Inspection on 13/05/03 for 16 Mansfield Road

Care Home For Younger AdultsMansfield Road (16)Heanor Derby Derbyshire DE75 7AJUnannounced Inspection13th May 2003 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 16 Mansfield Road Address Heanor, Derby, Derbyshire, DE75 7AJ Email Address MansfieldRoad@united-response.co.uk Name of registered provider United Response (Amber Service) Name of registered manager Ms Deborah King Type of registration Care Home No. of places registered 4 Tel No: 01773 711270 Fax No: 01773 711270Category of registration, (with number of places) Learning disability (4) Registration number C020000237 Date First registered 20th November 1995 Do additional conditions of registration apply ? Does Annex for 16 and 17 year olds plus Part VI Care Home Regulations ­ Children, apply? Date of last inspectionDate of latest registration certificate 30th July 2002 NO NO 05/11/02 If Yes Refer to Part CMansfield Road (16)Page 1 Date and Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector Name of Inspector 1 2 3 413th May 2003 Brian Marks -2.45.pmID Code 071398Name of Lay Assessor (if applicable) Name of Interpreter/Signer (if applicable)Mansfield Road (16)Page 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Inspection Methods Used & Findings The Standards. National Minimum Standards for Younger Adults 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementPart B:Mansfield Road (16)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to ascertain if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 and / or the Children Act 1989 as amended. This document summarises the inspection findings of the NCSC in respect of 16 Mansfield Road. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Mansfield Road (16)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED This small home, which incorporates the principles of ordinary living and care in the community, was developed as part of the closure programme of nearby Morley Manor ­ a large institution with which 3 of the 4 service users had links from their early years. Set in a good-sized detached family house, the home is on a bus route near to the town centre of Heanor. The home offers spacious accommodation to the 4 service users who all have single rooms. All of the service users have a severe learning disability with associated conditions that include autism, sensory disability and challenging behaviour. Multidisciplinary work has continued as the norm, with support being offered from outside professionals from a number of backgrounds. Ongoing assessment and care planning have continued to be extensive, and activities have been tabled to meet individual needs rather than those of the group. The staffing levels have been set high in order to meet individual needs, and the lifestyles experienced by the service users offer a range of community based experiences, as a result.Mansfield Road (16)Page 5 PART ASUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was a good inspection for the home with a number of recommendations and requirements made at the annual inspection being achieved. Further improvements had been made to the homes environment, particularly refurbishment of the upstairs bathroom, and it continues to be a spacious, comfortable and safe environment for the service users to live and staff to work in. A major change that has occurred since the last inspection and which has resulted in a number of tangible improvements in continuity of care has been the achievement of a full staff group. This has also allowed the manager to re-establish a number of support and administrative systems that had previously been prioritised out.Mansfield Road (16)Page 6 Requirements from last Inspection fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 3 5 YA5 Details of contracting arrangements relating to the service users accommodation, including terms and conditions of residence, must be kept at the home on individual files and be available for inspection. The registered person must ensure safe administration of medicines through accredited training of staff. The registered person must improve access to the majority of the garden, which was uneven. The registered person must ensure that records of staff employed by the home, as outlined in Schedule 2 and 4, are retained within the home. 31.12.03513YA2031.12.036 1213 17YA24 YA4130.03.04 31.12.03Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements.Mansfield Road (16)Page 7 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 YA2 The registered person should develop a background history for all service users that will complement the range of assessment material already available. The registered person should ensure that all care planning documentation is dated and signed on completion or review. The registered person should record situations where physical restraint has been employed separately from accidents and incidents, to assist with better monitoring. A copy of the financial plan for the home should be available for inspection.3 10YA6 YA4111YA43CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Mansfield Road (16)Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action All staff recruited after April 2002 must be subject to a check by the Criminal Records Bureau (CRB) before working unsupervised; an indication of this must be retained on the staff file at the home.119YA34ImmediateRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Recommendation Action Standard * 1 YA34 All staff employed at the home before April 2002 should receive checks by the CRB before September 2004.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Mansfield Road (16)Page 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO NO YES YES NO YES NO NO NO NO NO YES YES NO NO YES NO YES 13/05/03 14:45 2.0The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable.Mansfield Road (16)Page 10 Choice of HomeThe intended outcomes for the following set of standards are: · Prospective service users have the information they need to make an informed choice about where to live. · Prospective service users individual aspirations and needs are assessed. · Prospective service users know that the home they choose will meet their needs and aspirations. · Prospective service users have an opportunity to visit and to `test drive the home. · Each service user has an individual written Contract or statement of terms and conditions with the home. Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service guide to the home. 851.00 969.00 Range of fees charged From To £ £ Any charges for extras YES3 Key findings/Evidence Standard met? The manager had redeveloped the statement of purpose, in line with the Regulation, to complement the previously developed service user guide.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, involving the prospective service user and employing an appropriate communication method. 2 Key findings/Evidence Standard met? The manager had attempted to develop background histories of all the service users but there had been a limited amount of documentation passed to United Response at the point of admission. The manager was endeavouring to comply this recommendation by dealing directly with their families, although 1 had no longer any contacts.Mansfield Road (16)Page 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The manager had re-referred the service users to the Derbyshire advocacy service after a number of years without contact.