Inspection on 12/03/07 for 1 Whitehall Road

This inspection was carried out on 12th March 2007.

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 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

1 Whitehall Road 27/02/06

1 Whitehall Road 06/12/05

1 Whitehall Road 10/03/05

1 Whitehall Road 19/11/04

1 Whitehall Road 01/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 1 Whitehall Road, Cradley Heath West Midlands B64 5BG Lead Inspector Mr Jon Potts Unannounced Inspection 12th March 2007 09:55 1 Whitehall Road, DS0000004843.V325350.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 1 Whitehall Road, DS0000004843.V325350.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. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Whitehall Road, Address Cradley Heath West Midlands B64 5BG 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) 01384 357933 NONE info@Inshoresupportltd.com Inshore Support Mr Adam Webb, Mr Ian Forrest-Jones Mr Andrew Perkins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/2/06 Brief Description of the Service: 1 Whitehall Rd is an adapted terraced property that was refurbished for the purpose of providing long term care for three younger adults with a learning disability. The house is positioned in an established residential area within walking distance of the centre of Cradley Heath. Accommodation briefly comprises of three single bedrooms (two which are ensuite), bathroom, two lounges, dining room and kitchen. The building has a small rear garden area. The home is managed by Inshore support, a company that has a number of small homes that have similar aims and objectives to Whitehall Road. The staffing in the home consists of a manager, senior support and support workers. The staffing ratio is at least one staff member to one resident at day and night, although this is higher for support within the community. The home has an appropriate cars allocated for the transport of the residents. The current charges range between £2117.89 to £2621.84 per week, with the only additional charges relating to personal requirements such as hairdressing, clothing etc. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day and involved the inspector assessing the homes performance primarily against the key national minimum standards for younger adults. Evidence was drawn from a number of sources and included case tracking the care for two of the three residents (this involving looking at all the documentation in respect of their care and cross checking this with outcomes), observation of practice, discussion with the registered manager, staff and review of management records. There was limited discussion with the residents, although one was present for most of the inspection. Information was supplied pre inspection by the home and included questionnaires completed by staff with the residents. The residents and staff are to be thanked for their assistance with the inspection. What the service does well: What has improved since the last inspection? The most significant improvement is the homes introduction of a robust tool for self-monitoring, this clearly allowing the home to identify where the service performs well and where improvement is needed. Routine and robust monitoring by the company forms an integral part of this quality tool. The home now has a registered manager, which has lead to more stable leadership of the home. There has been some and is more planned works to maintain the presentation of the environment. It was also noted that the commenced development of person centred plans (that are more image and picture focused) is a positive step to further involving residents in planning their day-to-day care. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 6 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. 1 Whitehall Road, DS0000004843.V325350.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 1 Whitehall Road, DS0000004843.V325350.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): 1,2,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information on the service, sufficient to allow them to choose a home that meets their needs, is available to current and prospective service users but not always in appropriate formats. Prospective people looking to use a service have their needs and aspirations assessed, and are able to ‘test drive’ the service prior to admission. EVIDENCE: The home has not admitted any service users since the time of the last inspection although there was discussion with the manager as to the process of admission, this building on discussion at the time of previous inspections. The homes procedures on admission also supported the expectations of the national minimum standards. The manager clearly understands the importance of having sufficient information available for a prospective service user when choosing a care home. There was information available although it was not clear as to how much of this could be clearly understood by the residents, this as the 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 9 statement of purpose/service users guide were only available in written English. It was stated that thought is been given to developing these documents in other formats (such as pictorial) although it is acknowledged that in some instances support would need to be given through the assessment process to explain important information verbally in a format appropriate to the residents needs. Admissions are not made to the home until a full needs assessment has been undertaken. All the residents accommodated are funded through care management arrangements and there were assessments available for all current residents in addition to social services reviews for some residents (updating the original assessment’s information) and the homes own assessments processes. Any assessment for a new service user would be conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Such an assessment would be carried out by an experienced member of the management and involve members of the staff team, this at the service user’s present location with staff working alongside them where possible. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment/care plan. The manager stated and the procedures confirmed that prospective individuals are given the opportunity to spend time in the home with day visits extending to overnight stays. Practice and information giving is informed by the services written procedures. New residents are provided with a Statement of Terms and Conditions/Contract (called a lifestyle agreement); this sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. This is clear, jargon free, easy to understand and gives a very clear understanding of what residents can expect and there was evidence that some work has been taken to present this in a number of pictorial images, although again time would need to be taken to explain the document at the service users pace and understanding. Communication needs are clearly recognised as critical by the home based on the input around this area in their care plans. The manager stated that opportunity for discussion and clarification would be promoted, in accordance with a resident’s communication needs. 