Inspection on 23/10/06 for 140 Gloucester Road

This inspection was carried out on 23rd October 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

140 Gloucester Road 23/10/08

140 Gloucester Road 14/11/05

140 Gloucester Road 06/06/05

140 Gloucester Road 29/11/04

140 Gloucester Road 29/05/04

140 Gloucester Road 25/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 140 Gloucester Road Kidsgrove Stoke on Trent Staffordshire ST17 1EL Lead Inspector Jane Capron Key Unannounced Inspection 23 and 24 October 2006 03:00 140 Gloucester Road DS0000028867.V300564.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 140 Gloucester Road DS0000028867.V300564.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. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 140 Gloucester Road Address Kidsgrove Stoke on Trent Staffordshire ST17 1EL 01782 782596 01782 775918 linda.foden@staffordshire.gov.uk 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) Staffordshire County Council, Social Care and Health Directorate Linda Ann Foden Care Home 17 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (2), Learning disability (17), Learning disability of places over 65 years of age (6), Mental disorder, excluding learning disability or dementia (2), Physical disability (4) 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 Brief Description of the Service: 140 Gloucester Road is a home providing 24 hour care for 17 residents with a learning disability. A number of residents have additional needs including physical, sensory, challenging behaviour and mental health. The home is owned by Staffordshire County Council and managed by the Social Care and Health Directorate. The home is located in Kidsgrove. It is set back from the road in large grassed grounds. The home has two houses in the grounds for service users supported through the domiciliary services and their management is unconnected to the home. The home provides all single bedroom accommodation of which eight were downstairs. The home did not have a lift. The home had one large communal lounge and an industrial kitchen and three lounges with kitchens. The residents are divided into small groups and the groups spend time in their own lounge and eat together in their kitchen/diners. All except one of the residents attend Kidsgrove day services. The home provides residents with a high standard of accommodation. The aim of the home is to promote residents to be as independent ad possible. The current level of fees is £706 per week. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a two-day period lasting approximately ten and a half hours. During the inspection discussions were held with a number of residents both individually and in small groups. Several staff were spoken to as well as the manager. A selection of bedroom accommodation was inspected along with many of the communal areas. The arrangements for the storage, recording and administering of medication was examined as well as the arrangements for safeguarding residents’ finances. A sample of documentation relating to residents care was looked at. The arrangements for health and safety were also inspected. Prior to the inspection a survey of residents, relatives and professionals took place to gain their views of the home. What the service does well: ‘ I never thought I would have a family like this. I like everyone’ was the view of one resident about living in the home. There were positive relationships between staff and residents with residents making many positive comments about staff including: ‘I like my key worker. She helps me have a bath and takes me shopping’. ‘The staff are good’. ‘I have fun with some of the staff’. Residents felt that staff listened to them and acted on any issues they raised. One resident commented that ‘If I have a problem I tell the staff and they listen’. Support plans were of a high standard covering the areas of health and personal care, culture and spiritual needs, finances and education and leisure. Residents were involved in developing the plans through person centred planning identifying their hopes and wishes for the future. Most plans were being reviewed monthly and most residents had had a person-centred planning meeting within the last year. A couple of residents expressed some dissatisfaction with the home but the home was aware that it was not meeting these resident’s needs and had started assessments in order to identify more appropriate placements. The home was promoting residents rights to independence and choice. Residents said that they all helped with domestic tasks such as washing up and keeping their bedrooms tidy. Residents were encouraged to make choices over 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 6 what they wore and how they spent their time. One resident enjoyed gardening and had grown vegetables in the garden during the summer and was tidying the garden during the inspection. Other residents spoken to said they liked watching TV and some said they played board games in the evening. Residents chose where to spend their time either in their bedrooms or in the communal areas of their flats. The home provided a choice of meals and all residents spoken to said they liked the meals. Comments included ‘The food is good’, ’brilliant’ and ‘there is always a salad available’. The home was meeting the health and personal care needs of the residents. Residents said that they went to the doctor when they felt ill, to the dentist, the chiropodist and to the optician. The records confirmed this and showed that where relevant, residents were supported by a range of health specialists including the healthcare facilitator, psychiatrists, the behavioural services, and community nurses. Residents with hearing needs attended for hearing assessments and the nurse specialist in epilepsy saw several residents. The home had some procedures in pictorial form including the fire