Inspection on 10/09/08 for Wadeville Hostel

This is the latest available inspection report for this service, carried out on 10th September 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wadeville Hostel 20/10/06

Wadeville Hostel 27/02/06

Wadeville Hostel 06/09/05

Wadeville Hostel 10/02/05

Wadeville Hostel 31/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/11/2008.

CARE HOME ADULTS 18-65 Wadeville Hostel 2a and 2b Wadeville Close Upper Belvedere Kent DA17 5ND Lead Inspector Ms Pauline Lambe Unannounced Inspection 10 September 2008 09:25 th Wadeville Hostel DS0000037846.V366474.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 Wadeville Hostel DS0000037846.V366474.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. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wadeville Hostel Address 2a and 2b Wadeville Close Upper Belvedere Kent DA17 5ND 01322 432998 01322 440663 wadeville@mcch.org.uk www.mcch.co.uk MCCH Society Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manager post vacant Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 13 17th August 2007 Date of last inspection Brief Description of the Service: In December 2002 this home varied its registration and changes were made to the configuration of the home. The home is now registered for thirteen residents with a learning disability, two of whom may be over 65 years of age. The service provides 24-hour support with a sleep in arrangement and waking night support. The house is split into two separate units with seven bedrooms in 2a and six in 2b. Each unit has a kitchen/dining room, lounge, bedrooms, toilet and bathing facilities. The garden is a shared area for both units and is shared with people in the on site supported living accommodation. Daytime opportunities are provided through the day services previously operated by Bexley Council but now managed by MCCH Society Ltd. The Community Learning Disability Team provide specialist health and social input. Information on the current fees are £847.00 per week and residents contribute £98.60 per week. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The site visit for this unannounced inspection was undertaken on 10th September 2008. The acting manager was in charge of the home and with residents and staff assisted with the inspection. The last key inspection was carried out on 17th August 2007. Since the key inspection one random inspection were carried out on 6th February 2008 to assess compliance with requirements made at the key inspection. The inspection process included a review of the information held on the service file, a review of the information provided in the annual quality assurance assessment (AQAA), a review of satisfaction surveys returned by three residents and two members of staff. The Commission does not currently send surveys to relatives and as no relatives were seen during the site visit no feedback was received from them, however the home had sent out satisfaction surveys to relatives and others and these were reviewed. Time was spent in both units inspecting care, safety, relevant records, talking to residents present and when they returned from day centres and staff and viewing the environment. Currently an agency manager was in charge of the service and was supported in his role by a deputy manager working two days a week. The manager presented as committed to the role and had built up relationships with staff and residents. This home has not had a registered manager for a long time and has had frequent manager changes. Residents and staff would benefit from a period of manager stability. However the work undertaken by the current manager and the deputy have improved the service. Residents and relatives were satisfied with the quality of care provided, the environment, staff attitude, access to activities and holidays and the meals provided. Standards in the home had noticeably improved since the last inspection. What the service does well: Satisfactory information was provided about the service to assist prospective residents and their family to make a decision about admission to the home. Residents were admitted to the home based on an assessment of need. Care plans provided adequate guidance for staff on resident’s needs and how these were to be met. Efforts were made to involve residents with care planning, risk taking and making decisions. Risk assessments were up to date and kept under review. Resident’s healthcare needs were met and medicines were safely managed. Staff supported residents to take part in appropriate activities both in the home and in the local community. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 6 Staff treated residents with respect and involved them with decisions about their lives, holidays, meals, bedroom décor and other aspects of the service. Outcomes for service users were good and feedback received from relatives in the satisfaction surveys sent out by the organisation showed that they were satisfied with the quality of care and support provided. Complaints and safeguarding adults were well managed. Adequate staffing levels were maintained. Attention was given to providing a safe environment. The environment was clean tidy and homely. 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. Wadeville Hostel DS0000037846.V366474.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 Wadeville Hostel DS0000037846.V366474.