Inspection on 18/06/08 for 18 London Road

This inspection was carried out on 18th June 2008.

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

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

18 London Road 05/07/06

18 London Road 05/02/06

18 London Road 05/06/05

18 London Road 15/10/04

18 London Road 04/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 18 London Road Luton LU1 3QU Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 18th June 2008 12:15 18 London Road DS0000014932.V364480.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 18 London Road DS0000014932.V364480.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. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 18 London Road Address Luton LU1 3QU 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) 01582 877383 01582 721098 anete@anete.orangehome.co.uk Fairhome Care Group Limited Annette Yvonne Robinson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2006 Brief Description of the Service: 18 London Road is a home registered to provide long term personal and social care for up to 6 adults with a learning disability aged over 18 years. The home is a large detached property situated on a busy main road near to Luton town centre and local amenities. All service users have their own individually decorated bedrooms but five out of six share bathing facilities. The fee is in the range of £902.78 to £929.58 and the transport cost is extra that depends upon the usage. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This is the report of the unannounced inspection carried out on 18th June 2008 by Pursotamraj Hirekar over 5 hours 55 minutes. The senior staff member on duty coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, relevant care delivery documents, discussions with staff and people who use the services, observations of staff and people interaction and partial tour of the building. Annual quality assurance assessment (AQAA) – provider’s self-assessment and inspection feedback written response received from the registered manager is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? The service has a registered manager. Assessments and care planning process and documentation has improved, to enable the staff working with people who use the service to provide appropriate and timely care. People are encouraged to personalise their bedrooms, with the support from family and staff if required. The home had health and safety risk assessments and monthly checks carried out, these checks help in identifying any concerns to the premises; repair, maintenance, replacement and decoration programme that has been carried out included replacing stairs, landing and a bedroom carpet, installation of a new kitchen, decorated first floor toilet, bathroom and vestibule, stairs and landing, lounge, one person’s room, dining area and larder. Installed an additional handrail on the stairs and a second handrail on the exterior steps leading up to the home, as a result of a persons re18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 6 assessment of needs. A toilet has been installed in one person’s en-suite room. Two air coolers have been purchased. A larger door handle has been fitted to one person’s room to enable him to exit. The home continued to repair and replace items within the home as identified through the Annual Property Inspection and as and when required, so the house remains clean, homely and comfortable environment. The lounges furniture replacement and a person’s specially reinforced chair, work was in progress 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. 18 London Road DS0000014932.V364480.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 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service receive information about the home, and are involved in the assessment process to ensure their needs are met. EVIDENCE: Information about the home is contained in the statement of purpose and that was comprehensive and reflects the current services, offered to prospective and existing people who use the service. The process for moving into the home, facilities, and choices is detailed including the information on how to contact independent advocacy and complaints process. This is given to people when they move to the home as part of the admission process. However, it was found that, the information was set out in small fonts and not in an easy read style, to suit the communication needs of one person who was case tracked on this inspection. The registered manager stated in the annual quality assurance self-assessment that the home produce people’s introductory information pack in all formats before the need arises. Further, written confirmation was received from the registered manager post this inspection that the home was in the process of producing statement of purpose using Makaton picture symbols. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 9 There has been no new admission to the service since the last inspection. Therefore this standard could not be fully assessed. However 2 people using the service were case tracked. The home had undertaken a full assessment of needs for each of them. The method of assessment involved the person who used the service, the family, and other key stakeholders. There was also evidence that the home had regularly reviewed the assessments of need, through monthly meetings of the people. The home was able to demonstrate that it could meet the assessed needs of people staying at the home. Staff individually and collectively demonstrated that they had the skills and experience to deliver the service and care which the home said it could provide. There was evidence that the people who used the service whose lives were tracked had written contracts with the home. This included a statement of the terms and conditions, which had been signed by them or their representative, and the representative of the home. 18 London Road DS0000014932.V364480.