Inspection on 09/08/07 for 130 Whitworth Road

This inspection was carried out on 9th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

130 Whitworth Road 23/01/07

130 Whitworth Road 10/05/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Whitworth Road (130) 130 Whitworth Road Swindon Wiltshire SN25 3BJ Lead Inspector Pauline Lintern Key Unannounced Inspection 9th August 2007 11:45 Whitworth Road (130) DS0000061295.V343339.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 Whitworth Road (130) DS0000061295.V343339.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. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitworth Road (130) Address 130 Whitworth Road Swindon Wiltshire SN25 3BJ 01793 651678 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) londonroad@tiscali.co.uk Milbury Care Services Limited Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2007 Brief Description of the Service: The home is one of a number of homes owned and operated by Milbury Care Services. Situated in a residential area of Swindon the property is in keeping with other houses in the areas. The home is close to local bus routes and local amenities and within easy access to Swindon town centre. The service accommodates a maximum of four service users whose needs can be challenging. Staffing arrangements are determined by the needs of service users and at the time of the inspection there was a minimum of two staff on duty at any one time. The home provides waking night staff in addition to one member of staff sleeping in. The philosophy of care is underpinned by John OBriens five accomplishments with the emphasis of care to promote independence and support service users enjoyment in experiencing the wider community. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The first visit to this service was unannounced. Due to the manager being unavailable the inspector was unable to access certain documents and records therefore the inspector returned to continue the inspection a few days later by appointment. On the first day there were two staff on duty in the morning and three in the afternoon. All four service users were at home due to day services being closed for the summer holidays. The inspector was able to meet with three staff members to obtain their views and met each person living at the home. Prior to the visit to the home we sent out ‘have your say’ survey forms to each service user, staff members, relatives and friends. Two were returned from staff and two from relatives and friends. The judgements contained in this report have been made from evidence gathered during the visit and takes into account experiences of staff members and people using the service. The fees charged at 130 Whitworth Road range from £1,350 per week to £1,671 per week. What the service does well: The home provides each person with an illustrated service user guide, which contains information about the service, how to make a complaint, details of the fee charged, a copy of their contract and terms and conditions of their stay. There is also a pictorial copy of the home’s statement of purpose available. Each person has a care plan in place, which is kept under review. The plans reflect the person’s assessed needs and provide guidance of how these needs should be met. One person’s care plan evidenced that they had been involved in the development of their care plan, showing that the home are promoting person centred planning where possible. Staff were observed interacting with the service users and not solely with each other. Mealtimes are flexible and service users have input into the weekly menu. Health and safety is well managed, with staff carrying out regular checks on equipment etc. New staff receive induction training, which is equivalent to the Common Induction Standards and have adopted the El Box learning concept, which enables staff to complete some areas of training with the use of a lap top computer. Any complaints received are dealt with in accordance with the home’s policies and procedures and within the given timescales. Milbury carry out monthly audits and annual service reviews are completed to obtain the views of people using the service, their relatives or friends and staff members. The home was found to be clean and tidy and in good decorative order. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Whitworth Road (130) DS0000061295.V343339.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 Whitworth Road (130) DS0000061295.V343339.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): NMS 1 and 2 Quality in this outcome area is good. People are provided with the information that they need to allow them to decide if they wish to move into the home. Each person has an assessment of their needs to ensure that the home will be able to meet them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People are provided with information about the service to enable them to decide if they wish to move into the home or not. The statement of purpose is in a pictorial format and has been updated since the last inspection. Each person has a service user guide, which is also in pictorial format and contains information on what people can expect from the service, a copy of their contract and a pictorial service agreement. There is information on Swindon’s advocacy movement and a copy of the complaints procedure. Since the last inspection there has been a new admission to the service. The service user moved into the home as it was felt that their previous placement within Milbury was no longer meeting their needs. The service user appeared to have settled into their new environment and staff confirmed that the move had gone well. The inspector noted that the guidelines from the previous placement had not been reviewed however the manager explained that they did not wish to unsettle the service