Inspection on 21/03/05 for 122 Scorer Street

Care Homes For Adults (18 ­ 65)122 Scorer StreetLincoln Lincs LN5 7SXUnannounced Inspection21st March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 122 Scorer Street Address 122 Scorer Street, Lincoln, Lincs, LN5 7SX Email address scorerstreet@msn.com Name of registered provider(s)/company (if applicable) Adrian O`Brien Rachel Amiee O`Brien Name of registered manager (if applicable) Adrian O`Brien Type of registration Care Home No. of places registered (if applicable) 2 Tel No: 01522 804167 Fax No:Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (2) Registration number C530002050 Date first registered 28th May 2004 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 8th June 2004 NO NO 14/08/04 If Yes refer to Part C122 Scorer StreetPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 321st March 2005 1:00 pm Kathryn EmmonsID Code078098Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr Adrian OBrien and Mrs Rachel OBrien122 Scorer StreetPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers Agreement122 Scorer StreetPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of 122 Scorer Street. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.122 Scorer StreetPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 122 Scorer street is a care home providing personal care and accommodation for 2 service users who have autistic spectrum disorders. It is owned by Mr and Mrs OBrien, with Mr Adrian OBrien being the registered manager. The home is located in a residential area a two-minute walk from the high street and town centre of Lincoln. The home has been registered since May 2004. The home is a two story terraced house with a courtyard style garden. There is road parking outside the front of the home.122 Scorer StreetPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) At the last inspection in August 2004 the home did not have any service users. In the 2 weeks prior to this inspection 2 service users have been admitted to the home. Choice of Home (standards 1 ­ 5 ) 5 of these 5 standards were inspected and met Service users made positive comments regarding their experiences of being admitted to Scorer Street. A service users guide is on display and it was evidenced that service users had entered into contracts for their admission to the home. Individual Needs and Choices ( standards 6 ­ 10) 3 of these 5 standards were inspected and met Care plans had been produced with service user input and consultation. These were being reviewed and were comprehensive in their detail. Service users were satisfied with the lifestyle they had since being admitted to the home. Lifestyle (standards 11-17 ) 5 of these 7 standards were inspected and met. Activity programmes are drawn up with service user involvement. It was established that service users were afforded many opportunities to participate in the local community. Service users confirmed that they were given choice over many aspects of the care and support they received. Personal and Healthcare Support standards 18-21 2 of the 4 standards were inspected and were met Both service users are registered with a local GP surgery. Service users were satisfied with the support they received from the home to access their health care needs support systems. Concerns ,Complaints and Protection (standards 22 ­ 23) 0 of these 2 standards were inspected. Not inspected on this occasion. Environment (standards 24 ­ 30) 5 of these 7 standards were inspected and met Service users were pleased with their bedroom décor and furnishings and had been able to personalise their bedrooms. The home was clean and tidy and in good repair. Servicing of equipment such as the fire safety system has taken place and certificates were in place. Staffing (standards 31 ­ 36 3 of these 6 standards were inspected and 2 were met The home employs 5 staff in addition to the 2 proprietors. One of the staff files inspected identified that references were not current and a member of staff had commenced work 122 Scorer Street Page 6 without a POVA check in place. A requirement has been made regarding this issue. Staff continue to receive supervision session and an training programme is in place. Conduct and Management of the Home (Standards 37 ­ 43) 3 of these 7 standards were inspected and met The home has a quality assurance questionnaire in place and this will now be utilised as service users are admitted to the home. Monthly regulation 26 visits are taking place and reports are forwarded to the local CSCI office on a monthly basis. Mr OBrien is the registered manager of the home and service users made very positive comments regarding Mr OBriens management style.122 Scorer StreetPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)122 Scorer StreetPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action All staff must have current references in place. YA34 All care staff must have a current CRB and POVA check in place prior to commencement of employment.1Schedule2 (5) & (7)31 May 2005RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report 122 Scorer Street Page 9 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES NO YES YES YES NO NA YES NO YES NO YES YES NO NO NO YES NO YES 2 0 0 NO NO YES YES 6 0 21/03/05 13:00 2.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 122 Scorer Street (Commendable) Page 10 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.122 Scorer StreetPage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 1250 1800 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Chiropody and hairdressing 3 Key findings/Evidence Standard met? The home has a statement of purpose in place and a service user guide. A copy of the homes service users guide is on display in the main hallway of the home. This document contains the necessary information and is updated when needed.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Since the last inspection two new service users had been admitted to the home. The service users spoke with the inspector about the admission process and their involvement in assessments and decision-making process regarding the admission.122 Scorer StreetPage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? It was established that the home maintains a network of contact with relevant health and social care professionals in order to provide all the support the service users may require which is not provided by the home. Ongoing training is in place to enable care staff to meet service users needsStandard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? From discussion with one of the service users it was confirmed that a prospective visit to the home had been offered. This forms part of the assessment process and is included in the terms and conditions in respect of trial periods of admission.