1 Whitehall Road, DS0000004843.V325350.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 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The majority of residents individual needs are reflected in care planning documents and their ability to make safe decisions are measured though the assessment process. The residents are encouraged to take a degree of risk as part of a lifestyle that would reflect their individual abilities and choices. EVIDENCE: Whilst care plans are not currently developed following person centred planning principals at present staff have received training in this area and are developing this approach, this at the pace of the residents who have in cases profound communication difficulties. Each resident however has a plan that has as far as is possible been agreed with him or their representative (for example parent or social worker) when consideration is given to communication difficulties. Plans are currently in written format and consider significant areas of an individual’s life although do need some development to provide more information in respect of activities that builds on the comprehensive activity 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 11 plans the home has, this to justify the reasoning behind the participation of the residents in these, for example going for a walk could be related to health promotion, stimulation; shopping at the supermarket could be related to the promotion of choices in respect of diet etc. The care plan seen was detailed in respect of other areas of need however and covered the full range of the service users needs which the exception of the aforementioned in detail from behavioural strategies through to personal preferences and communication. Discussion with the staff and the manager evidenced that they were clearly aware of the requirements of the care plan and observation of the staff interacting with the residents provided further evidence that it is used to inform planned and positive practice. There was evidence of regular reviews of the plans by staff and in cases through involvement of the funding body and representatives for some residents. The manager was clear there had been some difficulties organising multi disciplinary reviews for some residents and he was trying to arrange these with the appropriate social service departments. Due to difficulties with communication the home has employed varied assessment tools to identify where residents are able to be independent and where the service may limit their choices. Where there are limitations these are recognised through the homes risk assessment processes, with agreement by such as social workers on behalf of the resident, this due to difficultly communicating these. The recognised limitations to the one service user had been clearly documented and drew from the aforementioned assessment tools. The tool used for overall assessment did easily identify areas where there was judged to be a high risk through colour coded outcomes. The home has commenced holding regular key worker meetings where participants discuss the resident’s likes and dislikes, and issues in respect of consent, this to assist with person centred planning. These meetings are well documented and the records are useful in showing the resident’s progress towards set goals in care plans. 1 Whitehall Road, DS0000004843.V325350.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): 12,13,14,15,16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and are supported to maintain and develop their life skills. Social, educational, cultural and recreational activities are provided in accordance with the individual’s known needs, choices and expectations. EVIDENCE: Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community appropriate to their peer group, and to enjoy where possible the rights and responsibilities of citizenship. The staff and manager in discussion understood the importance of enabling the residents to maintain their independence and exercise their choices. This allows them to achieve their goals, follow their interests and be integrated into 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 13 community life and leisure activities in a way that is directed by the person using the service, this based on assessing their likes and dislikes through assessment and reactions to situations. Staff spoken to had a good grasp of what individual residents body language and behaviour indicated, and how this influenced their approach towards situations. Residents at the home are able to enjoy a full and stimulating lifestyle with a variety of options to choose from, this summarised in an activities plan that is available in a written/pictorial format. The plan is available to the residents within the home and reflects activities that combined leisure, exercise and involvement in domestic routines. Routines are flexible and resident’s choices are reflected in the care plan. The activities and plans are resident focused, and can be quickly altered to meet individuals changing needs and the effect of such as residents choices on particular days which would impact on the activities they may be involved with. Ways in which staff communicate with residents is clearly detailed in plans and is understood by staff and followed as was seen to be the case through observation. The home actively encourages varied opportunities for people using the service to maintain social contact, this through supporting contact with family (as a part of the residents weekly routine) and others through such as weekly discos. The development of person centred plans are seen to be key in focusing on the involvement of residents in all areas of their life, and actively promotes the rights of individuals to make informed choices, providing links to specialist support when needed. The service actively supports people who use services to be independent and involved in all areas of daily living in the home, with staff seen to encourage residents to make drinks with them as opposed to staff making drinks for them. This includes where appropriate, having involvement in domestic tasks that are the residents are able to complete safely such as clearing the dining room table, cooking, helping to wash the car, shopping and so on. Keys are not currently provided for residents, this reflected in risk assessments. Meals are well balanced and nutritional and cater for likes and dislikes of the residents at the home with an emphasis on balancing what is a healthy diet against the resident’s favourite foods. The staff have completed nutritional assessments in respect of the residents with outcomes as to actions needed detailed. All meals taken by the residents are documented and their likes and dislikes were reflected within the choices documented in these records. For those individuals who need support during mealtimes, including those who have swallowing or chewing difficulty staff give assistance in accordance with clear documented strategies, understood by the staff. Mealtimes are flexible. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs and in accordance with care plans. Staff promote the principals of respect, dignity and privacy and the management of medication is efficiently carried out. EVIDENCE: Personal healthcare needs including specialist health and dietary requirements are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. Discussion with staff and observation indicated that personal support is responsive to the varied and individual needs and preferences of the residents, in accordance with care plans. This means that the delivery of personal care is individual, flexible, consistent, reliable, and becoming more person centred. Staff were seen to treat residents with dignity and were aware of the need to be sensitive to changing needs. The staff team is diverse in terms of culture 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 15 and gender and there is scope to reflect the gender of the carer in terms of the resident’s personal choices. Residents are encouraged as far as possible to be independent and take responsibility for their personal care needs as far as possible, although there were some limitations due to residents assessed abilities. Residents were seen to be able to have the ability to wander freely around the home as they choose although staff were seen to be observant to times when they needed assistance. People who use services have access to healthcare and remedial services, and staff make sure that those residents who are fit and well enough are encouraged to have regular appointments at the local health care services. The health care needs of residents when unable to leave the home are managed by visits from local health care services. Staff have access to training in health care matters and are encouraged and given time to attend training on specialist areas of work, including autism, epilepsy, mental health and the administration of stesolids. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. There is documentation to support the safe administration of medication available to staff including photographs of the medication residents are taking and information on side affects. People who use services are risk assessed as unable to administer their own medication, and the home was seen to have obtained consent for medication from professionals representing the resident. Thought has been given to providing safe but appropriate facilities for keeping medication, based on the domestic nature of the home. Staff that administer medication have completed and passed an appropriate accredited medication course. In addition the manager carries out assessments to ensure each member of staff is competent to handle, record and administer medication properly. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 16 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): 21 & 22 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Stakeholders in the service are made aware of the complaints procedures and invited to express their concerns through this robust and effective procedure. Staff are aware of the need to be vigilant to residents expressions of dissatisfaction and there are strategies in place to protect them from abuse. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It is also available in a pictorial format and the written version of the procedure is sent to parents annually with questionnaires in respect of their views of the service provided. Staff spoken to were aware of the need to monitor residents behaviour for signs of dissatisfaction and all those spoken to were aware of the homes and the local authorities procedures in respect of adult protection, and the steps they should take if concerned as to practices within the home. There have been complaints from neighbours about noise since the last inspection, these fully investigated by the responsible individual and registered manager. The fitting of double-glazing to the rear of the house is partly is response to these issues. The policies and procedures regarding protection of individuals are of a high quality and are reviewed annually and updated. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 17 Training of staff in the area of protection is regularly arranged by the Home and the majority have received training. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. The home employs behaviour strategies that may involve restraint as a last resort and the majority of staff (all but one) has training in MAPA (Managing Actual or Potential Aggression). All restraints are fully documented on ABC charts and also within incident reports that detail events leading to restraint and the exact actions taken. Any injuries are fully documented on body maps. The strategies employed are in accordance with detailed care plans related to behaviour management and in the first instance the emphasis is on the use of redirection techniques rather than physical restriction. The use of as needed medication to manage medication was clearly understood by staff to be a form of restraint and any decision to administer this was in accordance with clear protocols. Based on discussion with the manager and staff the residents are supported by an organisation that has resident’s protection and safety as a priority. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment that allows independence. EVIDENCE: The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the residents who live there. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable. Whilst there are some limited areas where refurbishment is required this has been identified by the provider through regular audits and plans are in place to address any issues. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 19 Residents are encouraged to see it as their own home. It is a very well maintained, attractive home, which is accessible to community facilities and services. There are some adaptations in place to meet individual residents needs such as the provision of radiator guards. The home is designed to provide small group living where residents can enjoy maximum independence in a discrete non- institutional environment that resembles a domestic dwelling. Residents are encouraged to be involved in decisions about the décor and any changes to the accommodation. The home provides only single room accommodation. The rooms are very well planned and there is easy access to toilet and bathing facilities. The fixtures and fittings are of a high quality, well maintained and adapted to meet the known wishes of the present service users. Individuals are able to personalise their rooms and bring in their own possessions and furniture if they wish. There are two communal lounges as well as the dining area, this meaning that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. The bathrooms are homely and include aids and adaptations to meet the current needs of the residents. There was evidence from water temperature records and checking the hot water supply that there is always plenty of hot water and the temperature in the home can be changed to meet their personal choice. The home was very well lit, clean and tidy and smelt fresh. The management has a proactive infection control policy and staff understand how to manage infection and maintain a safe and clean environment. Risk assessments and items necessary to support infection control were seen to be available (such as liquid soap and paper towels). 