of holidays for individuals’. The home had a long weekend away in Butlins, which was a resident request, one person told me how much he enjoyed it and recalled many details of the weekend. The home work hard to support people to maintain contacts with family members, there was evidence that one person had been helped to re-contact siblings over the past year and had spent some time with them at Christmas and on other special occasions. All the residents have contact with a family member or friend and the home has recently obtained the services of an advocate to ensure that the residents’ views are properly represented. Each resident has their own menu, according to their needs, choices and tastes. Residents choose, shop for and prepare their own meals with support from the staff. They are given a financial allocation and helped to make appropriate decisions about what to eat. People have weight charts, as appropriate and are supported to adopt healthy eating plans, if necessary. A referral to a dietician was made recently for one resident. Healthy eating plans are developed with the advice of the surgery nurse or a specialist dietician, as appropriate. One person told me why they are trying to eat more health food and the advantages of losing some weight. The staff had obviously worked extremely hard to help them understand the benefits of healthy eating and the effects of being overweight. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 14 The home eat Sunday lunch and special meals together, if residents wish to but they have small kitchens available on two of the floors so that they are able to access snacks, drinks and meals in those if they wish to. Menus seen were, overall, well balanced and reflected the specific dietary needs of individuals. Three residents said that the food was lovely and they could choose what they wanted to eat but staff helped them with shopping and cooking if they needed it. One resident was seen to be encouraged to help with meal preparations on the day of the visit. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. The home effectively supports people with their personal and healthcare needs, people receive support in the way that they prefer and are kept as healthy as possible. Medication is stored and administered safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for four residents were looked at, peoples’ preferences, choices and equality and diversity needs are clearly recorded on the care plans. Methods of communication and how to show people respect and how and what needs to be done to support them is also included. One person has only just begun to show an interest in their cultural background and staff are working with them to introduce them to some aspects of their culture. Staff were seen to interact positively and respectfully with residents and there were discussions about things people wanted to do to meet some individual interests such as buying a particular style of dress that reflected their culture. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 16 The needs of one person who is more elderly are carefully noted and day services have been changed to adapt to their changing needs. The individual who is moving on to independence has a care plan that reflects this and they keep most of their care planning paperwork in their room, at their request. Some residents have a newly developed health care plan, they are detailed and include residents’ healthcare needs and how the staff are to deal with those identified needs. One persons plan details how they might become suddenly ill because of their health condition and how to deal with such an event. The manager advised that she had prioritised completing the health plans for those residents who had specific health issues but would be developing one for all residents in the future. Health care records included all visits to primary health care professionals, such as the G.P, dentists, chiropodists and opticians. Regularity of visits is dependant on individuals’ need for instance one person visits the podiatrist every three months as they have particular issues with the condition of their feet and legs. Residents see the psychiatrist regularly to check on their mental health but there are currently no issues in this area and no challenging behaviours that require specific behavioural plans. The home receive good support from the G.P surgeries and from the Community nurses, from the Learning Disability Team, if required. They seek assistance in a timely manner if people show any signs of ill health. The home operates the Boots monitored dosage system, two staff administer medication and all records seen were accurate. The manager confirmed that there had been no medication administration errors since the last inspection. The home keeps stock control and administration records for all ‘homely’ remedies, the manager is to review whether it is more effective to record these on the daily recording sheets, provided by the chemist. One resident self medicates, when he has to take medication and this is monitored on a daily basis and is in preparation for him to move to more independent living. Medication is safely stored in a medicine cabinet attached to the wall of the staff office. Staff were observed administering medication, carefully and sensitively to residents who were encouraged to take as much responsibility for it as is possible. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People experience good quality outcomes in this area. Residents are protected from all forms of abuse and are sure that their concerns are listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints file, the manager confirmed they had received no complaints since the last inspection. Residents have made one complaint to the organisation about the rear garden, staff helped them to put it in writing and follow the procedure. The complaints procedure is sent to relatives, to raise their awareness of it and residents verbally confirmed that they know how and who to complain to. Four residents confirmed that staff listen to them and always ‘do something about it’. The Annual Quality Assurance assessment noted one safeguarding adults issue but this was not about safeguarding in the home but one within the community. The home has a copy of the local interagency protocols and two staff spoken to (a bank and an agency staff member) were aware of the procedures. Both staff had a good understanding of their responsibilities with regard to protecting people in their care. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 18 Four people said that they feel safe and two said that they spoke to staff if anything outside the home made them feel ‘scared’. One person said that staff help him not to feel afraid of the dark. The manager has found an advocate, as noted on the Annual Quality Assurance Assessment, to support residents with meetings and decisionmaking but she has not started to work with the home, as yet, because of personal circumstances. Residents were observed to be confident, communicative and relaxed when interacting with the manager and staff on duty, on the day of the visit. The Commission for Social Care Inspection has received no information with regard to complaints or safeguarding issues about this service. Two residents cash accounts were seen and the records were accurate. Residents have either the local authority or family as appointees. Those residents who are able retain responsibility for their own finances are encouraged to do so and there are agreements on care plans with regard to peoples savings plan and budget plans. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. The home is kept clean and hygienic and provides a pleasant environment that meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The communal areas and three bedrooms were seen. The home is, generally, well kept with good quality furniture and fixtures. The home lacks light shades in some areas, the manager said that there was no budget for these. There was a discussion about what the organisation is responsible for providing and light fittings were identified as some of these. All bedrooms are en-suite and residents chose whether to have a bath or shower in their room. The home is well maintained and resident’s rooms reflect their personality, choice and interests. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 20 The kitchens /bathrooms and laundry facilities are clean and hygienic. The home is large and is cleaned by care staff with the help of some residents, who are able to participate. There was a discussion about the most effective use of care staff with regard to the cleaning of such a big house. Three residents said they are very happy about their home and their own rooms. One person described how they had been involved in choosing colours and furniture for the home at the refurbishment a few years ago. Two residents said the home was ‘lovely’, ‘really lovely’. Residents are not happy with the back garden as it is uneven and not useable, they are very keen to have it made useable so that they can spend the summer months in it. They have been supported to write a letter of complaint to the housing association with regard to their dissatisfaction with the back garden. The manager has, in the past, found community groups to help with the garden maintenance but this is not now a possibility. The residents and staff feel that if the garden could be made useable they would be able to get involved in maintaining it in the future and would like to plant flowers and do some gardening projects. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience adequate quality outcomes in this area. The home has a small number of staff but they use regular bank and agency staff so that the consistency of care offered to the residents is not compromised. Permanent staff have individual development and training plans to ensure that they are properly trained to meet the needs of the residents but bank staff do not receive training from their employers. The recruitment processes are generally safe except for obtaining staff’s proof of identity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has eight staff in total, four full time and four part time, there is one full time vacancy at present and the recruitment advertisement is to be published before the end of March. The home uses few agency staff relying mainly on bank staff employed by the organisation. The bank staff regularly work in the home and know the routines Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 22 of the home and the needs of individual residents. Some agency are used but these are specially requested staff who know the service. On the day of the visit one bank and one agency staff were on duty with the manager, they were observed to be enthusiastic in their work and had excellent interactions with the residents. They were both spoken with and were knowledgeable about the individual residents and the home. The home has a minimum of two staff on duty during the daytime and a sleep in person. Currently there is a waking night staff because the emergency call bell system is not working. The manager uses a ‘buddy’ system (that is volunteers from a local charitable organisation) to ensure that residents can access activities and events in the community in the evenings and at weekends on a 1:1 or 1:2 basis. Staff records for two staff were seen and included all the necessary information to ensure that they are safe except for ‘proof of