Inspection on 20/11/06 for 100 Goldstone Crescent

This inspection was carried out on 20th November 2006.

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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

100 Goldstone Crescent 10/10/08

100 Goldstone Crescent 18/01/06

100 Goldstone Crescent 02/08/05

100 Goldstone Crescent 18/01/05

100 Goldstone Crescent 20/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 100 Goldstone Crescent Hove East Sussex BN3 6BE Lead Inspector Niki Palmer Unannounced Inspection 20th November 2006 2pm 100 Goldstone Crescent DS0000060757.V314087.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 100 Goldstone Crescent DS0000060757.V314087.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. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 100 Goldstone Crescent Address Hove East Sussex BN3 6BE 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) 01273 553718 01273 553718 www.caremanagementgroup.com Care Management Group Limited Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of service users to be accommodated is three (3). That service users should be younger adults aged between eighteen (18) and sixty-five (65) years on admission. That service users to be accommodated have a learning disability, not falling within any other category. Date of last inspection Brief Description of the Service: 100 Goldstone Crescent is a care home, which provides personal care and accommodation for up to three residents with mild to moderate learning disabilities. The home is owned and run by Care Management Group (CMG) who are a large national organisation that provides care for people with learning disabilities. The home is located in a quiet residential area in Hove. There is access to local amenities and public transport. There is limited car parking available at the home, however free parking is permitted on the street. All rooms are for single occupancy and are located over two floors with suitable bathing facilities to meet the assessed needs of residents. The layout of the home is not suited to accommodate wheelchair users and residents must be able to independently mobilise to access the first floor. There is a wellmaintained rear garden, which is accessible for residents to use. The home provides personal care and support to residents who are funded by Social Services. The home’s fees as of the date of inspection range between £1100 - £1300 per person per week dependent on needs. Additional costs are charged for hairdressing (£8 - £18), chiropody (£10), some toiletries and holidays (£ variable). Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home’s most recent inspection report is available on request at the home. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 100 Goldstone Crescent will be referred to as ‘residents’. This unannounced inspection took place on Monday 20th November 2006 and lasted approximately five hours. Three residents were accommodated on the day of the inspection, two female and one male aged between 33 and 39 years of age. All residents were at home during the evening and had the opportunity to meet and talk with the Inspector. In order to gather evidence on how the home is performing, individual discussions took place with two members of care staff on duty, whilst the majority of the inspection was undertaken with the acting Manager. In addition, a telephone conversation with a resident’s member of family took place during the inspection. All three care records were examined in some detail for the purpose of monitoring care. Other records and documentation inspected included: the home’s preadmission assessment procedures, medication practices, the provision of activities, complaints procedure and the systems in place to safeguard residents from harm, staffing levels and the provision of relevant training. In addition the home’s systems for monitoring their own effectiveness and managing residents’ monies were inspected. All communal areas and individual rooms were seen. A detailed pre-inspection questionnaire was received prior to the visit to the home. This provided the Inspector with information relating to the premises, maintenance and associated records, details of the homes policies and procedures and staffing details. What the service does well: 100 Goldstone Crescent is a well managed service. Residents are supported by a skilled and effective staff team who are knowledgeable about the needs and support required for each resident. A good level of information is provided prior to admission in order to support prospective residents in their decision of where to live. The compatibility of residents currently living at the home is good. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 6 Comprehensive and person centred care plans clearly support staff in understanding and meeting residents’ assessed needs. Residents are involved in the formulation and reviewing of these. Residents are supported to take part in a wide range of activities to lead fulfilling lives, meet their individual needs and ensure their personal development. Residents play an active and fulfilling role in their community. Staff encourage and support residents to be involved in menu planning, shopping and meal preparation. This helps to promote choice, participation and to develop day to day life skills. Individuals’ personal and healthcare needs are met well. What has improved since the last inspection? What they could do better: Albeit that there was evidence to support that the home is managed by an experienced and competent person, it remains an outstanding requirement for an application to be submitted to the CSCI for a person to become registered as the Manager. This is the only outstanding requirement. A small number of minor shortfalls were identified during this inspection, namely in relation to how residents’ personal healthcare needs are recorded as the home currently has a number of different methods. These include maintaining daily records, updating risk assessments and implementing individual epilepsy management guidelines. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 7 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. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 8 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 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and others are provided with sufficient information prior to admission in order to support their decision of where to live. Good systems are in place to ensure that only residents whose needs can be met are admitted to the home. EVIDENCE: The home has a detailed Statement of Purpose and Service Users’ Guide in place, which have been updated following the last inspection. The Statement of Purpose provides the reader with an introduction to CMG including the home’s aims and objectives, details of the Registered Provider and Manager, organisational and staffing structure and colour photographs of the accommodation provided. The Service Users’ Guide offers a good level of information regarding the services and facilities provided, residents’ charter, contact details of the CSCI and the arrangements in place for health and social care support. Both documents are presented in an easy to read and understand format, which incorporate the use of colour pictures and symbols. Although there have been no new admissions to the home since the last inspection, discussions took place with the Manager of the home in respect of how new admissions are assessed. CMG employs a team of centrally based assessment referral officers, who are responsible for considering and assessing 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 10 all initial referrals for each of the care homes across the South East region alongside the Manager. It was evident through observations made during the inspection and discussions with each of the residents and staff that the compatibility of residents within the home is at this time good. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents are supported well by the home’s care planning procedures. Staff enable residents to make decisions about their lives on a daily basis. EVIDENCE: Three care records were seen. Care plans are titled “All about me’, which were noted to be exceptionally comprehensive and person-centred to individual needs. Photographs are also included of residents’ families and other things that are important to each person. All have been written in the first person in an easy to read and understand format, which clearly outline how individuals’ needs are to be met. Residents and staff confirmed that residents are always involved in the reviewing of plans every six months or sooner if required. The home currently uses a number of different recording methods in addition to the care plans. Separate daily records are kept (which were noted to be exceptionally brief), in addition to separate healthcare records and a daily diary, which residents maintain. It is required that detailed daily records are maintained in respect of each person. It is also recommended that the current 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 12 different recording methods are reviewed in order to combine all records together. In addition to detailed care plans, all residents have a completed Health Booklet in place, which have been produced by CMG. These cover all aspects of residents’ physical and emotional healthcare needs. These are updated as necessary. Residents, their relatives and staff confirmed that residents are supported well by staff to make their own decisions about many aspects of their lives, for example what to do each day, what to eat and holidays etc. The staff team is innovative in using photographs and pictures to help residents make informed choices and decisions. All of the residents are encouraged to take responsible risks where necessary in order to promote their independence. A number of risk assessments were seen in individual plans of care for all activities of daily living. There was clear evidence that these are reviewed by the Manager on a regular basis, signed and dated. Not all however, gave a clear picture of why the risk assessment was being completed or what the overall level of risk is in relation to the person. This indicates that some risk assessments are being completed as a matter of course rather than being person centred and specific to individual needs. The home is required to ensure that key risk assessments are reviewed in order to make them person centred based on the actual level of risk specific to individuals. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in a wide range of activities to lead fulfilling lives, meet their individual needs and ensure their personal development. Residents play an active and fulfilling role in their community. They are supported to maintain positive relationships with family and friends. The ethos of the homes promotes the right of residents to make choices in all aspects of their lives. EVIDENCE: All of the residents have structured daily activities in place Monday to Friday. These include day service provision and college courses. There is no person in paid employment at this time. As each of the residents are out for most of the day during weekdays, evenings and weekends are mostly relaxed. Residents said that they are offered a number of activities at these times including: going to the pub, bowling, walks, shopping, theatre productions, musicals and pop concerts [this list is not 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 14 exhaustive]. Residents are encouraged and supported by staff to use public transport. One member of staff commented: ‘Residents are always out and about. They have a very busy social calendar’. In-house activities include watching the TV etc. and/or just relaxing. On the evening of this inspection one of the residents had a friend over to join them for an evening meal. This was followed by karaoke, which both residents and staff took part in. All daily activities are displayed on a large information board in the kitchen/dining area, which is called ‘Today is…’ Residents are supported on a weekly basis to clearly map out and plan what they would like to do on a daily basis for the following week using pictures and photographs. It also acts as a guide for residents as to which members of staff are on duty and when. All of the residents go on holidays each year, which are organised by the home. Indeed on the day of this inspection they had recently returned from a mini cruise. Residents spoke very positively of this and the staff that accompanied them. Both residents and their relatives confirmed that the home support residents well in maintaining friendships with others. All residents have regular involvement with their families including telephone contact and short breaks away. A relative commented: ‘The home always keep in touch and we’re always made to feel welcome each time we visit – often unannounced’. Throughout the duration of the inspection all staff were observed to knock on residents’ bedroom doors prior to entering and address them by their preferred term. All residents are encouraged to help with menu planning, shopping and meal preparation. Specialist diets and smaller snacks are appropriately catered for. Residents are encouraged to dine together alongside staff in the relaxed and pleasantly decorated dining area. Residents were observed to lay the tables prior to the meal and help clear away the kitchen afterwards. The main evening meal served on the day of the inspection looked appetising and plentiful with fresh vegetables available. Residents spoke highly of the variety and taste of the food provided. One person said: ‘My favourite is mushroom pie’. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 provide sensitive and dignified support to meet the individual needs and preferences of residents. Residents are supported to access a range of healthcare services to meet their physical and emotional well-being. Residents are safeguarded by the homes policies and procedures for the safe administration of medicines. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all healthcare appointments as necessary. Specialist advice from the Community Learning Disability Team (CLDT) is requested on an individual basis. The Manager confirmed that in the event of a person becoming unwell requiring an admission to hospital, the home tries to ensure as much as is possible that a member of staff is allocated to stay with them during this time. All of the residents spoken with said that the daily routines within the home are quite flexible. For example they can determine what time of day they would prefer to have a shower or bath and in most instances can choose the member of staff that they would like to support them (if necessary). All 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 16 personal care needs are carried out in either one of the bathrooms or in the privacy of residents’ own bedrooms. Two of the residents living at the home have epilepsy, which is well controlled with medication. Indeed, not many (if any) of the long-standing members of staff have ever witnessed any seizures, as the frequency is so rare. CMG have provided the home with standardised guidelines for managing seizures, however the home is required to liaise with family members and healthcare professionals in order to devise and implement individual epilepsy management guidelines in the event of a seizure occurring. These must include a brief history of the person’s seizures, a description of what form the seizure takes (if known) and instructions for staff to follow in the event of a seizure occurring. The home’s medication records and storage systems were inspected. The home uses a pre-packed blister pack issued by the local pharmacy, which is easy to use and monitor. All members of staff have received the appropriate training and have been assessed as competent in the administration of medicines. Only senior members of staff hold responsibility for the reordering and returning of medicines to the pharmacy. It was pleasing to note that all records were accurately maintained and there were clear guidelines in place for all medicines that are prescribed on an ‘as and when’ basis (PRN). In addition, as a measure of good practice the home has a medication communication book in place. This acts as a useful source of information for staff for example when a resident is prescribed any new medications or if there has been a change in dose. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately. Residents are protected from potential harm, neglect and abuse through the home’s robust policies and procedures and through staff receiving appropriate training. EVIDENCE: The home has a detailed complaints procedure in place, which is included within the home’s Statement of Purpose and Service Users’ Guide. This is also available in a pictorial format. It gives clear guidance with regards to how a complaint can be made and how the complainant can expect it to be dealt with. All of the residents spoken with said that they would feel confident in raising concerns directly with their keyworker or Manager. No complaints have been received by either the home or the CSCI since the last inspection. The home has a detailed Adult Protection policy and procedure in place, which has been updated since the last inspection to state that all allegations of abuse must be referred to Social Services. In addition, the Manager has incorporated information regarding the Protection of Vulnerable Adults (PoVA) list within the policies and procedures, however it is recommended that this be more detailed to provide staff with clearer guidance regarding the referral process. The home’s whistle-blowing procedure has also been expanded upon to inform staff that whistle-blowing relates to all practices within the home and not just abuse. All staff spoken with had a good understanding of the home’s whistleblowing and Adult Protection procedures. Both in-house and external Adult Protection training has been provided by CMG. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 18 No alerts have been raised since the last inspection. The manager acts as an appointee for all three residents. The home holds residents’ personal allowances at the home, which all care staff have access. A sample of these were randomly checked and found to be in order. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 100 Goldstone Crescent offers a friendly and relaxed environment that is kept in good decorative order. It presents as a clean, well-maintained and homely place to live. EVIDENCE: 100 Goldstone Crescent is a four-bedroom house, which is located over two floors. There is an office and sleep-in room for staff on the first floor alongside two bedrooms and a bathroom. The fourth bedroom with en-suite facilities is on the ground level. Since the last inspection one resident’s bedroom has been redecorated in addition to the lounge, dining area, kitchen and hallway/landing, whilst new carpets were due to have been laid the week following the inspection. Residents confirmed that they were involved in choosing the colours of the paint and carpets for their own rooms. Much work has been undertaken since the last inspection to make the garden accessible to residents. Trees have been cut back, new fencing has been put 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 20 up and brickwork replaced. The Manager commented that this process was reasonably slow, which meant that unfortunately it was not usable throughout the summer, however residents will benefit from this during spring/summer 2007. The Manager hopes to involve the residents in the planning and development of a sensory area in the near future. Each of the residents kindly showed the Inspector their bedrooms. All were found to be nicely decorated and reflective of individuals’ personalities and preferences. All rooms contained personal belongings and furnishings and in most cases a TV, video, DVD and CD player. The home has one main bathroom, which is located on the first floor. Two of the residents and staff use this. Since the last inspection flooring in this area has been replaced. It was noted that there is currently no curtain or blind in the main bathroom and although the windows are frosted, it is recommended that the home consult with residents and staff regarding their preferences in relation to this. CMG employs a team of maintenance persons to carry out any repairs or redecoration. Any areas that are in need of addressing are recorded in a maintenance book, which staff confirmed are usually promptly dealt with. All areas of the home were found to be clean and hygienic on the day of the inspection. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by a skilled and dedicated staff team who continue to work hard to meet the needs of residents. Residents are supported and protected by the home’s robust recruitment procedures. The staff team are supported to provide consistent care and meet the needs of residents through regular supervision and staff meetings. EVIDENCE: The home employs a total of five Support Workers in addition to the Registered Manager. Residents, staff and duty rotas confirmed that there are always two members of staff on each shift, however as all of the residents are mostly out in the daytime, staff working hours need to be flexible. There is currently no need for a waking night person although a sleep-in member of staff is always allocated. This is sufficient to meet the current needs of residents at this time. Agency staff are rarely used if at all. 100 Goldstone Crescent is staffed by a strong team of people, the majority of which have worked at the home for a number of years and therefore know the residents very well. All members of staff spoken with spoke very positively of the home. One person said: 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 22 ‘I love working here. It has a great atmosphere and it’s really homely’. All members of staff are due to complete their NVQ Level 2 in Care imminently. Recent training includes: fire safety, the Protection of Vulnerable Adults, first