Inspection on 05/02/07 for 10 Melbourne Road

This inspection was carried out on 5th February 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 10 Melbourne Road 10 Melbourne Road Halesowen West Midlands B63 3NB Lead Inspector Mr Jon Potts Key Unannounced Inspection 5th February 2007 10:15a 10 Melbourne Road DS0000066783.V325355.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 10 Melbourne Road DS0000066783.V325355.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. 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10 Melbourne Road Address 10 Melbourne Road Halesowen West Midlands B63 3NB TBA 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) info@Inshoresupportltd.com Inshore Support Limited Anita Webb Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First key Inspection Brief Description of the Service: 10 Melbourne Rd provides long term care to 3 adults with a learning disability, all who are currently male. The house is sited near Halesowen in an established residential area. There is easy access by car to a range of local facilities. Staff also have access to a car for transporting the residents between venues. The house is a large semi detached property that has been adapted for its current use and consists of two living rooms, a kitchen and dining area. There are three single bedrooms one an ensuite. There are sufficient bathrooms and toilets available. The main stated aim of the home is to provide a service that reflects the expectations of the residents: identifying and fulfilling their individual needs by means that are valued by society; this in order to develop and support individual and personal experiences and characteristics which are culturally valued and maintained. There is a staff group that consists of a manager, senior support and support workers. There are waking staff available 24 hours per day. The manager is responsible to a service manager and directors of Inshore support who have a number of homes of similar size and purpose. The current charges range from £2166.37 to £2996.66 per week, with the only additional charges relating to personal requirements such as hairdressing, clothing etc. 10 Melbourne Road DS0000066783.V325355.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 two half days 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 including case tracking the care for two 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 some discussion with the residents. Information was also supplied pre inspection by the home and via resident’s comments cards (that they were assisted with in some cases by the staff). 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? What they could do better: There were few areas where the home needed to improve. There are some areas of training that the manager is aware of that staff still need to complete or have provided to them, including NVQ level 2 and Equality and Diversity. Beyond this there were a few limited incidents where documentation needed to be more accurate, one in respect of a health care plan and the other in respect 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 6 of behaviour records. The review of an activity risk assessment is also advisable for one resident. 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. 10 Melbourne Road DS0000066783.V325355.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 10 Melbourne Road DS0000066783.V325355.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): 1,2,3,4,5, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective people looking to use the service, and their representatives have the information (in a standard written format) needed to choose a home, which will meet their needs. Prospective residents have their needs assessed and opportunity to test drive the service and meet other residents and staff. They also receive a contract, which clearly tells them about the service they will receive, this in written form. EVIDENCE: Significant time and effort is spent making admission to the home personal and well managed. There is a high value on responding to individual needs for information, reassurance and support. The homes statement of purpose is a specific document to the home based on a generic format used by the companies other homes (which all offer a similar service). It clearly sets out the objectives and philosophy of the home and includes a range of information about the service provided, the accommodation, staffing (experience and qualifications) how to make a complaint and so on. All residents have a copy of the statement of purpose/service user guide available to them in their case file although the use 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 9 of a more pictorial based document would be better for the current resident group. Contracts (called lifestyle agreements) were also available and these set out the basic terms and conditions of the service but again would benefit from presentation in a format that would better suit resident communication needs. Copies of the information about the home are made available to resident’s relatives. All new residents receive a full comprehensive needs assessment before admission that builds on the assessments obtained through care management arrangements, with staff carrying this out with skill and sensitivity. The service is efficient in obtaining a summary of any assessment undertaken through care management arrangements. Individuals are supported and encouraged to be involved in the assessment process with the full involvement of all relevant professionals. Information from carer’s as well as their views are taken into account. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnicity and diversity needs of the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Prospective residents are given the opportunity to spend time in the home; this on numerous occasions with a gradual build up to longer stays where appropriate. The manager or a senior would be available to give information, special attention, help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. 10 Melbourne Road DS0000066783.V325355.