procedure and the complaints procedure. What has improved since the last inspection? What they could do better: The home is providing residents with a good service however there are certain improvements that need to be made to ensure that the home meets all the standards and regulations. Whilst having excellent support plans in place there were some that Similarly there were a few risk assessments that needed to be reviewed and in one case a resident with specific needs did not have a fire risk assessment in place. The medication was being provided correctly but there were practices that needed to be addressed. The home needed to take the temperature of the medication fridge correctly and needed to date short life medication when it was opened and make sure it was got rid of before it became out of date. The home also needed to make sure it that residents had agreed for the staff to give them their medication. Whilst in the vast majority of staff appointments the home’s recruitment procedure was protecting the residents there were isolated instances when there was no photo on file or the identity if the staff member had not been verified. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 7 The home has a low number of staff qualified and the home needs to look how this can be increased. In addition a number of recommendations were made. The home was asked to look at ways some of the residents could be more involved in running the home such as planning the meals, food shopping and cooking. The home was also asked to look whether it could provide more chances for residents to go out of the home to do for example shopping or to take part in social activities. Whilst the home had some systems in place to look at the service it provided it was asked to see if there were more ways they could do this. It was recommended that they ask more people what think of the home for example doctors and nursing staff. 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. 140 Gloucester Road DS0000028867.V300564.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 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures ensured that residents were only admitted following an assessment and that residents had the opportunity to visit the home prior to making a decision to move in. The home’s staff were able to meet the needs of the residents and and involved other professionals when needs were not being fully met. EVIDENCE: Examination of documents relating to the residents showed that residents were assessed prior to being admitted to the home. The assessments covered a prospective resident’s health and personal care, their education and leisure needs, their spiritual and cultural needs and their domestic needs. The resident that was most recently admitted confirmed that he had an assessment with a Social Worker and had visited the home prior to agreeing to move to the home. He said that he had looked at another home but decided he wanted to move to Gloucester Road as he felt that people were friendlier. Placements were not made permanent until a review had taken place that included the resident and other significant people. Residents’ files confirmed that the local authority provided contracts outlining they rights and responsibilities. The staff had the necessary staff to meet resident needs and had developed positive working relationships with health care staff needed to provide health care support to residents. A GP who responded to the pre inspection survey 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 10 felt that the home was aware of residents’ needs and that the staff worked in partnership with the GP. A Community Nurse felt that residents’ specialist needs were incorporated into the care provided by the home. The home was aware when it was not fully meeting residents’ needs and ensured that they worked with other professionals to find appropriate alternative placements. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes support planning process ensures that residents’ needs are identified and that residents are involved. However a minority of plans needed to be reviewed. Although the home had developed risk assessments to ensure that residents were not unnecessary restricted or exposed to unacceptable levels of risk a few assessments needed to be reviewed. Residents were supported to make decisions about their lives and to participate in activities related to the running of the home but there was scope for greater involvement by residents. EVIDENCE: Sampling of resident files showed that residents had a completed support plan in a person centred format. Residents said they were involved in developing the plan and some residents had completed their own plan. These contained all the necessary areas including health, personal care, spiritual and cultural, educational ,finance and domestic and social. Those with sensory needs had plans relating to this including hearing assessments by audiologist. The resident who was a wheelchair user had regular mobility assessments. The plan included methods for responding to any behavioural issues. The elements 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 12 were generally being reviewed monthly and most residents had had a person centred planning meeting within the last year. All residents had key worker and residents knew how this was. All files showed that home had developed risk assessments including bathing, accessing the community, finances and use of domestic appliances. Whilst most had been reviewed there were some that needed review. Discussions with residents showed that they were supported to make decisions over their lives. They could decide where to spend their time when in the home, for example in their bedrooms or in the communal room in their flat area. Residents said staff supported them to go shopping to buy clothes and to undertake leisure activities. The home