user by changing any guidelines/routines already in place if there was no need to. She confirmed that they are Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 9 monitoring whether any changes are necessary. The same person has moved in with risk assessments already in place however records show that these were due for review in June 2007 and this was still outstanding. The manager confirmed that she would ensure they are all reviewed to take into account any changes, which may have occurred. Records show that people who use this service have had a needs assessment prior to moving into the home. This includes all aspects of their life such as mobility, communication, physical and emotional needs, medical, social and cultural needs. The manager has now written to each person confirming that the home is currently able to meet his or her needs. Each letter is kept in the person’s case file. At the present time the home do not operate a key worker system however the manager reported that this is an area they are considering developing in the near future. Whitworth Road (130) DS0000061295.V343339.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): NMS 6, 7 and 9 Quality in this outcome area is good. People needs are assessed and this is reflected in their individual plan. People who use this service are given the opportunity to make decisions about the way they choose to live their lives. Strategies are in place to support people to take responsible risks however one person’s assessment was in need of reviewing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two case files were sampled as part of the inspection process. Both care plans showed that the person’s care needs have been kept under review. Individual plans contain information on the person’s health, social needs, emotional needs, mobility, communication needs, medication, likes and dislikes, cultural needs and social and leisure needs. There is evidence to show that the home is working with a person centred approach. One person has made handwritten entries in their care plan such as the foods that they like to eat. This is good practice and could be developed further by the person signing other documents contained in their care plan such as their desired funeral arrangements. The manager has agreed that this would be implemented. The Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 11 inspector discussed the role of a ‘link resident’ with the manager and one service user who confirmed that they would be interested in taking on this role. The inspector will forward further information on the scheme to both for their perusal. Each case file has a photograph of the person on the front which explains to the reader ‘who the file belongs to’. People have identified their goals and aspirations and how they need staff to support them to reach them. One person told the inspector that their goal was to have their own front door key and the manager confirmed that they were working towards this. The manager reported that they are pleased with the way the person has learned new skills and is able to be much more independent now in may aspects of their life. There is evidence to show that care plans are kept under review and that service users participate if they wish in the meeting. One person was able to inform the inspector of the month their next review meeting was due. Plans focus on the positive aspects of people’s strengths and character and not necessarily on their disability. Files record ‘what I am good at’ and ‘I am working with staff to stay safe and comfortable’. Feedback from relatives /friends surveys state that one person feels that the home always give the expected/agreed amount of support to the service user and one person felt that they usually do. We received the same responses when we asked ‘does the care home meet the different needs of people for example; race, ethnicity, age, disability, gender, faith and sexual orientation. Discussion with the manager took place on how the home may be able to provide effective communication tools for one service user. The manager confirmed that she would explore the possibility of purchasing tactile objects and other sensory related equipment to enable the person to become more independent. It had been identified in the person’s care plan that a referral to the sensory impairment team could prove beneficial with regard to available aids. Staff members explained how service users are empowered to make decisions in their day-to-day life. For example they provide one person with the information on what a particular piece of clothes looks like and will then let them feel the material to decide which item they choose to wear that day. One person explained that they are able to make decisions on when they go to bed and get up. Risk assessments are in place and generally kept under review. However it was noted that one person’s risk assessments had not been reviewed in June 2007 as recommended. The manager confirmed that she would address this straight away. The manager explained how she ensured that all new staff were aware of any potential risks to service users and any current situations that may pose a risk had been explained to them. There is evidence to show that any current risks relating to one person has been kept under review. Whitworth Road (130) DS0000061295.V343339.