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? Service users are given a copy of the homes terms and conditions of accommodation on admission to the home. This document details what the fees are and what services the service users can expect to receive. Due to needs of service users, fees vary and each contract is produced individually.122 Scorer StreetPage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? During the inspection both service users were case tracked. This involved reading all documentation pertaining to the service user, speaking to the service user and cross referencing any information contained within their records with other relevant records held by the home. Where needed risk assessments are in place. Reviews of care plans and risk assessments are undertaken when needed, such as when a change in care need or change in treatment is identified. Service users are allocated a key worker who will work through their care plan with them. . The service users spoken with confirmed that they had been consulted when their care plan had been produced and were aware of who their key worker was.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not inspected on this occasion.122 Scorer StreetPage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Service users stated that they were consulted daily regarding activities taking place. A weekly plan is produced of service users involvement with household tasks and activities they can participate in. All policies and procedures are reviewed on a regular basis and it is clearly outlined in the service user guide that their involvement in shaping the homes polices and procedures is positively welcomed.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? Not assessed in detail on this occasionStandard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Through speaking with the manager it was established that staff had received training in relation to confidentiality. Policies are in place for staff to follow. Those service users spoken with confirmed that they were satisfied that any information held on them by the home was kept safe.122 Scorer StreetPage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users stated that they felt supported by the whole care team. Positive comments were made regarding service users being given opportunities to have a presence in the community. One service user said that they were hoping to get a job working in a nearby charity shop. Due to the home only having 2 service users the proprietors normally involve both service users in activities together. There is a car for service users to go in with care staff. On the day of the inspection one service user was going into town with one care staff while the other service user was involved in an activity at the home. The manager stated that due to both service user sonly having been living at the home for a couple of weeks it was still at the stage of assessing what activities and level of social inclusion in the community the service users were comfortable with. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not assessed on this occasion.122 Scorer StreetPage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The home ethos, which forms part of the statement of purpose, concerns itself with community participation. The home works with the service users to learn life skills and be come part of the community with a view to the possibility of eventually becoming as independent as possible. The homes location enables service users to access the town centre and the local community events, which are taking place.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The home has provided a statement of purpose and service users guide. Both refer to a range of activities, which take place in the local community as well as further a field such as a local train museum and a home allotment. Speaking with service users confirms that these activities are taking place.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Both service users confirmed that their relatives were kept in contact with by the home. The manager confirmed that service users relatives and friends were able to visit the home whenever they wanted to. A visitors book in place in the hall way and this is used as a fire roll call register. On the day of the inspection one service user was going out in the evening to meet a friend for a drink.122 Scorer StreetPage 17 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users stated that they were given many opportunities to spend their days undertaking activities, which interested them. Risk assessments are in place for those activities, which take place out in the community.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users spoken with all stated that the food was of a good quality and that a choice was always available. Service users undertake the shopping on a weekly basis with the homes proprietors. The kitchen is well laid out and sufficient in size for service user to work with care staff to prepare the meals. .122 Scorer StreetPage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The home does not provide nursing care. The service users spoken with stated that they found that staff always spoke with them in an appropriate manner. Service users gave examples of their rights being upheld.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Not inspected on this occasion Standard met? XX 0122 Scorer StreetPage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Currently only one service user has medication. A risk assessment is in place and it had been assessed that the service user was unable to self medicate. All staff have received training in the administration of medication and a clear audit trail was in place from ordering to receipt to administering of medication. The medication administration sheet had been completed correctly. The home has entered into a local pharmacy agreement. The pharmacist provides training and advice when needed. The manager informed the inspector that the home from the following month would be using a monitored dosage system.