Inspection on 21/02/08 for 13-15 Darlington Road

This inspection was carried out on 21st February 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13-15 Darlington Road 30/11/06

13-15 Darlington Road 06/01/06

13-15 Darlington Road 27/09/05

13-15 Darlington Road 30/11/04

13-15 Darlington Road 11/05/04

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Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME ADULTS 18-65 13-15 Darlington Road Community Restart Team 13-15 Darlington Road Kirkholt Rochdale Lancashire OL11 2LL Lead Inspector Val Bell Announced Inspection 21st February 2008 10:10 13-15 Darlington Road DS0000034553.V360014.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 13-15 Darlington Road DS0000034553.V360014.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. 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 13-15 Darlington Road Address 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) Community Restart Team 13-15 Darlington Road Kirkholt Rochdale Lancashire OL11 2LL 01706 658559 01706 340259 ssdarlingtonroad@rochdale.gov.uk Rochdale MBC Miss Katherine Dawn Schuller Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the total number of 3 places, there can be up to 3 service users in the category MD. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 30th November 2006 Date of last inspection Brief Description of the Service: The Community Restart team is a local authority service, which provides a range of housing support services to people with enduring mental illness and/or significant mental health problems. Within this housing range, the service offers 3 crisis/emergency/respite beds at 13/15 Darlington Rd, Rochdale for persons suffering with a mental disorder between the ages of 18 years - 65 years. This house is the only registered facility of the service. The house is situated close to the centre of Rochdale and provides 3 single bedrooms, together with lounge/diner, quiet lounge (1st floor), kitchen, and 2 bathrooms. Owing to its layout the house is not suitable for service users who may have difficulty with mobility or who need the use of a wheelchair. Darlington Rd is staffed 24 hours per day. A garden is available to the rear of the property, and parking spaces are provided to the front of the home. Darlington Rd is funded by the local council and is free of charge to people living within the Rochdale Metropolitan Borough Council boundary. 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. Site visits to the home form part of the overall inspection process and the lead inspector conducted a site visit during daytime hours on Thursday 21st February 2008. The purpose of this inspection was to look at the core standards of the National Minimum Standards (NMS). This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit, time was spent talking to two people living in the home and an advocate from Mind, a mental health organisation. Discussions were held with the person-in-charge and a senior support worker. An Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, had been completed by the staff team and returned to the Commission prior to the inspection visit. The Commission did not receive any satisfaction surveys from people using this service. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: The method of assessing peoples needs is robust and this ensures that the home only admits people whose needs can be met. People using the service are central to the assessment and care planning processes. Staff are effective at empowering people to take decisions that affect their lives. The advocate said that the way staff promote the rights of people admitted to the home is one the many strengths demonstrated by this service. She added that staff working in the home, encourage people to express their views and take every opportunity to make improvements in response to individuals’ suggestions. The advocate went on to say, ‘Kathy, the manager, is passionate about the service. She is always asking what can be done to make it better. The staff have excellent relationships with people using the service, social workers and community psychiatric nurses. I am invited to become involved in consultation processes, such as that undertaken with people prior to the smoking ban being implemented last year. Staff are very knowledgeable and skilled and communication is good. It’s an excellent service.’ Staff demonstrated a commitment to meeting the diverse needs of people in a person-centred way. A self-assessment document provided by the manager and support team stated, ‘We plan to continue to look at how we can improve 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 6 on delivering a high quality service and provide one-to-one packages of care that are tailor made to suit the needs of each individual.’ The service was commended for the quality of support provided to people. The support provided had prevented the need for people to be admitted to hospital. One person said, ‘There should be more places like this. It’s much better than having to stay on a hospital ward. There aren’t the same rules. I like the fact that I can cook my own food, when I want and not have to wait for staff to do it. There’s no rules on when to go to bed or get up either.’ Particular attention had been paid to assessing and managing risks to ensure that people were supported in a safe way. Furthermore procedures and staff knowledge about safeguarding issues afforded protection to the welfare and personal safety of people using this service. People are provided with meaningful opportunities for self-development and encouraged to develop support links in their local community. This enables people to regain control over their lives and is commended as an example of best practice in person-centred care. What has improved since the last inspection? What they could do better: One requirement was outstanding from the last report. A further requirement and five good practice recommendations were made during this inspection visit. The person-in-charge on the day of the inspection visit said that the registered person had left the organisation. This had not been notified to the Commission in writing as required by care home regulations. Furthermore, regulations also require that a senior manager of the organisation conduct monthly visits to the home, to report on the performance of the service and the quality of outcomes experienced by the people accommodated. These audits had not been undertaken as required at the last inspection. Further improvements could be made in line with good practice in five areas. Staff should be trained in the management of infection control and an assessment of how this is currently managed by should be undertaken completing the Department of Health guidance document ‘Essential Steps.’ The lounge area would benefit from redecoration and this would provide a 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 7 more attractive and homely environment for people using the service. Contract cleaners employed by the council should have standard Criminal Record Bureau disclosures in place to determine that they are suitable to be in contact with people using the service. Two members of night staff should receive training in fire safety. It was further recommended that a fire drill be undertaken to assess the competence of these two members of staff to evacuate people safely in the event of a fire. 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. 13-15 Darlington Road DS0000034553.V360014.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 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. A robust assessment process ensures that people can be confident the service will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose had been updated as required at the last inspection. This provided people enquiring about the service with useful information to reach a decision on whether the service would be suitable to meet their needs. A person admitted during the inspection visit was complimentary about the way staff had taken time to answer questions and offer reassurance to her. She said that she had found staff warm and welcoming and this had helped her to be less anxious about agreeing to a period of respite care, which was a new experience for her. Assessments of need had been obtained for both people using this service. One of the assessments was an updated version of the one received prior to the person’s last admission. The pro forma in use had been reviewed following consultation with staff and people using the service to prompt the referrer to include information about recent changes in the person’s condition. This ensured that the service had accurate and up to date information to decide if the person’s needs could be met. Both people had signed the assessments of 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 10 need confirming that they had been involved in the process and that the information was accurate. This was one example of a number that provided evidence of a commitment to continuous monitoring and review that had resulted in improvements to the way information was recorded. 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. People receive the kind of support that meets their assessed needs in an individualised way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is explained to people on admission that they will have a plan of care written up within 24 hours. Staff spend time with people to ensure that they are central to this process. Equality and diversity issues are identified at this stage and at the time of this visit staff had been booked on a training course in multicultural awareness. Confidentiality is explained and people are made aware that any information disclosed will be in the best interests of their care. The care plan seen contained comprehensive information on the support the person would receive to meet their assessed needs. The information was written in a person-centred way and this provided evidence that people were empowered to take decisions that affected their lives. The advocate from the Mind organisation said that the way staff promote the rights of people 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 12 admitted to the home is one the many strengths demonstrated by this service. The advocate regularly visits people to discuss their placements in relation to issues they might have or suggestions for improvement. This, together with the outcome measurement tool that had been introduced, demonstrated a commitment to meeting the diverse needs of people in a person-centred way. A self-assessment document provided by the manager and support team stated, ‘We plan to continue to look at how we can improve on delivering a high quality service and provide one-to-one packages of care that are tailor made to suit the needs of each individual.’ The service was commended for the quality of support provided to people. Particular attention had been paid to assessing and managing risks to ensure that people were supported in a safe way. Staff working in the home had received refresher training in risk assessment to ensure that they were competent in this area. 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This service demonstrated best practice in empowering people to recover from crisis situations and regain and further develop their quality of life experiences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This service is designed to support people in times of crisis by empowering them to regain the ability to live independent lifestyles of their choice. Examples of positive outcomes achieved for people using this service were found in records and from talking to staff on duty. In particular, the good quality support provided had prevented the need for people to be admitted to hospital. One person said, ‘There should be more places like this. It’s much better than having to stay on a hospital ward. There aren’t the same rules. I like the fact that I can cook my own food, when I want and not have to wait for staff to do it. There’s no rules on when to go to bed or get up either.’ It was evident that people are supported in a person-centred way, particularly in 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 14 relation to maintaining and strengthening supportive relationships. Staff place a high importance on relationship building by inviting relatives to become involved in individuals’ care. Care records and minutes of meetings contained examples of people being afforded opportunities to safely discuss their personal achievements and future plans. Written information and support is provided for people to access selfhelp groups, adult education and other opportunities for self-development and people are encouraged to develop links in their local environment. This enables people to regain control over their lives and is commended as an example of best practice in person-centred care. People admitted to the home are expected to maintain their independence in shopping for and preparing their own meals. Staff provide support and guidance in achieving a healthy diet and with budgeting skills. Emergency food supplies and funds were available for people admitted from crisis situations. One person who had used the service before said this system works well and that he liked the flexibility to eat at times of his choice. People have the facility to store their food safely in locked cupboards. 