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): NMS 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. Generally people have the opportunity to participate in appropriate leisure activities and are part of the local community however this is an area that could be further improved. Links with family and friends are supported and encouraged. People’s rights are respected. Mealtimes are flexible and menus are varied to suit the needs of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection each person now has an activity timetable. Some of the activities are ‘in house’ such as helping to clean their bedroom, hovering, cleaning drawers out, watching television, foot spa, massage and listening to music. People also have the opportunity to attend day services such as the ‘Gateway’ club. One person informed the inspector that they usually attend college three times a week however they were now on summer break. The first day of the inspection was a particularly nice summers day and the inspector noted that there was little or no activities planned for that day. The home has a pleasant garden area, which could have been accessed for a BBQ or just to Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 13 relax in however all of the service users remained in the home watching television or in their bedrooms. Discussion with the manager followed on the second day of the inspection regarding this observation. The manager agreed that there was some room for improvement in this area and that she would be discussing activity opportunities further with the staff team at the next staff meeting. One relative’s/friends survey commented that they ‘feel some consideration should be given to encouraging regular simple exercise, when no other activity takes place’. One person reported that they would like to ‘go out for a night on the town’ if possible. They added that they enjoy going to the cinema, bowling and to the pub to play pool. Daily diaries record that two service users had been to the theatre to watch Starlight Express, which one person confirmed they had enjoyed. Most people have the opportunity to have an annual holiday away from the home. Two people had recently been to Butlins in Minehead and comments such as “we went dancing and stayed up until 12.00pm” suggested that they enjoyed the experience. The manager reported that one person had commented that they would like to go to Blackpool to see the lights and they were hoping to arrange to take them this year. The weekend before the inspection one person had celebrated their birthday and they informed the inspector that all of their college friends, family members and friends from another local Milbury home had been invited to the home for a BBQ. Links with family and friends are encouraged and supported by the staff team. Any restriction set are clearly detailed in the care plan and supported by a risk assessment. Guidance and support is offered to enable people to develop and maintain personal relationships. All service users at the home are offered a key to their bedrooms. Service users can choose when they wish to be alone or in company. During the inspection one person was seen to spend time in their bedroom while others spent time in the lounge with staff. The first day of the inspection staff were observed chatting to service users and mainly communicating with them rather than solely with each other. However on the second day it was noted that whilst one service user was talking to a staff member they appeared to be more interested in the magazine they were looking at rather than responding to the person who was trying to communicate with them. This was shared with the manager during ‘feedback’ time at the end of the inspection. One relative/friends survey reported that ‘staff sometimes speak to each other in a foreign language (not understood by the resident), which they felt is bad manners in what is the residents home, but can also make them feel excluded’. This was discussed with the manager who confirmed that there might have been occasions of this in the past, which she had addressed and she confirmed that this practice did not take place with the current staff team. During the visits to the home the inspector did not observe this practice taking place. There is a menu board in the hallway at the home, which details the choices of food for the week people have made. A staff member explained that people are able to make choices on the food that they eat. Staff were observed Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 14 discussing the menu and shopping list with one service user and they were choosing what items needed to be bought. Service users accompany staff to buy the food for the home. One person reported that they had helped cook the Sunday lunch by preparing the vegetables and another person confirmed that they had laid the table. Whitworth Road (130) DS0000061295.V343339.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): NMS 18, 19 and 20 Quality in this outcome area is good. People using this service are well supported with their personal and healthcare needs. Medication is managed well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has an individual care/support plan, which includes preferred times and flexibility. Guidelines are in place to instruct staff on how to carry out particular routines in a way that the person prefers. One person’s care plan states that they do not like clothes with frills or labels and will reject them if offered. One service user has limited verbal communication skills and their method of communication is detailed in their care plan, which states that they use facial expressions, gestures and body language to express their needs. There is evidence to show that people are supported to attend appointments with healthcare professionals when needed. All service users are registered with a local doctor. One daily diary records a recent hospital appointment attended by a service user with staff support. One person reported that they have an appointment to attend with the dentist soon. There is evidence to show that the consultant psychiatrist inputs into the management of service users mental health needs if necessary. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 16 The manager reports that since the last inspection there have been five incidents when restraint has been used. She confirmed that most incidents were relating to self-harming and that on each occasion records were completed including body maps. Staff receive training in Non-Violent Crisis Intervention (NVQ 1), which is updated regularly. Medication administration records were examined during the inspection and records appeared to be completed correctly. Arrangements for the storage of medication are correct. The manager explained that following a ‘good practice recommendation set at the last inspection she now ensures that staff member receive ‘in house’ refresher training on medication policies and procedures. Training in the safe handling of medication is covered during the induction period. The home is in the process of providing service users with Health Action Plans. Whitworth Road (130) DS0000061295.V343339.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): NMS 22 and 23 Quality in this outcome area is good. People tell us that they feel that they can raise concerns and they will be acted upon. Policies and procedures protect people from any form of abuse where possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager states that in the last twelve months there have been no complaints made to the service. The home has a log for recording any complaints and at the time of the inspection there were no recent entries. Minutes from the house meeting evidenced that when one person had raised issues about another person in the home this has been taken ‘on board’ and the manager confirmed that they are looking at ways of alleviating the situation. One person said that they would know who to go to if they were unhappy. Both people who spoke to the inspector confirmed that they had no worries or concerns regarding this service. Feedback from relatives/friend surveys report that one person knew the procedure for making a complaint, whereas the other person said that did not know how to. Each service user has a copy of the complaints procedure within their care plan, which is in a pictorial format. This is called ‘letting us know what you think’. Each person also has a ‘help card’ for raising concerns with the appropriate person within the organisation. As mentioned earlier in this report staff are trained in NVCI to ensure that any incidents of restraint are carried out safely and in the service user’s best interest. The home has a ‘whistle blowing’ policy in place to enable staff to feel protected if they wish to disclose any information regarding suspected abuse. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 18 Evidence shows that the manager will address any concerns she may have with the appropriate people to safeguard the people living at the home. There is a copy of the local protocols for reporting suspected abuse (No Secrets) in the home for staff to access. Staff who met with the inspector confirmed that they know the procedure to follow. All new staff receive training in safeguarding people and have refresher training every two years. Service user’s finances are audited by the operations manager ion a regular basis. The manager explained that one service user now manages their own finances and is able to count their money and know the price of things. For safety her money tin is securely locked away however they are able to access it as and when it is needed. Whitworth Road (130) DS0000061295.V343339.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): NMS 24 and 30 Quality in this outcome area is good. The environment is homely, clean, hygienic and comfortable for the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On both days of the inspection the home was found to be clean and tidy. One service user said they had recently cleaned their bedroom and changed their bed. The home is generally in good decorative order with suitable and comfortable furniture and furnishings. The most recent person to move into the home had their room decorated for them in colours, which would aid their vision. The manager and inspector shared other ideas, which may enhance the person’s sensory awareness and independence. The manager confirmed that they are hoping to redecorate all of the other bedrooms over the next twelve months. Bedrooms have been personalised with pictures, photographs and ornaments. There is a pleasant garden, which is well maintained and has sufficient garden furniture for people to use. The manager reported that one person enjoys potting plants into pots around the garden. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 20 The home has a vehicle to enable them to access the wider community. The home is in keeping with others in the area. Bathrooms and toilets have adequate lockable facilities to ensure that their privacy is promoted. The home has suitable laundry facilities to meet the needs of the service users. This is not located near food preparation areas and was found to be clean and hygienic. Anti-bacterial hand wash and protective clothing is available to staff and located around the home. Staff receive training in infection control as part of their induction period and refresher courses take place every three years. Whitworth Road (130) DS0000061295.V343339.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): NMS 32, 34, 35 and 36 Quality in this outcome area is good. Staff members report that they are provided with a good level of training, which enables them to meet the needs of the people who live at the home. Service users are protected by the home’s recruitment procedures. Staff are now receiving regular formal supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a multi cultural staff team, though service users themselves appear to have no specific cultural requirements. Staff members report that they are provided with sufficient training to enable them to carry out the tasks expected of them. One member of staff commented that they had completed training in first aid, health and safety, manual handling, physical intervention, safeguarding adults, infection control and medication. One new member of staff confirmed that they had completed an induction and another added that they were waiting to complete their mandatory training but had spent time going through the home’s policies and procedures. One member of staff reported that they had an induction book and all relevant information was provided alongside a thorough verbal induction to the service’. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 22 The manager confirmed that all staff are familiar with and comply with General Social Care Council standards. Staff have the opportunity to work towards their National Vocational Qualifications following completion of the Learning Disabilities Award framework (LDAF). Milbury have a regional training and development manager who ensures that a regular updated training programme is implemented. Recruitment procedures protect service users from potential abuse where possible. Appropriate checks are made prior to someone working in the home, including police checks. Staff records show that two references are also sought and proof of identity is obtained. Feedback from staff surveys confirms that staff felt they were recruited fairly and thoroughly. Staff members confirmed that the manager is supportive and that they have regular access to her for one to one supervisions. Examination of staff supervision and annual appraisal records further endorses this. One staff member told us ‘There are regular supervisions scheduled and available on request’. Evidence shows that regular staff meetings take place. Minutes were sampled from meetings held on 12/07/07. Whitworth Road (130) DS0000061295.V343339.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): NMS 37, 39 and 42 Quality in this outcome area is good. The home is well run. There are opportunities for people who use the service to share their views and participate in the development of the home. The health and safety of people who live at this home is promoted and protected where possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has many years experience of working within the care sector. She has successfully completed her NVQ level 4 and is currently waiting to start her Registered Managers Award. There is an ‘open door’ policy to her management approach and service users were observed being relaxed and comfortable in her company. At the time of the visit to the service both the manager and the senior support worker were taking annual leave at the same time, which raised some concerns for the inspector. The manager explained that she had made Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 24 arrangements for the manager and deputy of another Milbury service to support and oversee the service in their absence. Opportunities are being provided to ensure that service users are able to raise issues openly. Since the last inspection the manager has ensured that regular house meetings take place, which provides a forum for exchanging ideas and raising concerns. On the 4/3/07 one of the service user had written the agenda ready for the planned meeting themselves, which is good practice. Monthly management audits are completed by the operations manager and are available for inspection at the home. Milbury complete an annual audit of the service when they obtain the views of staff and people using the service, this includes the views of family/friends and health care professionals. The results of the annual audit are used to form the home’s development plan. The most recent inspection report from the Commission is available for any interested parties. Policies and procedures are kept under review to reflect any changes in legislation. Company policy manuals are accessible to all staff members and service users are provided with accessible formats. As part of the inspection process various health and safety records were sampled. Examination of the fire safety log demonstrates that staff are receiving fire safety training in addition to participating in fire drills on 27/4/07 and 17/7/07. Each service user has a copy of their individual evacuation procedure in the event of a fire. There is a fire risk assessment in place, which was reviewed on 16/6/07. Fire fighting equipment was last checked on 16/7/07 and emergency lighting on 23/7/07. Records show that fridge/ freezer and hot water temperatures are regularly checked to ensure the safety of the people living at the home. All toxic materials are safely locked away and relevant data is available. All radiators are guarded to protect people. There is a current gas safety certificate dated 26/2/07 and portable appliance test certificate dated 1/9/06. All accidents/incidents and near misses are recorded correctly. Whitworth Road (130) DS0000061295.V343339.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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 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 4 X X 3 X Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 26 No 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 YA9 Regulation 13(b)(c) Requirement The registered person must ensure that any potential risks to service users are identified and kept under review. Timescale for action 09/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA12 Good Practice Recommendations It is recommended that the staff team explore further activities and leisure opportunities to ensure that service users are able to live a full and active life. Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Whitworth Road (130) DS0000061295.V343339.R01.S.doc Version 5.2 Page 28 - 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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