involved advocates to help residents make decisions. The home looked after money for nearly all of the residents. The support plans identified the nature and level of support needed. A sample of records were examined and this showed that appropriate records were being kept and receipts over a minimum amount were obtained. Residents were encouraged to participate in a range of activities related to the running of the home including cleaning and tidying bedrooms and washing up. Comments included’ I clean my bedroom’ and ‘ I do washing up, and hoover and dust my bedroom’. Every three months flat meetings were held to ascertain residents’ views about such issues as food and activities. Several residents said that they had raised an issue at the last meeting and this had been immediately addressed by the staff. There was scope for more regular meetings and more involvement in aspects of running the home for example menu planning and shopping. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to have a varied lifestyle including attending the local authority day services and accessing a range of community resources. The home supports residents to maintain and develop relationships. The home provided residents with varied meals taking into account their preferences but there was scope for some residents to be involved in food shopping, menu planning and cooking. EVIDENCE: All the residents except one attended the local authority day services five days a week where they participated in a range of educational, occupational and social activities. All the residents accessed the community through the use of public transport or taxis. They went out to the pub, to the cinema, theatre, the local hairdresser and to use local health care resources. There was scope for further community access. Examination of the staffing rosters showed that more staff were on duty during the evenings and weekends when the residents were in the home. Activities out of the home did need to be arranged in advance to ensure that there were adequate staffing levels on duty. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 14 The residents said that the home’s routines were quite flexible. There were few rules except respecting other people. They said they could go to bed when they wanted, could go to their bedroom whenever they wanted or sit in the lounge in their flat. If they wanted to visit someone in another flat they would ask their permission. All bedrooms had locks on and several residents said they locked their door when they went out. Observation confirmed that staff did not open residents’ mail and residents said that staff brought letters to them and if they wanted, the staff would read them to them. Staff and residents chatted to each other throughout the inspection and there was a relaxed and friendly atmosphere. The home supported residents to maintain contact with family and friends. On the first day of the inspection one resident was out with his family. Another resident said that she had visitors to the home and that they could stay for meals. Relatives that responded to the pre-inspection survey said that they felt welcomed when they visited the home. The home had supported residents’ rights to develop close and intimate relationships and in such instances has arranged for them to receive specialist health advice. All residents spoken to said they liked the meals with comments made such as ‘ Brilliant’, ‘I like the food ‘ and ‘There is always a salad’. The meals were cooked in the main kitchen downstairs and transported to the flats where residents ate. Breakfast was cereals and toast which residents had when they got up. There was always a main meal a day and the second meal was more of a lighter type such as pizza, something in toast or sandwiches followed by a sweet. There was always baked potatoes with fillings and salad available as well as the meal on the menu. The home provided a lot of home baking and on both days of the inspection there were homemade puddings. There was always fruit available. The home was able to provide for specialist diets including a diabetic diet and a soft diet. Although residents did not plan the menus their views were sought over the meals they wanted. The home undertook surveys to gather this information. The staff provided residents with any supported needed with meals. There was scope for some residents to be more involved in meal planning, shopping and cooking. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was ensuring that the personal care and healthcare needs of the residents were being met. Whilst residents were receiving the prescribed medication there were some practices related to storage and administration that needed to be addressed. EVIDENCE: The support plans identified the personal care and health care needs of the residents. These showed the wishes of residents and how their needs were to be met by staff. The residents were seen to be well groomed with hair and nail care attended to. Discussions with residents said that they went to a hairdresser in Kidsgrove. They said that a chiropodist cut their nails. Discussions with a resident with mobility needs stated that they found the staff sensitive to her needs and that they respected her privacy. Several residents said that they went shopping with staff and that staff supported them to buy clothes and toiletries. Residents were supported by a range of health professionals including staff from the psychiatric and behavioural services, occupational therapy staff, specialist nurses and community nurses. Those residents with hearing needs attended the audiologist. The home involved advocates to assist residents with decision making in respect of health issues. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 16 Residents said that they saw the doctor when they felt ill and went to the dentist and the optician. Record showed that residents went to ‘well person’ clinics and received health screening. Replies from the pre-inspection survey confirmed that health staff could see residents in private and that specialist advice was incorporated in the residents’ support plans. The home had a monitored dosage system for the administration of medication. The examination of a sample of the medication administration records showed there to be no gaps in the records and that medication had been administered as prescribed. The home did need to ensure that short life creams were dated when opened and disposed of when out of date. Also the home needed to ensure that the temperature of the medication fridge was taken correctly. The home did not have consent from residents to administer medication recorded on all files. All senor staff except one that administered medication had undertaken training in medication. The other staff member was in the process of completing the training. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a suitable complaints procedure and there was evidence that residents were listened to and concerns acted upon. The home’s protection procedures were working to safeguard the residents. EVIDENCE: The home has a complaints procedure that is displayed in pictorial form in the hallway. The home had received no complaints. The residents said that they felt listened to and felt able to raise any concerns and were confident that staff would act on them. Several residents stated that they had raised an issue at a recent resident meeting and the staff had immediately sorted the issue. Discussions with several residents confirmed that the home arranged for residents to have access to advocates. The pre-inspection survey identified that most relatives were aware of the complaints procedure. The manager stated that she would send all relatives a copy of the procedure to make sure all were aware of the procedure. The home worked to the local authority’s procedure for the protection of adults. Discussions with some staff showed them to be aware of the procedure and how to respond should they have any concerns. Most staff had been trained in adult protection either through the local authority or as part of their NVQ training. The home had behavioural plans in place to respond to any incidents of aggression and violence. The staff were trained in diversion and distraction techniques and the only restraint used was to guide residents. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 18 The home had appropriate systems in place to safeguard residents’ finances. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided residents with accommodation that was of a good standard and was domestic in style. The residents had comfortable bedrooms that they could personalise and that provided them with privacy. The home was protecting residents through hygiene procedures that controlled the spread of infections. EVIDENCE: The home is set back from the road and is surrounded by a large grassy area. The home is located about a fifteen-minute walk away from the centre of Kidsgrove. It is not on a bus route and therefore many residents need to use taxis to access the local shops. Whilst the home is a large building the staff have divided the building into make four living areas. Residents were divided into four small groups and three groups had their own communal room that provided a small kitchen area, an eating area and a lounge area. The fourth area is larger with a lounge with dining area and a conservatory with a small kitchenette. This area was used by the more dependant residents and for parties and times when all residents met together. Each flat had its own TV. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 20 The home was decorated in a domestic style and had suitable lighting and heating. The home had all single bedrooms that have suitable furniture including seating. All bedrooms had sufficient storage space and had adequate plug sockets and had a lockable space where residents could keep items securely. All bedrooms were lockable. Residents said they liked their bedrooms and all the bedrooms seen had been personalised by their occupants. They had a range if personal items including TVs, radios, photographs and ornaments. Some residents had bought their own items of furniture. Comments from residents included ‘ I like my bedroom’ and ‘I have a nice bedroom full of my things - TV, video and my play station’. The home was clean and tidy throughout. The home employed domestic staff that cleaned the home and completed the laundry. The home had a laundry, which had equipment that was able to wash at a heat that could disinfect soiled laundry. The home had procedures in place to control the spread of any infections. All the staff were currently undertaking distance learning training in infection control. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are adequate to meet the needs of the residents but additional staff would provide greater opportunities for residents to access the community. The staff promoted residents rights and showed them respect. The homes’ recruitment and selection process was generally ensuring that residents were protected. EVIDENCE: The home provided adequate staffing levels to meet the needs of the residents. Examination of the roster showed it had always met its minimum staffing levels of three staff on duty at any time during the day when all residents were in the home. The home often had four staff on duty and the home needs this level if any residents were to access the community. At times the home needed five staff on duty as some residents needed two staff to access the community. The home provided two waking night staff. Also employed were 2 part time domestic staff, a laundry assistant, two part time cooks and a part time handyman. Discussions with staff showed that they were aware of residents’ needs and the level of support they