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): 6, 7 & 9 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home had developed detailed care plans based on the needs and risk assessments of the people who use the service to support all aspects of their lives. EVIDENCE: The care documents of 2 people using the service were seen which, included the goal plan, support plan and health action plan outlined the individual need with regard to their personal care needs, support, health care, daily routines, domestic tasks, communication, transport, cultural issues, finances, social interests and risk assessments. The information was holistic and from the view of the people using the service in relation to their choice of lifestyle, needs and interests. These various plans were reviewed quarterly or as and when the need arouse and the changes were reflected in their care plan. For example a person had 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 11 an accident in the home and was referred to the GP, their changing needs have been reflected in the goal plan to ensure their care needs are appropriately met. And for another person, support plans were updated to reflect changing needs with clear guidelines for staff with regard to their unsteadiness, approaching front door and risk to other people at the home, to ensure that the daily routine at the home are properly followed up and quality of life goals were being met. However, on the day of inspection when he/she was offered fruits, he/she made a choice to eat the ‘plum’, the staff on duty were polite and offered him/her after washing the fruit without removing the stone. The person had eaten the plum with the stone as well, the 2 staff members on duty requested him/her to spit it out, and he/she didn’t and appeared to choke on it and then swallowed it. This was discussed with the registered manager post this inspection. The registered manager had confirmed in writing that a risk assessment has been implemented which details the importance to staff of removing anything from food which this person may be at risk of choking on. The registered manager further said that this will be highlighted at the next staff meeting to ensure that all staff are aware of those fruits which contain stones. The staff working were aware of the changes to the care plan of the person. Information was written to help staff to provide the right level of support in relation to promoting independence and skills for daily living such as personal care, domestic tasks, and accessing the community. People using the service said staff knew their routines and choices. The daily routines presented in the support plans reflected in the daily reports of the people using the services. People using the services can access social and community activities locally, which include their daily routines; going to their day centre. Observations made indicated the relationship between people using the services and staff is relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. The staff on duty said people make their own decisions or are supported through conversation to make their own decisions. For example, a staff member was providing 1:1 support to a person, who appeared relaxed at the home. Information received from the home prior to the inspection has stated that care plans have been developed in a format to suit each individuals level of understanding. Limitations on facilities, choice or human rights to prevent self harm or self neglect, abuse or harm to others are documented in individual care plans. Risk assessments have been implemented where freedom of choice is restricted and people are enable to access advocacy support. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service experience and enjoy a lifestyle that suits them, being part of the community and having meals of their choice. EVIDENCE: Staff members on duty, said people moving to the home are supported to continue participating in daily social and community activities. Information about each individual’s daily, social and community activities are detailed separately for morning, afternoon, and evening in the assessment and are included in their care plan. The people who use the service, confirmed during the discussion that they continued to participate in daily activities ranging from attending the day services, going out socially with family and friends. People can choose how to spend the evening and weekends, including seeing family. Activities and daily routines were reflected in the daily records were consistent with the interests 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 13 recorded in the individual care plans. 1 person who was scheduled to go out for shopping and lunch out could not go because she appeared a little low on health, and the staff on duty confirmed this. People using the services appeared to have control of their life at the home and were not restricted in what they did, except for 1 person who had detailed risk assessments that have been implemented with regard to freedom of choice. This has resulted in restricted access to the kitchen, because of their altering behaviour patterns this assists in preventing self harm and dangers to others living at the home. There was evidence that the home supported people who used the service to maintain family links and friendships inside and outside the home, in accordance with their wishes. People who were spoken with, who lived at the home, said that their families and friends could visit at any time supported this evidence. Staff demonstrated a good understanding of the people they key work, recognising if the person is anxious or unhappy, and how to approach them. People using the service spoken to, have said that they have the freedom to make choice of the meals and mealtime. Staff have received training in preparation and safe handling of food. Staff said they always encourage the people to choose the meals, offering fresh fruit and vegetables. For example 1 person who is diabetic, she refused to eat her lunch, the staff member on duty persuaded her to eat on time because of her health needs. When this person had made her choice of food and agreed to eat it in her bedroom. When we asked how was the lunch, the person said ‘yes the food was good and I like it’. The information received prior to this inspection from the registered manager stated that the key code to the back door has been removed during the day. The area to the rear of the house has had fencing replaced to allow people to have access to the garden at their own free will whilst maintaining safety for those who are risk assessed as not having adequate road safety skills. An electronic magnetic system has been installed on the kitchen door to enable easy access for all whilst maintaining fire safety regulations. An electronic lock release system has been installed on one person’e bedroom door to allow this door to be kept locked for privacy but allowing access as required. Lines of communication with one person’s family has improved regarding the person’s regular visits to the home, this was raised by the family, they are now happy with the changes. A person who was underweight has gained a stone through appropriate measure taken by the staff team to encourage them to eat. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The personal and health care needs of people, who use the service, are met promoting their independence and quality of life. EVIDENCE: The personal and health care needs of the people who use the service are detailed in their individuals’ health care plans, which were presented in a pictorial format, and staff has guidance in relation to the level of support required, if any. Risk assessments are detailed and include information about personal care, personal hygiene, toileting, medication, and technical aids, domestic tasks, social, and day care activities. Six monthly reviews were held for all people and the multidisciplinary team are made aware of all risk assessments in place for each person. If any agency feel the need for additional risk assessments to be added this was acted upon. For example, a social worker suggested that a risk assessment be put in place when a person started having giddy spells and this 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 15 was implemented immediately. Also, as part of the safeguarding investigation involving a person, a suggestion was made that a risk assessment was required concerning the risk to other people living at home, when this person was attempting to take their drinks. This was implemented with immediate effect. The registered manager, staff, and the people who use the service appeared to have good working relationships. This was supported through the observations made during the interactions, between the people and staff members. Records viewed suggested people received personal support in the way they preferred and most were encouraged to maximise their independence. Each person who used the service had a key worker. They were each able to identify who this was and they said they were happy with the support received from them. The registered manager also, had key worker responsibilities for a person living at the home The home had made arrangements for the people using the service to maintain contact with family and friends. Care plans detailed emergency contacts and health care professionals involved in their care. The records showed people had regular appointments with the general practitioner, nurse, psychiatrists, speech and language therapist, and occupational therapist and for aromatherapy as well. Trained staff administers people’s medication, staff training records, and staff spoken to have confirmed this. The staff on duty demonstrated a good understanding of the medication, people using services take and the importance of having the medication on time. People said they do receive their medication on time. However, 1 person medication given at 13.00hours was not signed off on the MAR sheet for today only, when this was pointed out to the staff member, she signed immediately. Medication is stored in a locked cabinet with the medication records in the individual people’s bedroom. The medication for two people using the service was checked, which was consistent with the medication records. The information received prior to this inspection from the registered manager stated that the home has been involved in the pilot scheme of health action plans. Which are now in place for all people and reviewed annually. Staff liase with other health care professionals promptly when required and encourage reluctant people to attend appointments which are in their best interests. Technical aids and equipment including bath step, seat and handle handrail to external steps, and wheelchairs are replaced. Toilet installation to a person ensuite room and installation of a door handle to another person’s room enabling him to exit, as they were having difficulties, were implemented. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. Staff are trained and people who use the service have their interests protected by procedures and practices including handling of money. EVIDENCE: The complaints procedure was available in an easy read style for the benefit of people using services that have communication needs. The people using the services indicated that they were aware of how to express concerns about the provision of care provided at the service. A person spoken to said if, “I am not happy, I just speak with the manager or my key worker”. Another person said ‘I speak with staff or manager’ The home had made 8 adults safeguarding referrals and cooperated in their investigations and 2 staff members were referred to the list of protection of vulnerable adults. The home continues to let us know about things that have happened since our last key inspection and they have shown that they have managed issues well. The service had arranged for staff training on safeguarding. The staff on duty, demonstrated an adequate awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff were confident to whistle-blow poor or bad practice and confirmed that the registered manager is available should any concerns arise. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 17 The people can choose to manage their own money if they are able to do so. Records of money transaction were maintained. The staff on duty described the process for recording and handling of money for people, which ensures people are protected. The money transaction records and the balances were checked for 2 people, and found to be correct. The information received prior to the this inspection from the registered manager stated that the home had planned to carry out staff training around interpretation of ‘restraint’ and ensure that all the staff received adult protection training. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service live in a warm, clean and a homely environment. However, further development was needed to always ensure that the home is free from any objects that may be potentially harmful to the people with special needs. EVIDENCE: The home was clean and tidy without any offensive odours and in appearance suits the lifestyle of the people living there. There is good lighting throughout the home. Individual bedrooms were personalised to suit the choice and taste of the people who use the service. The bedrooms are appropriately furnished and include personal objects as well. Two persons bedrooms were visited. . Onepersons bedroom had been personalised with photographs and toys that reflected her interests and hobbies. Another persons bedroom had limited 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 19 furniture due to altering behaviour patterns. This person’s bedroom had a basket full of soft toys. There was almost a 12-inch broken sharp wood piece placed with the toys in the basket. This was shown to the staff member who was with the person in the bedroom at the same time providing 1:1 support. The staff member stated the bed was repaired and the maintenance person might have forgotten to remove the broken wood piece. The staff member then disposed it immediately. This was discussed with the registered manger post this inspection. Who had confirmed in writing that “it has been