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit and to live in the home on a trial basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed Contract/Statement of Terms and Conditions between the home and the service user. 1 Key findings/Evidence Standard met? It was reported that the parent organisation had taken responsibility to meet this standard, but progress had been made locally.Mansfield Road (16)Page 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · Service users know their assessed and changing needs and personal goals are reflected in their individual plan. · Service users make decisions about their lives with assistance as needed. · Service users are consulted on and participate in all aspects of life in the home. · Service users are supported to take risks as part of their independent lifestyle. · Service users know that information about them is handled appropriately, and that their confidences are kept. Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet the current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? Whilst the arrangement of and standard of recording in service user files remained as at the annual inspection, the manager reported that the organisation was about to launch a new system that would streamline the management of information and daily recording at the home. With the appointment of a full compliment of staff the keyworker system had been reestablished. From examination of care records reviews of care had also been re-established on a regular basis and a target of a six months interval was about to be achieved for al service users. Standard 7 (7.1 ­ 7.7) Staff respect service users rights to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 13 Standard 8 (8.1 ­ 8.5) The registered person ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring that they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 14 LifestyleThe intended outcomes for the following set of standards are: · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. · Service users are part of the local community. · Service users engage in appropriate leisure activities. · Service users have appropriate, personal, family and sexual relationships. · Service users rights are respected and responsibilities recognised in their daily lives. · Service users are offered a healthy diet and enjoy their meals and mealtimes. Standard 11 (11.1 ­ 11.4) Staff give service users opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Whilst not specifically examined at this inspection, it was noted that one of the service users had enjoyed a personal day at home with 1-to-1 staff support; the others returned from day services attendance towards the end of the inspection.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education and training, and / or take part in valued and fulfilling activities 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 15 Standard 13 (13.1 ­ 13.5) Staff provide opportunities for service users to become part of and participate in the local community in accordance with assessed needs and their individual Plans. 3 Key findings/Evidence Standard met? The manager reported that with the improved staffing situation programmed activities were now much more likely to take place and the rota was weighted to support particular activities in the evenings.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of leisure activities. 3 Key findings/Evidence Standard met? Service user holidays continued to be high profile activities within the home and 2 had had individual holidays with 2-to-1 staff support. Holidays for the other two had been planned for the near future, one with his mother who has remained in regular contact and supports him with activities and his social life.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 16 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate and are protected by the homes policies and procedure for dealing with medicines. · The ageing, illness and death of a service user are handled with respect and as the individual would wish. Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their own lives. 3 Key findings/Evidence Standard met? With the appointment of a full staff team, the manager reported that improved levels of general functioning by the service users had been noted with fewer incidents or periods of anxiety. Also because of the improvements in staffing the keyworker system had been reestablished.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been admitted to Accident & Emergency since last inspection No of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Not specifically examined at this inspection. Standard met? XX 0Mansfield Road (16)Page 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? Although the manager reported that training for staff was in hand and was being arranged with a local pharmacist; the manager was advised that this should be general rather than specific to current service users. The general administration of medicines was managed satisfactorily.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect and as the individual would wish. 3 Key findings/Evidence Standard met? The manager had consulted with relatives/advocates regarding the funeral plans for service users and had developed a form for inclusion within individual files. She reported that generally discussion of this sensitive issue had been welcomed.Mansfield Road (16)Page 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · Service users feel their views are listened to and acted on. · Service users are protected from abuse, neglect and self-harm. Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how to complain and to whom. No. of complaints made to the home since the last inspection No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved Percentage of complaints responded to within 28 days 0 0 0 0 0 0 3 Key findings/Evidence Standard met? A copy of the complaints procedure had been displayed in the entrance area of the home as required at the last inspection.Mansfield Road (16)Page 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists since last unannounced inspection Key findings/Evidence Not specifically examined at this inspection. YES0 Standard met? 0Mansfield Road (16)Page 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · Service users live in a homely comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. · Shared spaces complement and supplement service users individual rooms. · Service users have the specialist equipment they require to maximise their independence. · The home is clean and hygienic. Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meets service users needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Inspection of the premises indicated the following: A new front door had been fitted which had improved security. The hall, staircase, corridors, office and laundry had been redecorated. The upstairs bathroom had been refurbished. The manager indicated that this years budget allowed for refurbishment of the kitchen, replacement of shower (for Health and Safety reasons defined by central organisation) and for re-planning of the garden. Access to the latter remained uneven and difficult for service users.Mansfield Road (16)Page 22 Standard 25 (25.1 ­ 25. 13) The registered person provides each service user with a bedroom which has usable floor space, sufficient and suitable to meet individual needs and lifestyles. No. of service users with single rooms No. of single rooms with at least 10 sq.m. usable floor space No. of single rooms with at least 9.3 sq.m. & compensatory space No. single rooms less than 9.3 sq. m with no compensatory space No. of rooms accommodating wheelchair users with 12 sq.m. space No. of rooms accommodating wheelchair users with less than 12. sq.m. space No. of shared rooms No. of shared rooms with at least 16 sq.m. space No. of single rooms with en suite No. of single rooms without en suite No. of double rooms with en suite No. of double rooms without en suite Key findings/Evidence Not specifically examined at this inspection. Standard met? 4 4 4 0 0 0 0 0 0 4 0 0 0Mansfield Road (16)Page 23 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? Remains as at the annual inspection. The bedroom of one service user was planned fro redecoration in conjunction with his family.