needed. Observation of staff and residents showed that there was a relaxed and friendly atmosphere and that staff treated residents with respect. Residents and staff related positively. Residents felt 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 22 staff listened to them and residents were aware of the identity of their key worker. Comments from residents included: ‘I like my key worker. She helps me have a bath and takes me shopping’. ‘If I have a problem I tell the staff and they listen’. ‘The staff are good’. ‘I have fun with some of the staff’. Examination of a sample of staff files showed that the home undertook the required pre employment checks including obtaining two references and a Criminal Records checks and a check of the Protection of Vulnerable Adults list. All records seen except one had photo and confirmation of identity and the manager agreed to sort this out immediately. The home maintained excellent training records that clearly showed the training required and when this had been completed. Plans were in place to ensure staff received the necessary updates. Staff had undertaken induction training with some staff taking training through the Learning Disability Framework. All staff were in the process of taking a distance learning course in infection control. The home had a relatively low number (five) of staff trained to NVQ level. Professionals that responded to pre-inspection survey felt the home worked well with them. 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager with the support of the senior staff is providing the residents with a well managed home. The home is reviewing and monitoring its performance and is obtaining the views of residents however there is scope for further development. The home’s health and safety procedures are providing a safe environment but the home needs to ensure that all fire risk assessments are in place. EVIDENCE: The Care Manager had the necessary skills, knowledge and experience to be an effective manager. She has undertaken periodic training to keep up to date with current practices. She had responsibility to manage the home to ensure that it met the necessary standards and legislation. She is well supported by the senior staff. The home had some systems in place to review and monitor the quality of the service provided. This included a six monthly Health and Safety audit, random 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 24 checks by manager and resident surveys. Until recently the local authority completed a full external audit. As this had ended the home needs to put in place its own process and the manager stated that the checks that she completed informally would in the future be recorded. The home operated the health and Safety procedures of the local authority. The home displayed Health and safety posters. The home had a range of risk assessments to ensure safe working practices. A sample of Health and Safety documentation was looked at. Fire safety checks including the fire alarm and emergency lighting were completed. The home had regular fire drill that included the residents. The fire procedure was in a pictorial format. The home provided internal fire training for the staff twice a year and there were plans in place to ensure that staff that had missed the training received it. Other health and safety training was up to date and an update in moving and handling was scheduled for later in the month. Observation of electrical items showed that Portable Appliance Testing had taken place. The temperature of water, hot and cold was monitored. The home had an evacuation plan in place and all residents except one with specific needs had a fire risk assessment in place. 140 Gloucester Road DS0000028867.V300564.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 X 2 3 3 3 4 3 5 3 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 4 25 X 26 3 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 3 X 3 X X 2 X 140 Gloucester Road DS0000028867.V300564.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. 2. Standard YA6 YA9 YA20 Regulation 15(2) 13(2) Requirement To ensure that all support plans and risk assessments are reviewed A maximum/minimum thermometer must be used to measure both the maximum and minimum temperatures on a daily basis to ensure that the fridge was maintained at a temperature of between 2 and 8°C. Medication that has a short shelf life when opened must be dated upon opening and discarded after the specified time period. To ensure that consent is obtained for staff to administer medication The home to work to increase the number of qualified staff. To ensure that a recent photo and confirmation of identity is kept of all staff. To ensure that all residents with specific needs have a fire risk assessment in place. Timescale for action 01/12/06 30/10/06 3. YA20 13(2) 30/10/06 4. 5. 6. 7. YA20 YA33 YA34 YA42 13(2) &12(2) 18(1)(a) 19 Schedule 2 23(4)(iii) &13(4)(c) 01/12/06 01/02/07 07/11/07 07/11/06 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA8 Good Practice Recommendations To develop further the participation of the residents in aspects of the running of the home including involvement in menu planning, food shopping and food preparation and cooking and to consider increasing the regularity of resident meetings. To look at whether residents’ access to the community can be increased. To consider the home having the use of its own transport To further develop the system for the review and monitoring of the home’s performance including for example seeking the views of professionals. To have one fire training a year provided by an external fire specialist. 2. 3. 4. 5. YA13 YA13 YA39 YA42 140 Gloucester Road DS0000028867.V300564.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 140 Gloucester Road DS0000028867.V300564.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. 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