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. People using this service receive the right kind of support to meet their personal and healthcare needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the two people using the service had a plan of care in place. The second person had been admitted on the afternoon of the inspection visit. This person said she had been informed that a senior member of staff would sit down and discuss how her needs were to be met later that day, once she had settled in. People using this service require minimal support with their personal care needs and this was reflected in the care plan seen. The care plan was written in a person-centred way. This person was coming to the end of his stay and said he had used the service before. He confirmed that his identified needs had been met in line with his agreed plan of care. He added that staff had been very supportive in helping him to overcome his period of crisis. 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 16 The person-in-charge explained that people admitted in crisis situations can be confused and that this can disrupt their usual routines. Staff provide the right kind of support for people to develop coping mechanisms with stressful events and so regain the routines that typify their preferred lifestyles. Staff provide prompts for people to address their personal care needs and help with referrals or guidance on where to access advice on promoting good health. Thoughtful provision had been made to supply people admitted in a crisis with a bag of selected toiletries for their private use. Medication no longer needed had been disposed of and a full record had been kept of this as recommended at the last inspection. All medication brought into the home by people using the service is recorded. People are encouraged and supported to take responsibility for administering their own medication and are provided with secure facilities in their bedrooms for this purpose. Staff support and a secure medication cabinet is available in the office if people need to develop confidence in taking full control of their medication. 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Robust procedures are in place to afford protection to the welfare and safety of people using this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Procedures were in place for the recording and management of complaints within prescribed timescales. People admitted to the home were given information about what to do if they had concerns or complaints and information on how to proceed with a complaint was on display in the home. One person said he had used the service several times. He had no concerns and said that he was confident about talking to any member of staff if he was worried about something. People using the service also had access to an independent advocate employed by Mind, a mental health organisation. The advocate said that staff working in the home encouraged people to express their views and took every opportunity to make improvements in response to individuals’ suggestions. Rochdale local authority’s inter-agency procedures for safeguarding adults from harm had been implemented in the home. Staff on duty confirmed that they had received regular training in this area and were able to describe the correct procedures to take if abuse was suspected or alleged. There was evidence that staff had followed the correct procedures for a person previously admitted to the home, who had been identified as at risk of abuse within her home situation. 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 18 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. People using the service are provided with a living environment that is generally homely and safe, although this could be improved with additional investment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From a tour of the building it was evident that a number of improvements had been made to the environment such as new curtains in the lounge, vertical blinds in bedrooms and a new TV. However, one of the people using the service commented that curtains were missing from a window in the lounge, although there was a set of vertical blinds fitted to this window to afford privacy. She said it would be cosier with curtains up. The person-in-charge explained that they had been taken down for laundering. The décor in the lounge area was tired looking and in need of a facelift. The two people using the service agreed with this. The ceiling was stained above one of the windows from a previous leak and wallpaper was peeling away. There were 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 20 screw holes in one of the walls where a notice board had been removed as recommended at the last inspection. This lounge should be redecorated to provide a more attractive and homely environment for people staying in the home. Equipment, furniture and fixtures had been maintained in good condition. The self-assessment document provided by the manager and staff team indicated that future plans included the provision of garden furniture and pictures, chosen by people using the service, to decorate walls. The personin-charge commented that the staff team would like to make further improvements to the environment but this was compromised by budget restrictions, which were outside the control of the registered manager. The home’s communal and private areas were clean and no unpleasant odours were present. Contract cleaners are employed to clean communal areas from Monday to Friday and vacated bedrooms in preparation for people due to be admitted. Staff undertake these duties at weekends. The person-in-charge did not know if checks had been undertaken to ensure that cleaning staff were suitable to work in close contact with people staying in the home. The registered person should check that contracted cleaning staff employed by the council have satisfactory standard Criminal Record Bureau disclosures in place to afford protection to the welfare of people using the service. The self-assessment document referred to above, confirmed that there was a policy in place for preventing infection and managing infection control. However, it was noted that staff had not received training in managing infection control and that the Department of Health guide ‘Essential Steps’ has not been completed to assess current infection control management. A good practice recommendation was made to this effect. 