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): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information was provided for people about the service. New residents had the opportunity to visit the home prior to admission. Residents were admitted to the service based on the outcome of a pre-admission assessment. EVIDENCE: The statement of purpose had been reviewed and amended to ensure it complied with regulation. Residents received individual copies of the service user guide. Prior to admission prospective residents were encouraged to visit the home, spend time with staff and other residents and have overnight and weekend stays. This was to help them make a decision as to how the service would meet their needs and lifestyle. Since the last key inspection one resident was admitted. The learning disability team (LDT) provided a detailed assessment of the person’s needs. The resident had spent time in the home prior to admission and their family was involved in the admission process including personalising and furnishing the bedroom. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual support plans were prepared for residents. Residents were supported to actively participate in the day-to-day running of the home and make personal decisions. Resident’s were supported to take risks based on assessment. EVIDENCE: Twelve residents were living in the home at the time of this inspection. Care records for two people were inspected. Due to the many manager changes in this service staff struggled to keep up to date with constant record changes. The current care plan format was considered repetitive and could be more streamlined to ensure staff keep them up to date. This was discussed with the manager who agreed the format should be reviewed. Both sets of records seen included care plans, risk assessments and detailed information about the person’s needs and lifestyle. Risk assessments were completed in relation to bathing, going out alone and using public transport. Relevant care plans were prepared to show how identified needs were to be met and provided good Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 10 guidance for staff. ‘Pen pictures’ were written of the residents and these provided very good guidance for new or temporary staff. None of the care plans seen were signed or dated so it was not possible to know when or who wrote them. There was also no evidence to show that care plans were reviewed. Feedback surveys sent by the organisation to relatives were seen and these showed that generally people were satisfied with the quality of care provide. Comments made included “it is home from home”, “residents are very well looked after” and “every need is met”. Requirement 1. From talking with residents and staff and reviewing records it was evident that people were supported to make personal choices and decision about their lives. Residents were encouraged to be involved with life in the home by maintaining the garden, food shopping, preparing, cooking, planning and serving meals, laying and clearing tables, washing and ironing their own clothes and bed linen. Most of the residents were able to go out alone and had travel passes to enable them to make the most of local facilities and to spend time in the local community. Residents were encouraged to suggest ideas for activities and holidays. Individual support plans were prepared with residents so that their preferences were addressed. Residents were very proud of the garden, which looked very nice with blooms, tomatoes and beans growing. They also enjoyed picking unusual plant containers. Residents were encouraged to develop particular interests for example cooking, art and involvement in musicals. As mentioned risk assessments had been written for all residents as needed and were up to date and signed. Personal decisions about a person’s lifestyle were made based on risk assessment. When a risk was identified staff worked with the person to reduce the risk so that they could be involved in the activity of their choice. For example areas considered included access to the kitchen, participating in cooking, safety when out in the community and safety in relation to mobility. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported to take part in leisure and social activities of choice both in and out of the home. All residents had an annual holiday this year and were supported to keep in touch with family and friends. The choice and variety of food provided in the home was good. EVIDENCE: Care records seen included a social history of the resident and their weekly activity programme. The activity programme included attendance at the day centre and commitments or regular leisure activities the resident was involved with such as attending church weekly. Residents were able to take time off from the day centre if they wished but staff said they enjoyed going to the centres and only took a day or a half-day off each week to complete personal domestic chores, spend one to one time with their key worker or to attend appointments. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 12 Staff supported and encouraged residents to access local facilities and leisure activities such as attending club evenings and discos, swimming, pub lunches and cinemas. Activities such as parties, BBQs, games and film nights were arranged in the home and residents were encouraged to invite family and friends to these events. All residents had an annual holiday this year. One resident in the home during the inspection was excited about their forthcoming holiday and their key worker was helping them to pack. Residents regularly spent holidays at Camber Sands and staff said they enjoyed these breaks very much. Prior to this inspection MCCH had a celebration of their years in business and all of the residents attended. On return from the day centres residents were keen to talk about the event and to look at photographs the manager had taken. The residents and staff were very proud of a cake they had made for a competition as part of the celebrations. Daily diaries seen showed what leisure activities the person took part in. For example