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are well trained, skilled and motivated as well as available in sufficient numbers to effectively support the people whose home they work in. EVIDENCE: Residents appeared comfortable around the staff that care for them and observation indicated they were treated with respect by staff and in accordance with care plans. Rotas showed that staffing levels are maintained so as to ensure staff to resident ratios are not compromised, this consistent with the numbers of staff seen to be present on the day of the visit and examination of the rotas. There have been some issues with one resident not attending day centre although staffing arrangements have been altered to compensate for this, with the staff or the manager working overtime. The resident group is currently all male and the gender mix of the staff group does reflect the need for male staff to allow for the residents choices. The company does not use agency staff, but where necessary may offer overtime to support staff, or gaps maybe covered by the manager. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 21 Staff members sometimes undertake external qualifications beyond the basic requirements; this targeted and focussed on improving outcomes for residents. Based on the homes training plan and some sampling of certificates the staff are overall well trained although there were areas identified where staff needed input in specific areas this including Equality and Diversity training and NVQ 2. There has been a significant input into NVQ training with one staff now holding an NVO level 2 qualification and four near completion, this expected in March 2006. Two other staff are now also enrolled, which should lead to the home, based on reasonable assumption, having the minimum expected proportion of qualified staff within 6 months assuming there is no staff turn over. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. There was evidence from observation and discussion with staff that they are skilled in their role, and are consistently able to meet resident’s needs in accordance with set down strategies. The service uses external providers to deliver this training if they do not have the appropriate skills within the organisation. This training can be small scale and individualised if necessary in order to promote the delivery of person centred services. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services. Whilst the residents are not involved directly in the recruitment of staff there is a robust process for regular supervision of new starters that would consider their performance and interaction with residents. There was evidence that staff new to the service received supervision in accordance with the companies induction policies, although direct evidence of the staff involvement in the induction standards was not available, but was confirmed by staff as held by them within their training and development portfolios. There was however evidence of the newer staff having attended a weeks external training giving an induction into all the necessary core skills required, this via certification of the same. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 22 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 & 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent provider. Robust safe working practices protect the residents. EVIDENCE: The registered manager has achieved the required management qualification and has appropriate experience to allow him to run the home competently and meet its stated aims and objectives. The manager has sound knowledge of how to carry out effective management of the home, communicating a clear sense of direction to staff and showing a clear understanding of the needs of the residents. There are clear support networks in place for the manager from 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 23 senior managers in the company, and the provider’s representative’s deal with tasks for which the manager may not have responsibility. The manager is seen as approachable and supportive by the staff team. The manager ensures that staff follow policies and procedures. Staff have procedural handbooks and easy access to all documents, which are discussed during supervision, staff training and team meetings. Spot checks and quality monitoring systems provide management evidence that practice reflects the homes policies and procedures. The home has very efficient systems to ensure effective safeguarding and management of individual’s money including record keeping. All the working practices in the home are safe and where there are accidents there are steps taken to ensure outcomes are considered and minimised, this through risk assessment where appropriate. The home has a full range of policies and procedures to promote and protect resident’s health and safety, and discussion with staff and the manager, as well as case tracking indicated that staff consistently follow these. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. There is a good understanding of risk assessment and this is taken into account in all aspects of the running of the home. The quality assurance system confirms that the findings from health and safety checks and management audits have been actioned and the home continuously improves its systems for health and safety, with due regard to external developments. The manager ensures that the majority of staff are trained and aware of health and safety matters and have regular planned updates. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 2 33 x 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA6 YA35 Good Practice Recommendations To continue developing key policies and procedures such as the service users guide in pictorial or alternative formats that allow easier understanding by the residents. To better detail the justification for activities within the residents activity plans so that the reasoning for outcomes for residents is clearer. To continue with the training detailed within the homes training plan, this including the provision of NVQ 2 and equality/diversity training to staff. 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 1 Whitehall Road, DS0000004843.V325350.R01.S.doc Version 5.2 Page 27 - 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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