aid, food hygiene, manual handling and health and safety. Future planned training includes: Adult Protection, Digman, infection control, Person Centred Planning and Health Action Planning. Training courses are sought both internally and externally. Two staff recruitment files were randomly checked. Both files were found to contain all the required checks, including photograph identification, two written references, evidence of a PoVA First check and Criminal Record Bureau (CRB) check prior to employment. The acting Manager confirmed that she is in the process of updating the home’s induction processes in accordance with Skills for Care, which replaced TOPSS in October 2006. This will be followed up at the next inspection. All staff spoken with and a sample of supervision records confirmed that there is a programme of regular supervision for all staff, as well as team meetings. Staff also reported that they felt well supported by the management team in the home. All staff spoken with said they felt able to raise any issues or concerns they may have. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents and staff benefit from a well run and organised home. The views and rights of residents underpin the ethos and development in the home. EVIDENCE: The acting Manager commenced employment at the home in September 2005. She has been in care for approximately 25 years working in various positions including older peoples services and working with children. She has achieved NVQ Levels 3 and 4 and is currently working towards a Registered Manager’s Award (RMA) and to become an NVQ assessor. It remains an outstanding requirement for an application to be submitted to the CSCI to begin the process of registering a Manager. Residents’ meetings are held weekly, minutes of which are kept. Each of the residents spoken with said that these meetings are very informal, although can be very useful and informative. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 24 The Manager has a quality assurance file in place, which has been produced by CMG based on meeting the outcomes of the National Minimum Standards (NMS). Residents, staff, relatives and Care Managers were asked to complete an annual questionnaire in June 2006. The outcome of this was exceptionally positive. The Manager has produced a clear summary and action plan based on peoples responses. In addition to this the Regional Operations Manager visits the home on a regular unannounced basis, in order to gain feedback from staff and observe the daily routines and interactions within the home. Details of these visits are forwarded to the CSCI. Evidence provided within the home’s returned pre-inspection questionnaire identified that all equipment is well-maintained and regularly serviced including: fire equipment, environmental health issues, electrical appliances central heating system and emergency lighting. Following an immediate requirement, which was issued at the last inspection regarding hot water, new thermostatic controllers have been installed to all hot water outlets throughout the home. This ensures that all hot water is delivered at a maximum temperature of 43°C. These are checked weekly by care staff and records are kept. It was recommended at the previous inspection that hot and cold water taps are clearly labelled; this remains outstanding. Albeit that residents and staff know which is which, visitors to the home do not. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 26 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. Standard YA6 YA9 Regulation 17(1)(a) (3)(a) Requirement Timescale for action 31/01/07 3. YA19 4. YA37 That detailed daily records are maintained in respect of each person 13(4)(a-c) That key risk assessments are 31/03/07 reviewed in order to make them person centred based on the actual level of risk specific to individuals. 12(1)(a)(b) That individual epilepsy 31/03/07 15(1)(2) management guidelines are devised. These should be drawn up with the involvement of family members and healthcare professionals. These must include a brief history of the person’s seizures, a description of what form the seizure takes (if known) and instructions for staff to follow in the event of a seizure occurring. 18(1)(a) That an application for a 31/03/07 9(2) Registered Manager is forwarded to the CSCI [this remains an outstanding requirement from 31/03/06]. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 27 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. 5. 6. Refer to Standard YA1 YA6 YA23 YA29 YA27 YA42 Good Practice Recommendations That the Statement of Purpose and Service Users’ Guide are dated in order to evidence that they have been have been recently reviewed and are current. That the current different recording methods for daily records and for recording healthcare needs are reviewed in order to combine all records together. That information relating to the PoVA list is more detailed to provide staff with clear guidance regarding the referral process. That the home consults with the Sensory Impairment Team in relation to providing more suitable lighting throughout the home for persons with a visual impairment. That the home consults with residents and staff regarding the possibility of having a blind or curtains put up in the main bathroom. That hot and cold water taps are clearly labelled. 100 Goldstone Crescent DS0000060757.V314087.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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. 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