necessary to reinforce xxx bed on few occasions recently due to him/her dropping their body on to it and breaking pieces of wood off it. However, the registered manager further confirmed that staff would sort through xxx toy box on a regular basis over and above when xxx is accessing its contents.” The people who use the service appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. Information received from the registered manager prior to the inspection stated that the home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. Which, resulted in replacing stairs, landing and a bedroom carpet, installation of a new kitchen, decorated first floor toilet, bathroom and vestibule, stairs and landing, lounge, one person’s room, dining area and larder. Installed an additional handrail on the stairs and a second handrail on the exterior steps leading up to the home, as a result of a persons re-assessment of needs. A toilet has been installed in one person’s en-suite room. Two air coolers have been purchased. A larger door handle has been fitted to one person’s room to enable him to exit. The home continues to repair and replace items within the home as identified through the Annual Property Inspection and as and when required, so the house remains clean, homely and comfortable environment. The lounge furniture replacement and a person’s specially reinforced chair, work was in progress The service had carried out fire alarm, door close, fire evacuation, fire doors, emergency lights, fire drill, smoke & heat detection, and water temperature checks. The records that were available at the home, and the staff on duty confirmed this. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The people who use the service are protected by staff recruitment procedures, training, and supervision. EVIDENCE: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. The key worker was aware of the needs of the person’s routines and how best to communicate with them. The staff recruitment documentation was not seen on this inspection, as they were not accessible in the absence of the registered manager, the registered manager was on a weekl off. This was discussed with the registered manager post this inspection, who had sent written confirmation with regard to the details of the staff recruitment practices that include an application form with employment history and any gaps in employment, qualification, 3 references, and an enhanced CRB check. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 21 The service had more than the required NVQ level 2 and above qualified staff working at the service. Staff training records showed that staff have received induction training, safeguarding, moving & handling, person centred planning, medication, health & safety, and fire hazard. This was supported by staff spoken to, which identified varied training, which they had undertaken. The management was aware that the staff team do not reflect the cultural/gender composition of people living at the home. Equality & Diversity training has been hard to source, and free places on training courses run by Luton Borough Council are limited and on a first come basis. The registered manager planned to make improvements in next 12 months through staff training in this area. The service had maintained appropriate staff deployment ratio based upon the needs of the people who use this service. Staff on duty, confirmed they received supervision. In the staff supervision, concerns raised by staff are addressed in the best possible way, which benefits the people using the service. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home has good quality assurance systems and procedures that enable the management to run a well managed home, to promote the quality of life of the people who use the service. EVIDENCE: On discussion with the staff on duty and the people who use the service, the registered manager appeares to have developed good working relations with the staff and the people living at the home. The various care documents seen on this inspection confirmed that there are clear roles and responsibilities in relation to the management of the home and staffing. Staff meetings were held, to discuss people’s assessed needs and care delivery, to ensure people’s assessed needs and staff training needs were 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 23 being met. The staff spoken to were confident that registered manager would be available if there was an emergency. All policies and procedures are updated, reviewed, and shared with the staff. The home had the quality assurance system and procedure, which ensured that the service had been actively engaged in quality assurance work, to ensure that the people living at the service had their quality of life goals were met. As part of the annual quality assurance system, questionnaires that were received with feedback from the people who use the service and their families were analysed and the results were used to develop action plan. The action plan has been used as a reference document to introduce changes and making improvements to the people’s care planning and delivery mechanisms. The home had health and safety risk assessments and monthly checks carried out, these checks help in identifying any concerns to the premises. The people living at the service have regular monthly meetings, in the meetings any issue that surface in the day-to-day operations are discussed and staff responsibilities are identified to action. People, spoken to confirm that, they are encouraged to express themselves about the running of the home, what improvements are made in relation to their accommodation, décor and they can speak with staff at anytime. 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 24 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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 13 (4) (b) Requirement All objects that may be potentially harmful to the people with special needs must be removed and risk assessment put in place to keep residents safe . Timescale for action 21/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA35 YA20 Good Practice Recommendations Staff training in equality and diversity should take place to ensure that all people living at the home their life goals are being met. All staff should sign immediately on administering the medication to people who use the service, to avoid any errors. The statement of purpose should be in an appropriate format to suit the communication needs of the people using the service. 3 YA1 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 18 London Road DS0000014932.V364480.R01.S.doc Version 5.2 Page 27 - 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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