from the records seen one person had spent time on home visits, been on a 4 day holiday, and took part in activities in the house such as puzzles and sing-along sessions. Another person had attended church, the two-weekly social club and spent time listening to music or watching T.V. Residents spoken with either said or indicated they were happy and settled in the home. Staff were observed welcoming residents on their return home from the day centre. Residents were encouraged to talk about their day, have a warm drink and were free to do whatever they wished such as watching TV, going to their bedroom or staying in the dining area. Staff were very knowledgeable about residents and their needs, moods and preferences. Staff spoke about and to residents in a respectful and inclusive manner. Key workers played an important role in the resident’s lives and worked with them and where possible their family to ensure their needs were met and that they had a lifestyle suited to them. Residents were supported to maintain contact with family and friends. Relatives were welcome to visit the home, to take part in planned activities or to have residents home for visits. Residents made friends through attendance at day centres and the two-weekly social club evenings. Staff prepared weekly menus with the residents and encouraged residents to be involved with food shopping and meal preparation. Menus seen showed that a varied diet was provided. Bowls of fresh fruit were available in both unit lounges and residents could help themselves to this. Adequate stocks of fresh, frozen and dried foods were seen. Food was stored correctly and temperatures of fridge and freezers monitored. Residents had their meals in the dining area and were supported to help themselves to breakfast and lunch at times that suited them. Residents did not raise any concerns about the food provided and some indicated staff cooked nice meals. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 13 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): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff ensured resident’s emotional, health and personal care needs were met. Satisfactory systems were in place to manage medicines. EVIDENCE: Records seen included individual support plans to show what personal support the person needed and how this was provided. The support plans were prepared with the resident where possible. Staff spoken with provided details of resident preferences and how personal support was provided in line with resident choice, wishes and mood. All the residents had a named key worker who met with them regularly on a one to one basis to discuss individual goals and personal choices and to ensure these were addressed in support plans. Residents were supported to attend and be involved with meetings about their care, health and future to ensure involvement with decisions about their lives. Where appropriate relatives, advocates and staff were involved. A number of residents did not have family or advocates to speak on their behalf. This was discussed with the manager who agreed to refer residents to the advocacy service. However from time spent with staff it was apparent that if needed Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 14 they would act as an advocate for the person. Residents were supported to access healthcare from the GP, dentist, district nurse, psychiatrist, and chiropodist and to attend hospital appointments. Records were kept of these visits and guidance on care received was included in the person’s care plan. Comments received in the feedback surveys included “residents healthcare needs are met”, “residents get very good care” and “ the person’s mental and physical health has improved since admission”. Recommendation 1. Medicine management was reviewed in both units and was generally well managed. A medicine policy and procedure was provided and was reviewed on 22/3/07 and satisfactory systems were in place to manage medicines for social leave. Storage facilities were satisfactory and records were kept for receipt, administration and disposal of medicines. Internal and external medicines were stored separately. Medicines were supplied in blister packs and individual containers. Administration charts seen were well completed but two members of staff had not signed hand written entries they made on the charts. Medicine profiles were prepared for residents but required some amendments and this was discussed with a senior support worker. The manager had started assessing staff competency in relation to medicine management and was aware that this had to be done annually for all staff. Medicine records and supplies were checked for 3 people and were correct. Some residents were prescribed ‘as required’ medicines but protocols for administration of these had not been written. No controlled drugs were in stock on this occasion. Training records seen showed that since the last inspection some of the staff team had attended training on medicine management. Requirement 2 and recommendation 2. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 15 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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems were in place to manage complaints and to safeguard residents and their personal finances. EVIDENCE: A complaints policy and procedure was provided and a copy provided in ‘easy read’ for residents. A system was in place to record complaints made about the service. From information provided in the AQAA no complaints had been made about the service in the last year and no complaints or concerns were made to the Commission. No concerns were raised by residents or in the feedback received in relation to complaint management. A safeguarding adults policy and procedure was provided. Since the last inspection no allegations or suspicions of abuse were reported. Staff spoken with had a good understanding of safeguarding adults and their role in managing this. Safe systems were in place to manage resident’s money. A safe was provided to store money and records were kept for money received and spent by or on behalf of residents. Training records seen showed that all the staff had receive training on safeguarding adults on 15/7/08 Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 16 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): Standards 24, 25, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained to a satisfactory standard and all parts of the home seen were clean, tidy and odour free. Adequate bathing facilities were provided and bedrooms seen were nicely decorated and personalised. EVIDENCE: The home was maintained to a satisfactory standard and all parts of the home seen were clean, tidy, odour free, homely, welcoming and comfortable. Large flat screen TVs were provided in the lounges. Comments made by residents and staff and comments seen in relative feedback indicated that it took a long time to have repairs carried out. During the inspection a maintenance person was in the home. He said that staff recorded repairs and health & safety issues in a book and when he visited, which was a couple of times a week, he did the repairs where possible. It was suggested that he dated the record when the repair had been done to provide evidence as to how long it was taking to do repairs. Recommendation 3. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 17 Bedrooms seen were nicely decorated and furnished and personalised. Personal clothing was nicely laundered and stored. A programme was currently in place to redecorate bedrooms and this was done with the involvement of the occupant. Some residents were keen to have their room redecorated and some did not want this done. Where possible residents views were respected in relation to this work. One resident invited the inspector to their room to view a video of a musical they were involved in at the day centre. The residents said he liked his room and was happy in the home. Adequate bathing and toilet facilities were provided and those seen were clean, tidy and well ventilated. The manager said that there had been a problem with maintaining hot water temperatures and management had agreed to fit new thermostats to all hot water outlets. This will be reviewed at future inspections. All areas of the home seen were clean and tidy. Overall a high standard of hygiene was maintained throughout the home. Staff and residents worked together to keep the home clean and tidy as no domestic staff were employed. Liquid soap and hand towels were provided to ensure hand washing was practised. Care was taken with washing, ironing and storing resident’s personal clothing to ensure residents were always well presented. Key workers helped residents to do their laundry on their day off from the day centre. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 18 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): Standards 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Over 50 of support staff had achieved NVQ level 2 or above. Staff training had improved greatly. Some improvements were needed to the evidence provided relating to information obtained for staff at the time of recruitment. EVIDENCE: Information provided in the AQAA showed that 11 support staff were employed, 6 people had NVQ level 2 or above and 2 were currently undertaking NVQ 2 qualification. The home met the standard set by the Department of Health to have 50 of care staff with a vocational qualification in care. Staff rosters seen showed adequate staffing levels were maintained. Three support staff were on duty during the day and two waking staff at night. If an activity was planned whereby additional staff were needed this was arranged. The manager hours were in addition to the support hours provided. The Organisation’s human resources department recruited staff. Some time ago the Commission agreed that employee records could be held centrally and a form used to evidence that all of the information and checks required by regulation had been completed and for this to be kept in the home and Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 19 available for inspection. Since the last inspection a new format was being used to record recruitment information but this did not show that references received had been verified as genuine or if there were gaps in employment. However efforts were being made to hold the files or copies of them in the home. Three employee files were viewed and some information required by regulation was included but not all. For example there were no application forms so it was not possible to know if references received had been verified or were from the last employer if the post involved working with vulnerable people and there was no evidence of health statements. The files seen included start dates, designation, evidence of CRB checks, a recent photograph, proof of identity, training and supervision. The manager agreed to discuss this issue with senior management and work towards resolving the problem, as it has been an on-going issue in the home. Requirement 3. Since taking up post the current manager had taken steps to address staff training. Staff training needs were identified through supervision and discussion with individuals. The Organisation’s training department provided a monthly programme of training courses and a training directory. Training records seen showed that since the last inspection staff had received a lot of training and update training. For example staff had attended sessions on topics such as basic food hygiene, medicine management, risk assessments, infection control, first aid, care planning and all staff attended training on safeguarding adults and fire safety. Staff spoken with confirmed they had attended a lot of training courses relevant to the work they did. The training records seen for 9 staff showed that most of them had received 3 days training in the last year. A system was in place to provide staff supervision. Staff had a supervision agreement and the manager said that this was working on improving this area. Currently the manager supervised all staff. Records were seen for 3 members of staff and showed that supervision sessions had been held but not regularly. Recommendation 3. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 20 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): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has not had a registered manager for some time. Systems were in place to monitor the quality of the service. Records seen showed that a safe environment was provided for residents and others. EVIDENCE: Since the last inspection there had been a change of manager. The current manager had been in post for about 6 months. Prior to this a deputy manager was in charge of the service working 2 days a week. This service has suffered from lack of stability with management however management of the service overall had improved since the last inspection. Residents and staff would benefit from having a stable period of management. Some of the staff team had been in post for some time and provided stability and continuity of care for residents. Residents presented as relaxed, comfortable and readily approached staff on duty. The manager had an ‘open door’ policy for staff and Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 21 residents and it was reassuring to see residents going to the manager’s office on their return from the day centre. This service has not had a registered manager for a long period. Requirement 4. A quality assurance system was in place but due to manager changes this was not fully adhered to. A satisfaction questionnaire was sent by the organisation to relatives and others prior to this inspection. Responses were seen and indicated that in general people were satisfied with the service. However frequent staff changes was raised as an issue. The manager was aware of the need to implement the quality assurance system and together with relative, resident and staff feedback prepare a report on the service and if needed prepare an action plan for improvement. Once the report was completed a copy must be sent to the Commission. Progress with implementing the new quality assurance system will be reviewed at the next inspection. Visits were made to the service as required by regulation 26 and reports were available to view. Resident meetings were held to obtain feedback and suggestions about the service. Minutes were kept and were seen for the last meeting held on 26/8/08. The manager met regularly with the staff team to keep them informed and involved with any changes to the way the service was managed. Health and safety records were viewed including fire safety, electricity and portable appliance testing. All records seen were up to date. Fire safety records seen showed the alarm system and emergency lights were serviced on 18/07/08 and the system was tested weekly. A fire risk assessment and evacuation policy was provided. The last fire drill held during the day was on 14/4/08 and at night on 30/6/08. Training records seen showed that all of the staff had received fire safety training since the last inspection. Accident records seen were well maintained and showed that following accidents residents received appropriate care. Incident records were also maintained and were well completed. Three medicine errors were recorded in the incident records and one of these was not reported under regulation 37. Requirement 5. Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 4 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 2 3 Standard YA6 YA20 YA34 Regulation 15 Requirement Timescale for action 03/11/08 29/10/08 03/11/08 4 OP31 5 YA42 Care plans and records must be signed, dated and must provide evidence that they are reviewed. 13 Two people must sign hand written entries made by staff on medicine administration charts. 19 The agreed form used to record recruitment must show that checks are completed in full for all members of staff and kept in the home for inspection. (Timescale of 21/03/08 was not met). Care The person managing the service Standards must register with the Act 2000, Commission to ensure Part II (11 compliance with this section of – (1)) the Care Standards Act. The Commission must be informed in writing of the action taken to comply with this requirement. 37 Management must ensure that notifications are sent to the Commission in line with the requirements of this regulation, including reporting medicine errors. 03/11/08 29/10/08 Wadeville Hostel DS0000037846.V366474.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA19 YA20 YA24 YA36 Good Practice Recommendations Residents without family support should be referred to the advocacy service. A protocol for the administration of ‘as required’ medicines should be prepared to ensure all staff know when and why to administer the medicine. The maintenance person should record the date repairs are completed in the maintenance book. Efforts should be made to provide staff supervision in line with the requirements of this standard. Wadeville Hostel DS0000037846.V366474.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 Wadeville Hostel DS0000037846.V366474.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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