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. Individuals are encouraged to have involvement in decisions about their lives, and have a role in planning appropriate to their current ability and understanding and with support from the manager and staff. Care planning considers the individual’s choices and any input from other professionals. EVIDENCE: The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Management and staff understand the importance of residents being supported to, as far as possible, take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions and choices. The service user plan is developed where possible in partnership with the service user, based on an efficient assessment. The plan clearly sets out how needs will be met through positive and planned interventions. As far as 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 11 possible each resident has a plan that has been agreed with him or her and staff are currently working on person centred approaches to develop plans with service users, these to have use of photographs and images that will assist with a residents understanding. The plans are written in plain language and consider all areas of the individual’s life including health; specialist treatments, personal and social care needs. A key worker system enables staff to establish special relationships and work on a one to one basis. Key worker meetings to discuss progress that involve the service user are held monthly. Family’s views would be considered within the review of any plan. Care plans focus on how residents will develop their skills and independence with clear setting of long and short-term goals. There is also information as to which documents would contain evidence that it is carried out, to assist with any audit or review process. Whilst written in plain language service users would need support in understanding it, this through support of the staff. All members of staff regard the plan as a working tool and from discussion showed an understanding of it, with observation of practice showing that they support residents to achieve planned outcomes including independent living skills. Care plans are supplemented by comprehensive risk assessments. Management of risk takes into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, the decisions have been made with the resident and only following the staff carrying out an assessment. There are procedures in place to ensure that residents are informed of their rights to confidentiality, and may understand when staff may share information to ensure individuals are safeguarded. Residents are made aware of advocacy services and the staff do promote individuals understanding of their rights as far as this may be possible. The service is developing its approach to situations where the resident may not have capacity to give informed consent. The service is aware of current policy issues and good practice developments, and tries where possible to transfer this thinking into daily work. The home ensures that residents and their representatives are consulted on a regular basis (for example reviews and involvement in key worker meetings) to gather information about their satisfaction with how they are involved in both the development and review of the plan. 10 Melbourne Road DS0000066783.V325355.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 & 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who use services are able, with the appropriate support from staff, to make choices about their life style, and are supported and encouraged to develop their life skills. Social, educational, cultural and recreational activities meet individual’s known needs 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 all the rights and responsibilities of citizenship. The service has a strong commitment to enabling residents to develop their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 13 Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from including opportunities in the local community. They are encouraged and supported to have access to exercise (for example swimming and bike rides). The home seeks the views of the residents and considers their interests when planning the routines of daily living and arranging activities both in the home and the community. Staff were seen to actively offer choices in respect of activities to residents, giving responsibility for decision making. Routines are flexible, with any potential barriers to this documented within the care documentation following assessment. The routines, activities and plans are resident focused, regularly reviewed, and can be quickly changed to meet individual residents needs. The service actively encourages and provides imaginative and varied opportunities for residents to develop and maintain social, emotional, communication and independent living skills. Help with communication skills is given by the staff team, with strategies to assist this set down in care plans, with use of such as communication passports and specialists where appropriate. The service has a strong ethos and focuses on involving 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. This includes developing and maintaining family and personal relationships, and supporting carer’s involvement. Residents are provided with access to support with holidays by the service. Whilst residents are not currently in paid employment some access colleges or similar. Outcomes for residents are positive, and there is evidence that they are enjoying the life opportunities that they experience. The service actively supports residents to be independent and involved in all areas of daily living in the home. This includes where appropriate, taking some responsibility for domestic tasks, shopping, planning meals, and meal preparation within a risk management framework. Individuals are supported to be independent with the assistance of appropriate training and support. Mealtimes are relaxed, staff are patient and helpful, and allow residents the time they needed to finish their meal comfortably, with choice as to the foods taken given, this with support and guidance about healthy eating, with staff aware of the need to encourage a nutritionally balanced and healthy diet. Supervision during mealtimes is provided in accordance with risk assessments. 10 Melbourne Road DS0000066783.V325355.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 excellent 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. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Efficient systems are in place to ensure residents receive effective personal and healthcare support. The homes policies and procedures set out how the service is to address these with this process delivered effectively through a skilled, trained and knowledgeable staff group. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents as detailed in care plans and risk assessments. It is recognised that the delivery of personal care is highly individual and must be flexible, consistent and reliable. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of residents. Staff ensure that personal support is consistent, and responsive to the changing needs of the residents and are aware of and respect service users preferences and self-determination. They have accurate knowledge as to 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 15 resident’s individual personal needs, relating to such as the provision of intimate care. Whenever possible residents are able to have choice about who delivers their personal care and the staff team has a gender balance to enable choice of male or female staff when delivering personal care. Staff understand how to respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in privacy and that they support residents to be as independent as possible. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. The residents are encouraged to understand their involvement in their own healthcare including visual, hearing and oral care. They have the opportunity to access their GP and have access to all NHS healthcare facilities in the local community with support from the staff team. Regular appointments are seen as important and systems are in place to ensure they are not missed. The home would arrange for health professionals to visit residents at home when necessary. Staff are aware of health care triggers and warnings and fully understand how they should respond and take action. There were Health Action Plans in place although there was no evidence of the Primary Care teams involvement in these at present, with the sections that medical personnel should complete blank. Training on some health care issues that relate to the care needs of the residents is provided, details of the same seen in the homes training plan. The home works to an efficient medication policy supported by procedures and practice guidance. Staff are aware of and understand the guidance. High priority is given to maintaining and updating medication records. Staff follow robust systems to make sure that medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks and audits are recorded to monitor compliance. None of the residents currently has the current ability, following assessment, to keep and take their own medication although consent to staff giving the same has been gained by the service. The only issue of concern was that the one residents care plan still made reference to the use of Cordysl mouthwash, this in practice, and with justification not the case. The detail in the care plan should be reviewed to reflect this change. The home has systems to assist with compliance with the administration, safekeeping and disposal of Controlled Drugs if and when used and homely remedies are identified and agreed with the residents G.P’s. Care staff that administer medication have the required accredited training. Staff were seen from observation to be aware of the need to monitor any possible pain resident’s maybe suffering, especially where there were issues in respect of their ability to express this to others. 10 Melbourne Road DS0000066783.V325355.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): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure and are protected 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. The complaints procedure is sent to parents annually with questionnaires in respect of service quality, and has a high profile within the service. Residents and others associated with the home are reminded by staff how to make a complaint with explanation as to what can be expected to happen if a complaint is made. Staff are aware that the behaviour of a resident can indicate their dissatisfaction with the service in some way. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures regarding protection of individuals are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to. The company regularly arranges training of staff in the area of protection, and whilst there are staff without such training, a number were booked on the appropriate course. Discussion with staff indicated that they had a good understanding of abuse and the action to take if witnessed. There are a low 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 17 number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. The outcomes from any referral are managed well and issues being resolved to the satisfaction of all involved. The home has an open culture, which enables residents to express their views, and concerns in a safe and none blame environment. Residents and others associated with the service state that they are very satisfied with the service provision, feel very safe and well supported by an organisation that has their protection and safety as a priority. 10 Melbourne Road DS0000066783.V325355.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): 24,25,27,28,29 & 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, which encourages 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. Residents are encouraged to see it as their own home and do identify their bedrooms as their personal space. It is a very well maintained, attractive home, which is accessible to community facilities and services. Where there is need for adaptations these are provided, although the home is not designed to offer a service to residents with physical disabilities so adaptations are limited 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 19 to those required to meet individual residents needs, such a grab rails in the bathroom. The home is designed to provide small group living where residents can enjoy maximum independence in a discrete non- institutional environment. Some of the residents had a choice of the bedroom they had, although this would be limited by which room was available out the three. None of the rooms are shared and are very well planned with one having en-suite facilities. All rooms are above minimum size expectations, one well over. The fixtures and fittings are of a high quality, well maintained and adapted to meet the wishes of the present service users. Individuals personalise their rooms and bring in their own furniture if they wish. There is a selection of three communal areas inside the home, with an attractive and private garden area to the rear of the house. This means 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 kitchen is easily accessible to residents and allows the involvement of residents in domestic tasks and as part of developing or maintaining self-help skills. The space available in this area is beneficial in that it allows a number of people to be in this room. The laundry is sited in the rear of the garage but would be accessible to residents with staff support. The bathrooms are homely and include aids and adaptations to meet the needs of the residents. There are sufficient toilets to enable immediate access. All bedrooms enable privacy and have locks on the doors so residents have control and ownership of their own space. All residents have keys to their rooms unless a risk assessment indicates otherwise. Based on tests of the water temperatures carried out by staff and the presence of the hot water when the inspector used hand washbasins there were no issues as to its availability and the temperature in the home can be changed to meet individual’s personal choice, especially in their own rooms. The home is always very well lit, clean and tidy and smells fresh. The management has a proactive infection control policy and they would work closely with external specialists as and when needed. All staff have received training in this area. 10 Melbourne Road DS0000066783.V325355.