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. Staff are suitably qualified, experienced and skilled to meet the assessed needs of people using this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken to during the inspection visit were knowledgeable about the issues experienced by people who suffer mental ill health. Staff spoke in a respectful way about the people they provided support to and it was evident that good teamwork had been developed with the aim of meeting needs in a person-centred way. 66 of staff had achieved a National Vocational Qualification at level 2 or above and two staff were currently working towards this qualification. No new staff had been recruited to work at the project since the last inspection. However, evidence of the corporate induction available to new staff including issues specific to the project was seen. This complied with the specifications of the ‘Skills for Care’ induction programme. 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 22 Personnel files belonging to two members of the staff team were examined. These contained evidence of the required pre-employment checks to comply with a requirement made at the last inspection. Training files were held for individual members of staff. Copies of training certificates provided evidence that mandatory health and safety training and additional training more specific to the needs of people using the service had been achieved. Two of the night staff needed to undertake fire awareness refresher training and it was recommended that this take place. Staff had access to further training such as the implications of Mental Capacity Act, abuse awareness and loss and bereavement. Staff had also been booked on training in multi-cultural awareness. All staff had updated their skills in risk assessment. 13-15 Darlington Road DS0000034553.V360014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43 Quality in this outcome area is excellent. The home is managed in the best interests of people using this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A senior member of the support team was in charge and present throughout the inspection visit. The registered manager was unavailable at the time. The management and support team demonstrated a commitment to continuous monitoring, audit and review that had resulted in improvements to the way information was recorded and the manner in which the service was provided. It was pleasing to find that people using the service had been at the forefront of decision-making processes. Minutes of meetings where 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 24 consultations had taken place with staff and people using the service provided this evidence. Examples of best practice included an improved referral/assessment form and the outcome measurement form that was completed by people at the end of their stay in the home. One example of how feedback had improved facilities for people was the recent provision of a digital free-view television box. Creative use of available resources has ensured that people have access to a range of opportunities to influence positive change in the way the home is run. This includes access to an independent advocate from Mind, a mental health organisation. During the inspection visit the inspector had the opportunity to meet the advocate to ask her views on the management of the home. She said, ‘Kathy (manager) is passionate about the service. She is always asking what can be done to make it better. The staff have excellent relationships with people using the service, social workers and community psychiatric nurses. I am invited to become involved in consultation processes, such as that undertaken with people prior to the smoking ban being implemented last year. Staff are very knowledgeable and skilled and communication is good. It’s an excellent service.’ It was disappointing that a requirement made at the last inspection had not been met. This was for a senior manager in the organisation to undertake monthly visits to the home to report on the performance of the service. The person-in-charge said that the responsible individual had left the organisation and another one needed to be appointed. The Commission must be notified of the contact details of the appointed responsible individual and a senior manager in the organisation must conduct monthly visits to report on the performance of the service. This requirement is outstanding from the last inspection. This will provide evidence that the management of the home is being supported by the organisation to maintain high standards in service delivery. A sample of health and safety records was examined and found to be accurate and up to date. A recommendation was made to undertake a fire drill involving the two members of night staff that need refresher fire safety training. This will provide an opportunity to assess their competency in keeping people safe in the event of a fire. 13-15 Darlington Road DS0000034553.V360014.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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 2 13-15 Darlington Road DS0000034553.V360014.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. Standard YA39 Regulation 26 (2) Requirement A senior manager of the organisation must conduct monthly visits to the home to report on the performance of the service and the quality of outcomes experienced by the people accommodated. (Previous timescale of 31/01/07 has not been met.) The Commission must be given notice in writing of the change of responsible individual. Timescale for action 21/03/08 2. YA43 39 (e)(iii) 06/03/08 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. Refer to Standard YA24 Good Practice Recommendations The downstairs lounge area should be redecorated to provide a homelier and more attractive environment for people using the service. Staff should receive training in the management of DS0000034553.V360014.R01.S.doc Version 5.2 Page 27 2. YA30 13-15 Darlington Road infection control and current infection control management should be assessed using the Department of Health guide ‘Essential Steps’. This will ensure that staff follow current good practice in safeguarding the health and welfare of people using the service. 3. YA34 Contract cleaning staff working in the home should have standard Criminal Record Bureau disclosures in place to afford protection to the welfare of people using the service. The two night staff referred to in this report should receive refresher training in fire safety to ensure that they have the knowledge and skills to keep people safe in the event of a fire. A fire drill should be undertaken that includes the two members of night staff in need of refresher fire safety training. This will provide an opportunity to assess their competency in keeping people safe in the event of a fire. 4. YA42 5. YA42 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 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 13-15 Darlington Road DS0000034553.V360014.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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