Inspection on 30/11/06 for 13-15 Darlington Road

This inspection was carried out on 30th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13-15 Darlington Road 21/02/08

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

Similar services:

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 Sue Donovan Unannounced Inspection 30 November 2006 09:30 th 13/15 Darlington Road DS0000034553.V315592.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.V315592.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.V315592.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 865202 Rochdale MBC Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 13/15 Darlington Road DS0000034553.V315592.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. 6th January 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.V315592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told the inspection was to take place. The visit took place over seven hours from 9.30am to 4.30 pm and included a visit to the offices in Rochdale where the staff records are kept. The report was written after looking at the information sent to the Commission for Social Care Inspection (CSCI) including comment cards and after talking to service users of Darlington Road, a relative, the manager and staff and looking round the home. During the inspection care records were looked at to make sure service users needs were being met. The inspector also looked around the building to check if it was well decorated and clean. No complaints had been received by the CSCI since the last inspection and both a relative and service users confirmed that they knew how to make a complaint if they needed to. Service users said, “it’s good here,” “they talk to you when your ill,” “excellent” and “they take time to explain things.” What the service does well: What has improved since the last inspection? A new manager has been appointed who has good plans how to support service users and staff. A system to talk to staff on a one to one basis and to look at their strengths and training and development needs has been put in place. The home is being improved and new soft furnishings and fittings have been bought to make the home more comfortable. Service users have been involved in deciding what to buy. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good admissions procedure that makes sure that service users identified needs can be met. EVIDENCE: The statement of purpose that was displayed on the wall and the service user guide given to each service user were informative and included the organisational structure and arrangements for dealing with complaints. The guide explained what the service offers, who can use the service, what happens when you arrive, what is a risk assessment and care plan and how to get your views acted upon. Each area in the guide is discussed with the new service user and this was seen to be signed and dated. Since the last inspection in January 2006 a new manager has been appointed and the statement of purpose needed updating to show staffing changes. The last inspection report was displayed in the entrance to the home. Everyone admitted to the home, whether as an emergency or having planned respite care, receives an assessment of his or her needs prior to admission. A copy of this assessment is forwarded to the home by the care co-ordinator. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 9 The assessment is updated if necessary at each visit showing any changes in circumstances and risk to the original assessment. Staff at the home have an assessment form, which is completed at the time of contact with the person making the referral. This allows staff to determine if the placement is a suitable one by considering for example, the nature of illness, presenting problems and medication. A service user spoken with said he understood the rules of the home and that staff took time to explain things to him if he forgot. The manager said that she was planning to put a welcome pack together to be left in each room prior to all stays. This would include information about Darlington Road, what’s available from other services and information about the local area. A meeting was observed between an advocacy worker and the manager discussing this pack and plans were being made to involve suggestions from current service users regarding what would be useful to include in the pack. A DVD is also planned and funding agreed to make information more accessible to people interested in knowing more about the service. Two comment cards from service users both said that they had been asked if they wanted to stay at the home and that they had received enough information about the home to decide if it was the right place for them. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 67&9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were detailed and provide staff with the information they need to support service users. Service users are supported to make decisions about their life’s and links within the community are maintained. EVIDENCE: Two care plans were looked at. The assessment form was used as a basis to develop the care plan. The care plan is drawn up with the service user at a time that suits them, and is also dependent how well they are on admission. The care plans were seen to be holistic and included health issues, personal support needed, other professionals/agencies involved, medication, relationships, accommodation, financial and the management of risk. These were reviewed during each admission to the home. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 11 A service user spoken with said he had not seen his care plan but the member of staff supporting him explained what the plan was and said that he would go through it again with him. Progress sheets were completed for all service users at the home and the two files inspected were seen to be up-to-date and included comments on how service users health had been and activities service users had been involved in during their stay. Care plans showed that service users were encouraged to regain and retain control of their lives and this involved making decisions for themselves with the support of staff as necessary. One service user said, “staff are supportive, they talk to me and help me to decide things for myself.” Risk management strategies were seen on files. A traffic light system was used which showed how service users levels of difficulties might present. Green showed when a person was feeling fine and the support needed at this time, amber showed what extra support may be needed and any additional risk and red described behaviour that showed someone may be experiencing major difficulties/anxieties, how these presented and what support may help to reduce these. Staff provide service users with information and assistance to help them to make decisions about how they will spend their time during their stay and to maintain contact with relatives and friends unless this is seen to be unhelpful to the service user. This was documented in care plans. Service users said,” Its excellent here it gives me space,” and “it’s good here.” 