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities that meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? As noted above (Standard 24) the upstairs bathroom had been refurbished to a good standard.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 24 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Standard 30 (30.1 ­ 30.9) The home is clean and hygienic. 3 Key findings/Evidence Standard met? The laundry room had been fitted with a lock and standards of cleanliness at the time of the inspection were high.Mansfield Road (16)Page 25 StaffingThe intended outcomes for the following set of standards are: · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. · Service users individual and joint needs are met by appropriately trained staff. · Service users benefit from well supported and supervised staff. Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Remains as at the annual inspection and the manager had distributed copies of the code of conduct published by the General Social Care Council.Mansfield Road (16)Page 26 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 3 1 0 X 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours X X X X Nursing X X X003 Key findings/Evidence Standard met? With the recruitment of new staff, the manager and staff spoken to felt that effectiveness of the staff group had improved since the last inspection and much better continuity of service had been re-established. There are now 3 of the staff team completing NVQ level 3, and the manager indicated that when they had completed the other members of the team would commence.Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 3 Key findings/Evidence Standard met? With the appointment of 3 full time staff the staffing situation at the home was significantly improved and use of agency staff almost eliminated. Staff meetings had been held on a weekly basis and this had allowed the team to gel together and support the re-establishment of the quality of the service. As reported in the previous section 3 staff had commenced on NVQ training and it was noted that this had some impact on the numbers of staff on duty on specific days; it was agreed that this situation required continued monitoring. Mansfield Road (16) Page 27 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The new staff spoken to reported that they had been through and organised and professional recruitment system and that 2 references had been obtained and checks through the Criminal Records Bureau had been carried out; an indication of this happening was not contained within the staff files examined. The latter were now retained at the home but the process of acquiring the required information was not complete.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The new staff spoken to indicated that they had carried out an induction programme, designed in line with the principles of the Learning Disability Award Framework. It was commented that this programme did not take into account the requirements of experienced staff. The manager had reintroduced annual appraisals for staff and these had been used to identify training needs and individual plans.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? With the employment of a staff team the manager was able to re-introduce a formal supervision system and staff records and comment supported this.Mansfield Road (16)Page 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · Service users benefit from a well run home. Service users benefit from the ethos leadership and management approach of the home. · Service users are confident their views underpin all self- monitoring, review and development by the home. · Service users rights and best interests are safeguarded by the homes policies and procedures. · Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. · The health, safety and welfare of service users are promoted and protected. · Service users benefit from competent and accountable management of the service. Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. NO3 Key findings/Evidence Standard met? The manager reported that she was now completing a registered managers course at a local college and this was to the required NVQ level 4 standard. All other aspects were as at the annual inspection.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Not specifically examined at this inspection.Mansfield Road (16)Page 29 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? An annual plan for the home had been developed for the current financial year of the parent organisation.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 3 of the National Minimum Standards for Younger Adults and Adult Placements. 0 Key findings/Evidence Standard met? Not specifically examined at this inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 2 Key findings/Evidence Standard met ? Standards of record keeping at thehome were satisafctory apart from the following issues that were identified: Accident, incident and restraint records were not recorded separately. As reported in section 34 staffing records kept at the home, were not complete. The manager reported that individual care plan files and records for service user were about to be overhauled by the parent organisation.Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? All issues identified at the annual inspection within this standard had been carried out: Staff had attended fire safety training apart from 1 who would be going to another United Response for this. The 5-year electrical wiring certificate was present for examination.Mansfield Road (16)Page 30 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 2 Key findings/Evidence Standard met ? Evidence of business planning and acountability were not held within the home and were unavailable for inspection. Insurance was in place to the standard.Mansfield Road (16)Page 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceMansfield Road (16)Page 32 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Lead Inspector Date Public reports-SignatureBrian Marks 20/11/03SignatureIt should be noted that all NCSC inspection reports are public documents.Mansfield Road (16)Page 33 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 13 May 2003 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleMansfield Road (16)Page 34 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 16th October 2003, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the requirements in a timely fashionYESAction plan did not cover all requirements and required further discussionNOProvider has declined to provide an action planNOOther: enter details here NOMansfield Road (16)Page 35 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Jeanette Simms of United Response, 16 Mansfield Road, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Jeanette Simms of United Response, 16 Mansfield Road am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation DateMansfield Road (16)Page 36 Mansfield Road (16) / 13th May 2003Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000020050.V74919.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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