identity’, which was not available. Residents are involved in the recruitment process and are helped to formulate questions to ask candidates in an interview situation, four of the eight residents choose to get involved in the recruitment process. Permanent staff have completed all the necessary core training such as health and safety, protection of vulnerable adults and medication administration and some vocational training courses such as epilepsy, effective communication, diversity and equality and person centred planning. Four of the eight staff have an N.V.Q.2 or above qualification. The manager confirmed that there is an induction system, which is recorded, but this is being developed further and the paperwork has not been completed yet, it is still at head office, therefore no inductions were seen. Staff are supervised regularly and supervision notes showed that they included discussions on performance, necessary areas of development and day-to-day practice. They showed that the manager takes action, as necessary to help people to improve their performance and practice. Bank staff are not included on the training programmes and as they are integral to the effective running of the home this needs to be considered by the organisation. The two staff spoken to said that it was a very good home to work in, they felt well supported by the manager, they said it is ‘a very positive place to work’ and the team works ‘closely together’. Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use the service experience good quality outcomes in this area. The home is managed in the best interests of the residents, with their full involvement and people are kept as safe as possible from accident or injury. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for several years, she has been a manager for 10 years overall. She has a diploma in health and social care and has four modules left to complete of her Registered Managers’ Award. The manager has 20hours per week allocated for management work but explained that the home has suffered from staff shortages and her own ill health, the care has not been compromised but some of the administrative Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 24 work is just ‘getting back on track’, the home has recently appointed a new deputy who will share some of the managerial responsibilities. The two staff spoken to said that they felt well supported by the manager and that residents were given a good standard of care by a team that ‘worked closely together’. Residents said that they ‘liked’ the manager and they could always talk to her about anything they were worried about. Positive interactions were noted between the manager and residents and the manager and the staff team. The organisation has developed an ‘on-line’ Quality attainment system to monitor the quality of care offered by their residential homes and this new system is to be completed by the manger during March 2008. It consists of a document that is completed by residents, their families or friends/advocates and outside agencies such as medical professionals and social workers. The results will be analysed and a Yearly Quality Attainment Plan will be developed (annual development plan.) A copy of the plan will be sent to everyone who has contributed to it. Other Quality assurance systems include regular residents meetings and regulation 26 visits. There is evidence that staff take action if residents express dissatisfaction such as the garden or have requests such as a long weekend break that was arranged for the whole house. A sample of Health and Safety documentation was seen and information from the Annual Quality Assurance Assessment was used to evaluate this area. All checks were in place and a monthly Health and Safety audit is completed monthly, this has been regularly completed since November 2007. The manager confirmed that all COSHH statements are up to date and a minimum of hazardous products are used. Accident and incident recording is detailed, the person who was admitted to the Accident and Emergency ward was suffering from an illness and this was promptly responded to. Two incidents have been recorded since the last inspection, only one relating to residents (the other a security issue). Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19(b) Requirement To obtain all the information listed in schedule 2 of the Care Homes Regulations, including proof of identity, to ensure that staff are safe to work with the residents in the home. To ensure that all staff who work in the home, including those who do not work permanently in the home, are appropriately trained and qualified so that they are able to properly meet the personal needs and health and safety requirements of the residents in their care. Timescale for action 01/05/08 2. YA35 18.1(c) 01/12/08 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 YA2 Good Practice Recommendations To produce a clear and detailed admission policy and procedure describing the responsibility of the manager for appropriate admissions to the home, including a method of evidencing how the home will meet the individuals’ needs. DS0000011278.V359400.R01.S.doc Version 5.2 Page 27 Osborne House 2. YA9 3. YA24 To review the amount and detail of current risk assessments and increase and change them, as necessary to ensure that people are helped towards independence as safely as possible. That they review the external garden areas and improve them so that residents are able to make full use of them to enhance their lifestyle. Osborne House DS0000011278.V359400.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 Osborne House DS0000011278.V359400.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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