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were encouraged and supported to participate in community activities and to pursue a healthy lifestyle. EVIDENCE: Service users are given information regarding groups the can help them to find voluntary work or educational opportunities, a poster was seen on the notice board ‘get involved in volunteering’. The manager said that one service user continued with his voluntary work at the RSPA and the Oxfam shop during his stays. The primary purpose of Darlington Road is to provide support during times of crisis and to offer respite for service users and their families for a maximum 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 13 period of up to two weeks. Using this period may avoid admission to hospital or just allow the service user time to relax. One service user said, “it gives me space staying here.” Participation in any aspect of lifestyle is very much dependent on the service users mental and physical well-being. Whilst at the home service users are free to decide how to spend their time. Staff do however supply information and encourage service users to get involved in various groups that they can continue with or look into once they return home. Numerous agencies were advertised on the notice board and open to service users involvement. Balderstone Technology College ran courses that some service users had enrolled on. The hope group, funded by mental health services, ran a number of activities during each week and the manager was currently encouraging a service user who loved music to become involved in a music appreciation group. The Mental Health advice line number was also displayed. A service user spoken to said that he had been shown the local area and that he sometimes went into town or to the local shop. He said that during his stays he usually spent his time in the home watching television or listening to music. He also said that he found talking to staff really helpful, that they listened to him and helped him. The manager plans to include in the welcome pack, leaflets on what’s on in the local area and menus from local take aways. The manager and advocacy worker are planning asking Service users what they feel would be useful information to be included in the pack for someone who was new to the service. Families and friends are encouraged to visit their relative and the home has an open visiting policy up to ten o’clock at night. All service users and visitors to the home are asked to respect the rights of other people staying at the home. A relative said,”I visit X when he’s staying here, its good here. It gives me a break.” A family support service is available and the home can assist a carer to complete a referral form. The manager said she was passionate about families and carers being involved. Service users had keys to their rooms and had a lockable cupboard within the room. Service users were responsible for their own meals whilst staying at the home but a supply of food was kept for emergencies. Service users had their own lockable cupboard within the kitchen and space within the fridge and freezer. A separate fridge and storage area was kept for storing Halal foods if needed. Service users were encouraged to retain their cooking and budgeting skills and staff provided support in this area, this was documented in the care plan. The 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 14 manager said that staff encourage service users to eat a healthy diet and will demonstrate how to cook food. Meals are flexible, service users prepare food and make drinks when they want to but they are encouraged to eat if necessary. One service user said, “ I cook my own food, I cook mainly microwave food. Staff do show me how to cook and how to use the cooker.” A paid advocate is available who is managed by the National Association for Mental Health (MIND) but works for the community restart team. (this includes work at Darlington Road). This assists in making sue that service users views are sought and acted upon. On the day of the inspection the worker was seen meeting with service users. 13/15 Darlington Road DS0000034553.V315592.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports service users in their lifestyles. The health needs of service users are well met with evidence of good disciplinary work taking place. EVIDENCE: Service uses maintained maximum control over their lives, assisted, whenever appropriate by staff. Staff were seen to be actively listening and supporting service users. Service users are generally physically able to take care of their own personal care, although staff may prompt and encourage service users to maintain their personal hygiene and appearance. Routines are flexible and service users can get up and go to bed when they want. A service user said that she had stayed up the previous night till 11.30pm watching a film. Staff said they follow care plans and requests from 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 16 service users for example a service user may ask ‘can you give me a knock at 10’, staff will note this and follow this request. Service users are expected to bring their own clothing etc. into the home. But in an emergency some personal toiletries would be provided. Male and female staff are available to support service users on request. The manager said that four Asian workers that spoke Bengali were employed across the scheme and available if needed to support service users with cultural and communication needs. Healthcare needs of service users were assessed prior to admission and were monitored throughout their stay. Progress sheets showed evidence of this. Service users generally remain in contact with their normal doctor. Other mental health professionals remain involved in their wellbeing whilst they are staying at the home. The homes medication policy described the safe handling of medicines and makes reference to self-administration of medicines. Service users are encouraged through a risk assessment to self medicate and lockable space is provided in bedrooms to ensure safe storage of medication. The recording, handling and safekeeping of medication was satisfactory and the home had the facility for the safe storage and recording of controlled drugs. It was noted that unused medication was waiting to be returned to the pharmacy and this should be done on a regular basis. All staff involved in the administration of medication were said to have completed basic training in this area. Certificates must be held on staff files as proof of training or staff should re- take the relevant training. 