Inspection on 12/10/07 for 182 Ashby Road,

This inspection was carried out on 12th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

182 Ashby Road, 20/06/06

182 Ashby Road, 07/02/06

182 Ashby Road, 12/03/05

182 Ashby Road, 23/09/04

182 Ashby Road, 20/01/04

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 18-65 182 Ashby Road, Burton On Trent Staffordshire DE15 0LB Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 12th October 2007 08:15 182 Ashby Road, DS0000004910.V342885.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 182 Ashby Road, DS0000004910.V342885.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. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 182 Ashby Road, Address Burton On Trent Staffordshire DE15 0LB 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) 01283-563447 sue.russell@robinia.co.uk Robinia Care Homes (2) Limited Susan Jean Russell Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (without nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following category:Learning Disability (LD). The maximum number of service users to be accommodated is 5. The provider may accommodate service users aged 16 and 17 if their primary care needs on admission to the home are associated with Learning disability (LD). 20th June 2006 2. 3. Date of last inspection Brief Description of the Service: Number 182 Ashby Rd is registered for five younger adults with a learning disability. The building is a large period semi-detached house located in a residential area, on the outskirts of Burton upon Trent. The other half of the semi-detached property is owned by this company and registered separately. The home is conveniently situated close to a town, on a bus route and close to shops and all amenities. The house is set back from the main road and has limited parking space. Accommodation is provided on three floors and comprises of five bedrooms, an office/sleeping-in room, lounge, dining/activity room, kitchen, one bathroom and one shower room, laundry room and storage. The home is not suitable for any person with a severe physical disability. There is a large garden at the rear and a patio area. The home is managed to support people to move towards independence and individuals are supported to manage their own finances, shopping and after assessment may be able to access the community independently. People are able to use community services, social activities and education. The Service User Guide on 12 October 2007 recorded that the weekly fee level for the home was between £1,571 and £2,157. The manager confirmed this to be accurate. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over nine hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection the registered person completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. Three completed questionnaires were returned from people who use the service. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are using a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. The Expert by Experience was accompanied by a supporter, from Sandwell People First. A tour of the home was undertaken. On the day of the inspection, the home was accommodating four people. The inspection included an examination of records, indirect observation, discussion and observation of three people who use the service, and four staff on duty. Four Care Plans were examined along with three staff records. Observation of daily events took place. Inspection of the storage system and medication procedures were inspected. Three requirements and two recommendations were made as a result of this visit. What the service does well: The home provides a range of information regarding the facilities and service provided. An assessment of need is carried out prior to entering the home and the manager assesses whether the home is able to accommodate the person. From the assessment, a person centred plan is developed with the individual 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 6 and where appropriate their representative. The individual continues to have an active role in the development and review of the plan. The service is managed to support people to live an independent lifestyle, and to have opportunities to develop and to take responsible and reasonable risks. People participate in local events, attend college course and choose how to spend their personal time. Staff give sensitive support where required to assist individual activities. People are provided with support and opportunities to develop life skills including managing finances, cooking, and personal safety. People are aware of their rights and responsibilities and staff give suitable knowledge regarding consequences of any action. The staff team have a balance of skills, knowledge and experience to meet the individual needs of people who use the service and empower individuals to take control and make decisions. The people who used the service spoke highly of the staff team. Comments regarding the staff team include; ‘The staff are a good working team, they all work well together’, The staff here are nice. I feel I am treated well’. The Expert by Experience gave the following summary of the home. ‘Overall I felt this house was excellent, the people I met were really happy and were treated as individuals and had choices. The manager seems to have excellent values and promotes supporting people to achieve as much as they can. The home had a great atmosphere and I was made, along with my supporter, to feel very welcome. ‘ What has improved since the last inspection? What they could do better: People who use the service have a contract, which details the agreed fee, and a breakdown of additional funded hours. It is unclear whether all people receive the additional paid support as agreed with the placing authority. A 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 7 review of the staffing provided needs to demonstrate how this support is provided including the provision of the manager’s hours. 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. 182 Ashby Road, DS0000004910.V342885.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 182 Ashby Road, DS0000004910.V342885.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home only take place after a comprehensive assessment. People are able to spend time in the home prior to deciding whether to move in. EVIDENCE: The registered person has reviewed the Statement of Purpose to ensure it is in a format suitable for people using the service. The manager reported that people who use the service have been involved with the review process. Each person has a Service User Guide that sets out the objectives and philosophy of the home, and includes a contract with details of the fees. There has been one new referral to the home since the last inspection, and inspection of records revealed that a full needs assessment was completed, involving the person and their representative. People living in the home confirmed that they were able to visit prior to deciding to move in. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 10 Four people living in the home received additional funding to provide community support and it was not evident how all these hours are provided. This is addressed within the Staffing outcome group of this report. 182 Ashby Road, DS0000004910.V342885.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plan is developed with, and owned by the individual. The plan is person centred and focuses on the person’s strengths and personal preferences. The individual understands the information in the care plan, which is regularly reviewed. EVIDENCE: Each person had a plan of care written with the person who used the service. Information in the plan included ‘This is me’, ‘Things that are important in my life’, ‘what I want to change about my life’ and ‘the support I need’. The plan included information for all areas of support and any medical needs. In addition, each person had a Person Service Plan, which had been developed with the person, and clearly stated what the current needs were and how these 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 12 will be met. From the plan, specific aims and objectives are agreed and through the review process, a record of progress is recorded. On the day of the inspection, one plan of care was being reviewed with one person and their key worker. From observation the Key worker and individual discussed all aspects of the plan and the individual stated what they wished to be recorded, and if anything was to be changed. Discussion with the person who used the service revealed that he was fully aware of all information within the plan, had been involved in writing it, and was always included in the review process. All individuals have a Key worker; one person commented, ‘he’s fantastic, he knows all about me, what to do when I’m in a bad mood, and whether I missed a meal.’ The plan of care included assessments of risk within the home and the community. A number of people access the community independently and any risk had been identified and reduced. Staff reported they had a clear role in the home to support people to be independent and managing risk in a responsible and reasonable way. During the visit, staff were observed giving people choices and informing individuals of any negative consequence. People who use the service are able to consider any actions and make an informed decision. Individuals have access to an advocate. One person spoke at length regarding the good relationship with the advocate, and how they are able to support him with decisions about his future. The advocate is able to attend all reviews. One person has volunteered to participate in a local Forum group, made up of people using the services of Robinia. The person reported they had attended a two day training session with Paradigm, a Human service consultancy and development organisation. During the training people are able to volunteer to be elected to represent the Midlands at the National Robinia Service User Involvement Forum. The Forum groups aim for people who use the service to become more involved in decisions about their care and support, and the work within Robinia. People who use the service are involved informally in the recruitment of staff, after the interview, and are given an opportunity to speak to potential staff and consider whether they would be suitable in their home. In discussion with the Expert by Experience, people identified they would like to participate in the formal process of selection. The manager confirmed this was currently being reviewed, including how to support people with the interview and selection process. 182 Ashby Road, DS0000004910.V342885.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use services are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. Routines are very flexible and people can make choices in all areas of their life. Personal relationships are encouraged and people are able to develop and maintain relationships. EVIDENCE: From discussion with the manager and staff, it was evident the team are committed to ensuring that people who use the service are able to live an ordinary life, and have access to all community facilities and services. The manager, through discussion and observation demonstrated her commitment to ensuring that people are aware of their rights and able to take responsible risks. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 14 On the day of the inspection, two people were attending a local college, two people were involved in leisure activities and one person was returning from a holiday in France. Discussion with people who use the service revealed that they have been able to access local college courses of their choosing. One person stated they were studying Spanish and Information Technology. People are encouraged to be responsible for all personal daily activities, including preparation for college, transport and attendance. Discussion with one person stated, ‘I am able to do what I want, but it’s nice to know that staff will encourage and support me, especially when I’m tired, because that’s when I feel vulnerable’. People are able to be involved in a variety of leisure activities. Discussion with individuals revealed that they were able to choose to go to places of interest, and staff are flexible to enable activities where support is required to take place. A number of individuals are independent in the community and use public transport. The home does have a car that people are able to access places. One person spoke enthusiastically about being able to take driving lessons with a Driving Instructor. He stated that this had always been something he had wanted to do and reported, ‘since coming here [the home] I started going to college and I’m now more mature. This means I was able to start lessons’. All people in the home have had an opportunity to go on holiday. A t the time of the inspection, one person had chosen to go to France. Other people reported they had chosen to go Mablethorpe and Rochester. The manager stated all individuals are able to choose their holiday destination, and whether to go alone with staff, or with other people living at the home. People are able to develop relationships with people outside of the home and individuals stated that they consider the views of other people when inviting guests into the home. People are able to see friends in private, including their bedroom. The Expert by Experience discussed sexuality, and was impressed that people do not judge others according sexual preferences, decisions or choices people make. People who use the service also reported that they are not judged by staff for their actions. People who use the service have a responsibility to maintain their own rooms and help around the home. One person said’ ‘we work as a team, some things I’m better at and some things not, if we work together we get everything done’. The Expert by Experience noted that people were able to maintain their bedrooms in a style of their choosing and the bedrooms looked like young persons rooms, and were not strictly maintained. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 15 Each person has a separate budget for lunch time meals and are able to have a designated area in the kitchen to store foods. People are responsible for managing their own food money, shopping and preparing the food. Two people spoke enthusiastically about cooking, ‘ I love cooking food and not just English food, I’m very good at marinating foods.’ Further discussion revealed that people use each other’s knowledge and cooking tips to prepare a variety of meals. One person liked to use herbs and spices and wants to start to grow fresh herbs. There were a number of containers where people had planted vegetables in the garden. The manager reported people living in the home are deciding whether to have part of the large garden as a vegetable patch. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use service have access to healthcare services, and are encouraged to be independent, have regular appointments and visit local health care services. The home has an efficient medication policy supported by procedures, practice and guidance for staff. EVIDENCE: Three plans of care were examined and all plans included information about people’s health care needs. Each person is registered with a local General Practitioner, and people who use the service stated they are able to attend appointments independently if they wanted to. Where any health care is provided or appointments attended, the plan of care is updated to incorporate the changes. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 17 The service provider has links to an external Psychology Agency. Staff reported that support from the organisation is included within the contract price and additional support can be sought if a need is identified. The home operated the Boots Monitored Dosage System (MDS). The staff stated that there were no controlled drugs in use. Inspection of the medication storage system and Medication Administration Records were satisfactory and medicines had been recorded as appropriate. One person is responsible for administering a daily injection. This has been reviewed and assessed by medical staff, and a written record of the procedure recorded in the plan of care. Staff supervise the procedure, and record this on the Medication Administration Record. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and is available in a number of formats. The complaints procedure is supplied to everyone living at the home. The staff understand the procedures for Safeguarding Adults and have a good knowledge of procedures and how to respond to an alert. EVIDENCE: The home has a Company complaints procedure that is clearly written and easy to understand and is available in a variety of formats. The complaints procedure was displayed in the dining room and discussion with people who used the service revealed that they had a clear picture of the role of the Commission for Social Care Inspection (CSCI). The CSCI office contact details need to be changed to the regional office. There have been no complaints received by CSCI since the last inspection. Individuals are encouraged to raise any concerns and a record of concerns and complaints are maintained. In discussion with the Expert by Experience, individuals highlighted they would like an official response to complaints. This 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 19 was discussed with the manager. The complaint book recorded where a written response had been provided, in other circumstances a verbal response had been given. The manager stated she would review this system with people who used the service. The induction for staff includes safeguarding adults and the manager reported that this training is on-going for all persons working in the home. One member of staff had begun working in the home during the week of the inspection, and the manager reported that this training had already been booked for the following month. Discussion with staff revealed they were clear on how to respond to an alert. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 20 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, 25, 27, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are encouraged to see the home as their own. The home is a very pleasant, safe place to live and the bedrooms are personalised to reflect the interests of the people. EVIDENCE: The building is a large period semi-detached house located in a residential area, on the outskirts of Burton upon Trent. The house is set back from the main road and accommodation is provided on three floors, and comprises of five bedrooms, an office/sleeping-in room, lounge, dining/activity room, kitchen, one bathroom and one shower room, laundry room and storage. There is a large garden at the rear and a patio area. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 21 People stated they were able to choose the colours of the bedrooms, decorate and style their room according to individual preferences. All bedrooms inspected contained a variety of personal electrical equipment, gaming consoles, pictures and photographs. One person had a keyboard and kindly demonstrated his music skills. People are able to have a key to their room. The Expert by experience stated, ‘I was really pleased to see the room a bit messy and full of personal items’ The bedroom on the second floor has Velux windows fitted and does not have a blind so the room is often light even at night. It is required that the registered person fits suitable coverings in line with the preference of the individual. The home has two showers, although both need repair. There is one bath in the home but the shower room cannot be used, and the people who use the service stated this has caused some difficulty. It is required that both showers be addressed. The people who use the service identified that they disliked the lights in the home, ‘they look like prison lights’. Discussion with the manager revealed this had been identified, the lights were fully enclosed units to ensure no damage from accidental flooding; there is no risk identified within the home at present. It is recommended that this be reviewed with the people who use the service and domestic lights fitted in line with their preference. All areas of the home were clean and the manager stated that people who use the service are involved in the colour schemes and décor within the shared accommodation. In the bathroom one person had painted a large picture, which had been framed, the Expert by Experienced commented that ‘this made the home feel really individual to the people’. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 22 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, 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 service has a good recruitment procedure to ensure that people are not placed at risk. Staff receive an induction to the service and on-going training. A review of staffing needs to demonstrate there is consistently enough staff available to meet the needs of the people using the service in line with the agreed contract. EVIDENCE: On the day of the inspection the manager was working in a supernumerary capacity. Support staff on duty consisted of:1 1 1 1 1 Senior Care Staff working 7.30am - 10.30pm Care Staff working 8.00am – 3.30pm Care Staff working 10.00am – 4.00pm Care Staff working 2.30pm – 10.00pm Care Staff working 4.00pm – 10.00pm DS0000004910.V342885.R01.S.doc Version 5.2 Page 23 182 Ashby Road, During the night there is one sleep in person and one person awake. The usual pattern of shifts is three people working a morning shift and three people working an afternoon shift. The roster on the week of the inspection had changed as one person was on holiday in France with two members of staff. Inspection of contracts for all people, revealed that four people receive additional funding for an agreed numbers of hours per week. Each person also receives 3 hours for one to one work in the home each week. The staff roster, records of one to one support and daily notes were inspected. For two people the number of hours provided were calculated over for two separate weeks. For each person on each week, the hours provided was less than the agreement in the contract, up to a deficit of 7.5 hours for one person for one week. One person reported, ‘I’d like to go out more but there’s not always enough staff’. Inspection prices for Inspection each week of individual’s fee breakdown revealed that the agreed contract all people detailed the manager’s hours are supernumerary. of the roster and discussion with the manager revealed one shift is worked as part of the team. The staffing provided was discussed at length with the manager. A review of staffing is required and must demonstrate how the home provides suitable staffing in line with the agreed contracts, including hours worked by the manager. The review is to demonstrate how the individual one to one hours are provided, in addition to providing the basic staffing in the home to ensure people are safe. People who used the service spoke positively about all members of the staff team and reported ‘The staff here are nice and I feel I am treated well.’ Staff listen to me and help me out’. Three staff records were inspected and demonstrated the organisation has robust recruitment practices. All records included a photograph, an application form, two written references, a Protection of Vulnerable Adults (PoVA first) check and a Criminal Records Bureau Check (CRB). One member of staff had begun employment the week of the inspection and was working in a supernumerary capacity. Discussion with the person revealed that following the interview they had spent the day at the home and had an opportunity to spend time with people who use the service. The manager was completing an induction with the person and a formal induction to include training had been planned for the following month. Discussion with staff revealed that people have had the attended training for management of complex behaviour, safe administration of medication and 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 24 Food hygiene. The manager reported that all staff have received the required updates for Health and Safety and Moving and Handling, and training is planned for all staff for the Mental Capacity Act. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 25 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): 36, 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 has a clear understanding of the key principles and focus of the service and is person centred in her approach. People who use the service benefit from a professional management approach, whereby staff skills are promoted and personal achievements recognised. EVIDENCE: 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 26 It is evident from observation and discussion with staff, that the manager is extremely enthusiastic and committed to promoting people’s rights and providing a quality service. The manager discussed at length the plans to continue to improve the service and provide opportunities for people. The manager is person-centred in her approach and is open and transparent in all areas of managing the home. The manager’s skills, knowledge and practice has resulted in an improvement of the standards within the home. Staff commented they feel valued and part of a supportive team and would have no hesitation approaching the manager who is supportive and recognises personal achievement. Prior to the Inspection the Registered manager completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. The AQAA was completed to a good standard and related to the National Minimum Standards for each outcome area. Evidence within the AQAA was sampled and found to be accurate. The registered manager recorded that all maintenance work, annual checks, mandatory training, testing of equipment and regular fire drills are undertaken. 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 27 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 X 3 3 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 3 25 3 26 2 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 4 3 X X 3 X 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA26 Regulation 23 (2)(p) Requirement To fit a suitable blind to the second floor bedroom, in order that the room is darker during the night, in line with the preference of the person using the service. To ensure the current shower facilities can be used, to provide sufficient bathing facilities for people who use the service. Staffing provided in the home must be sufficient to meet people’s needs and in line with agreed contracts. A review of the staffing provided is to be carried out to demonstrate how this is achieved. Timescale for action 30/11/07 2 YA27 23 (2)(j) 27/11/07 3 YA33 18 (1) 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 29 1 2 YA6 YA24 To review the process for responding to complaints and provide an opportunity for written feedback To consult with people who use the service for fitting of domestic style lighting within the home 182 Ashby Road, DS0000004910.V342885.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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