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): 31,32,33,34,35 & 36 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 receiving targeted training that will improve their knowledge and skills, and are in sufficient numbers to support the people that use the service, this in line with their terms and conditions and supporting the smooth running of the service. EVIDENCE: Residents appeared comfortable around the staff that care for them and feedback indicated that they felt they were treated well. Rotas show that staffing levels are maintained so as to ensure staff to resident ratios are not compromised, with use of staff from other homes within the company in place of external agency staff. This has the advantage that staff that cover the rota are familiar with the companies aims, policies and procedures, also usually knowing the residents from prior working at the home. Particular attention is given to busy times of the day and changing needs of the residents. Staff members undertake external qualifications beyond the basic requirements; this targeted and focussed on improving outcomes for residents. There are however a number of areas where training is required, these 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 21 identified within the homes training plans and including NVQ level 2, adult protection and Equality and Diversity. Despite this there has been a good level of input into staff training since the home opened, and the Manager was clearly aware of the areas of training required, also recognising the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. There was evidence from observation, discussion with staff, residents and review records that staff working within the service are skilled in their role, and are consistently able to meet residents needs. The service uses external providers to deliver this training if they have not got 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. The manager stated that involvement of people who use the service in the recruitment process was through observing their interaction with potential/new staff. There was clear documented evidence that staff new to the service were well supervised and involved in a robust induction process that covered all the necessary core skills required, part of this a weeks external training in core areas of knowledge for new staff. Staff meetings and one to one supervision sessions are regular and staff find them helpful. Notes of the same are well documented. 10 Melbourne Road DS0000066783.V325355.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): 37,39,41 & 42 Quality in this outcome area is good 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 her 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 senior managers in the company, and the provider’s representative’s deal with 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 23 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 practice 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. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. The home has very efficient systems to ensure effective safeguarding and management of individual’s money including record keeping. Residents have access to their records whenever they wish. The service is faultless in its role as agent or appointee and fulfils all requirements. Record keeping is on the whole to a consistently high standard, although there were some limited instances where errors and omissions were seen to have been made. The majority of these had been identified and highlighted to staff by the manager. Records are kept securely and policies highlight the requirements of the Data Protection Act. Residents can get access to their records and contribute. All the working practices in the home are safe and there are no preventable accidents. The home has a full range of policies and procedures to promote and protect residents’ health and safety. 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. The home proactively consults other experts and agencies about health and safety issues, an example of this prior to when the home first opened when all statutory agencies were involved in providing advice. 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 all staff are trained and aware of health and safety matters and have regular planned updates. Following discussion with staff it was however felt that the homes risk assessments in respect of taking residents swimming may need review in respect of potential issues that maybe presented to female staff, above and beyond those present for males. 10 Melbourne Road DS0000066783.V325355.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 3 2 3 3 3 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 4 26 4 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 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 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X 3 3 X 10 Melbourne Road DS0000066783.V325355.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA35 Regulation 18 Requirement To continue training in those areas identified within the homes training plan, including NVQ level 2 in care and Equality and Diversity. Timescale for action 30/06/07 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 YA20 YA41 YA42 Good Practice Recommendations The reference to the use of Cordsyl mouthwash in the care plan for resident P needs to be reviewed. More care should be taken in completing records relating to residents behaviour to ensure that they are dated correctly and all information is correct. To review the risk assessment for resident L in respect of swimming to review the need to allocate this task to male staff only, this a issue that needs to be discussed with the staff team. 10 Melbourne Road DS0000066783.V325355.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 10 Melbourne Road DS0000066783.V325355.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. 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