13/15 Darlington Road DS0000034553.V315592.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory policies, procedures and practices were in place for complaints and protection of service users, who felt safe whist staying at the home. EVIDENCE: Two service users staying at the home said they were aware how to complain and the two ‘have your say ‘ comment books returned both indicated that they knew who to speak to if they were not happy. Copies of the complaints procedure are on the notice board and these are given to service users with the information pack when they start to use the service. The information pack is signed for under each section, including ‘how do I get my views aired and acted upon’ to show that they understand how to make a complaint if necessary. At the end of each stay each service user completes with staff an exit questionnaire that asks service users if they have had a number of areas explained to them during their stay, this includes the complaints procedure and gives them the opportunity to comment. All complaints are sent to the manager of community restart and they are logged and responded to, a copy of logged complaints/comments and compliments was sent to the home during the inspection. This showed that all complaints had been dealt with within agreed timescales. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 18 It was discussed with the manager that a complaints log should be kept within the premises showing any concerns raised, together with action taken to address the problems and the outcome of each complaint. The Commission had received no complaints since the last inspection. A copy of the Rochdale Inter-agency Protection of Vulnerable Adults (POVA) procedure was held at the home. A flow chart showing the procedure to be followed was displayed on the notice board. The manager said that staff had undertaken training re- the protection of vulnerable adults but no evidence was seen to show staff had completed this training .A member of staff spoken to said he hadn’t attended any training this year. 13/15 Darlington Road DS0000034553.V315592.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Darlington Road provided service users with a bright, comfortable, safe place to stay. The manager had a good understanding of the areas in which the home needs to improve. EVIDENCE: The premises are two semi-detached houses converted into one dwelling. Service users accommodation consists of three single bedrooms, one bathroom, a lounge with television and music centre, dining area, a quiet lounge and kitchen. Other parts of the house provide office areas, a staff bedroom and bathroom. There is a large garden area to the rear of the property and service users who wish to smoke use this. The house was decorated and furnished to a reasonable standard. It had a homely feel but was sparse with regard to soft furnishings and fittings. The 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 20 manager had been planning with service users and staff to improve these. Numerous items were seen on the day of inspection waiting to be fitted put out around the building, for example curtains, tablecloths, lamps, coat stand and coffee table. Improving the surroundings was an ongoing project and the advocacy worker was seen asking service users what type of pictures they would like to see around the home. Locks are provided to all bathroom and bedroom doors giving service users privacy. Keys for their bedroom, the cupboard in the bedroom and their food storage unit are given to them when they start their stay. Service users can bring items of a personal nature with them for their bedrooms but as stays are for a maximum of two weeks this tends to be just clothing and toiletries. A person admitted in crisis is less likely to bring their possessions. CCTV is fitted and shows the front of the home/entrance area. This is fitted for the security of both residents and staff. The pre-inspection questionnaire showed the last fire service visit was 04/10/06 no requirements were required. The premises were clean and contract cleaners employed to visit the home once a day. Personal protective equipment that staff needed for personal care was provided. A washing machine was provided for the laundering of clothes and this was sited within the kitchen area. 13/15 Darlington Road DS0000034553.V315592.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 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team had the skills to undertake their roles effectively and work positively with service users to improve their health and wellbeing. EVIDENCE: Staff who work at Darlington Road are experienced workers who support people with mental health problems. Most staff usually commence work at the home having had previous experience of working in the mental health field. As well as working at Darlington Rd, it is common for staff to move around all aspects of the community resart team. This allows staff get to know service users who live in other projects but may from time to time access the Darlington Rd facility. The home is staffed twenty-four hours a day seven days a week by a minimum of one support worker. This varies depending on the number of service users staying and their needs. One person is on waking watch with another member of staff on sleeping in duty. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 22 Staff work in partnership with other agencies and families to try and ensure the best service is provided for the service user. Other agencies involved include housing associations, health trusts and MIND. Feedback from a relative and service users with regard to staff was very good. “staff are supportive.” “staff talk to you when your ill,” “excellent staff,” and “he’s well looked after,” were just some of the comments expressed. The pre-inspection questionnaire showed that recruitment and selection policies and procedures were in place. The files of three staff were looked at to see if all the necessary checks had been done before they started work. Shortfalls were found on all three files, evidence was missing of the Criminal Records Bureau checks (CRB) and evidence of identification. The inspector visited the human resources department of Adult services in Rochdale and found all of these held on the central files. Copies of the CRB reference numbers should be kept at the home. The manager said that no one starts work at the home before CRB checks are undertaken and in place. As no new staff had started at the home recently it was difficult to see the current induction procedure. Although the scheme had its own induction which included a power point presentation, two weeks working across the project and supervision fortnightly. The home needs to ensure that the induction of staff is inline with the Skills for Care induction standards. Currently 40 of staff hold a National Vocational Award (NVQ) and two staff are qualified NVQ assessors. Four staff are presently working towards the NVQ level 3 promoting independence award. The new manager showed a commitment to training the staff team and she said that senior staff were enrolling on NVQ 4 in care/management. A training matrix was not available for inspection this should be developed to show all the training undertaken by staff. Protection of vulnerable adults (POVA) and health and safety training was organised by Rochdale Metropolitan Borough Council and staff are recalled for refreshers by the training department. The manager had introduced a one-to-one appraisal system for all staff. She saw this as an important starting point in getting to know staff and review their performance and development. These included a review of the past year, a job plan and planned training and development for staff. These had been completed for all staff. Supervisions were seen as very important and although files looked at showed, prior to August 2006, gaps of over eighteen months in the frequency of supervision, these were now seen to be taking place monthly. One member of staff said,” there has been a lull in training but this has been picked up by the new manager and training needs identified,” and “supervision is on a regular basis now.” 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 23 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a new manager that has a clear vision. The systems in place for consulting with service users are good, with evidence that service users views are listened to and acted upon. EVIDENCE: The new manager has been in post since August 2006. She is a qualified therapist (person centred counselling) has NVQ 4 in care, Registered Managers Award (RMA), City and Guilds 730 (teaching adults) certificate and is planning on enrolling for NVQ 5 in management in April 2007. She has many years experience working in the field of mental health. One member of staff said the manager was supportive and easy to work with, and that things had improved. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 25 The registered provider did not inform the commission of the person appointed to the post and the commission has not yet received an application from the new manager to register as is required by the regulations. This was discussed with the manager and she was asked to immediately forward her application. Some effective quality assurance systems are in place such as service user exit questionnaires, comment cards, staff meetings and service user meetings with the advocacy worker. There is a high level of satisfaction shown by people who use the service. One service user said,” it’s important to me, it gives me space,” and “I look forward to coming again soon.” Feedback given to the home from the comment cards between January and June 2006 included the following comments; good for chilling out, helped when I most needed it, safe and friendly place, everyone fantastic and staff did an excellent job. The regulation 26 visits, when a representative of the project visits and checks the home and speaks to service users then produces a report, had not been taking place. This was discussed with the manager. A suggestion box was in the home. One service user said he had asked for a digital television box for the home and this had been purchased. The pre-inspection questionnaire showed that health and safety policies were in place and that regular maintenance checks were undertaken. However on random sampling portable appliance testing had not taken place since August 2005 and no evidence could be seen that all staff had had fire training. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 35 2 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation Reg.4(c) Requirement The registered person shall complete in relation to the home a written statement that shall consist of a statement as to the matter listed in Schedule 1. The registered person must ensure that the statement of purpose is updated. The registered person shall ensure the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. Specifically a record of training undertaken by each staff member employed at Darlington Rd must be supplied to the CSCI. (This needs to include POVA, medication and fire training) This was previously requested 6th January 2006. Where the registered provider is an individual, but not in day to day charge of the care home, he shall visit the care home in accordance with this regulation. Specifically the registered person must ensure monthly visits to DS0000034553.V315592.R01.S.doc Timescale for action 30/01/07 2. YA35 Reg.18 (1 c I) 31/01/07 3 YA39 Reg. 26 (1) 31/01/07 13/15 Darlington Road Version 5.2 Page 28 audit the service take place. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Refer to Standard YA24 YA20 YA34 Good Practice Recommendations The registered manager should consider removing notices from the lounge area and relocating these. The registered manager should ensure medication no longer required is returned to the dispensing pharmacy. The registered manager should consider keeping a photograph of staff on their files with evidence of CRB and personal identification. 13/15 Darlington Road DS0000034553.V315592.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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.V315592.R01.S.doc Version 5.2 Page 30 - 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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