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not inspected on this occasion122 Scorer StreetPage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not inspected on this occasion. X X X X X X X Standard met? 0122 Scorer StreetPage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence Not inspected on this occasion. YESX Standard met? 0122 Scorer StreetPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home comprises of two bedrooms a bathroom and an office on the first floor. There is also a bedroom through the office, which is occupied by the proprietors. On the ground floor of the home there is quiet room, a lounge diner, a kitchen, separate utility room and a shower room and separate toilet. The door from the utility room leads out to the courtyard garden, which has a small lawned area. The home also has a pet rabbit and a tropical fish tank.122 Scorer StreetPage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 2 0 0 0 2 00 0 0 03 Key findings/Evidence Standard met? Both of the bedrooms have sinks fitted. It is envisaged that eventually one of the bedrooms will have the bathroom for sole use as an ensuite and a shower room will be installed within the other bedroom. Both rooms exceed the minimum spatial requirements.122 Scorer StreetPage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? Both service users said they had been assisted to personalise their bedrooms. One service user chose to spend a quantity of time in their bedroom. Each service user had a computer available to them. Bed linen was clean and in good repair. Décor was appropriate for the service users.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The service users have a sink in their bedrooms and a shared bathroom on the first floor. Down stairs there is a shower room and a separate toilet. The grouting on the shower cubicle is in need of replacement. This had already been identified and an action plan has been implemented.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? A tour of the home was undertaken. All areas were safe, clean and tidy and well maintained. The services users each have a bedroom. In addition to this there is a lounge dinning area and a quiet room.122 Scorer StreetPage 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Not inspected in detail on this occasion122 Scorer StreetPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? Not inspected on this occasion.122 Scorer StreetPage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 2 X X X 2 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X1X3 Key findings/Evidence Standard met? The duty rota was inspected. It was established that at least 2 staff were on duty at all times. Night time arrangements were one sleeping and one waking member of staff.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? One staff members recruitment records were inspected. It was evidenced that an application form had been completed and references obtained. However, the references were from a couple of years previously. This was discussed with Mr OBrien who confirmed that new references had been sent for. This member of staff was working in the home and their CRB and POVA first check were not in place. This has been discussed with Mr OBrien.122 Scorer StreetPage 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? It was confirmed by Mr and Mrs OBrien that all staff now receive supervision session monthly. Mr OBrien undertakes these except for Mrs OBriens supervision sessions, which are undertaken by an external person. Records are in place to demonstrate that sessions have taken place.122 Scorer StreetPage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? The home continues to be managed by Mr OBrien on a whole time basis. At the last inspection Mr OBrien was also working in another job, as the home had no service users. Mr OBrien has many years experience of caring for service user with learning disabilities, mental health conditions and has spent 4 years working in a specialised unit for service users with Aspergers syndrome and high functioning Autism spectrum disorders. Mr OBrien is in possession of NVQ Managers Award.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The service users were spoken with regarding the homes management style. Both service users said they got on very well with the whole staff team and felt like family. Both service users said that they were given many opportunities to go into the community and learn new life skills.122 Scorer StreetPage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The home is visited on a monthly basis by a nominated individual who produces a regulation 26 report on behalf of the home proprietors. These are forwarded to the local CSCI office. The owners are implementing a quality assurance programme in the near future.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? Not inspected on this occasion.122 Scorer StreetPage 31 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not inspected on this occasion122 Scorer StreetPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorKathryn EmmonsSignature Signature SignatureRegulation Manager Rachel Cook Date122 Scorer StreetPage 33 Public reports It should be noted that all CSCI inspection reports are public documents.122 Scorer StreetPage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 21 March 2005 of 122 Scorer Street and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include Provider responses in the published report. In the meantime, responses received are available on request.Action taken by the CSCI in response to provider comments: 122 Scorer Street Page 35 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan within 28 days, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther:NO122 Scorer StreetPage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 We Mr and Mrs OBrien of 122 Scorer Street confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 We Mr and Mrs OBrien of 122 Scorer Street are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.122 Scorer StreetPage 37 122 Scorer Street / 21st March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000052443.V208333.R01© This report may only be used in its entirety. 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