Inspection on 09/05/06 for 186 Meadow Way

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

186 Meadow Way 30/05/08

186 Meadow Way 18/04/07

186 Meadow Way 04/11/05

186 Meadow Way 29/06/05

186 Meadow Way 26/02/05

186 Meadow Way 26/08/04

186 Meadow Way 15/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 178 Meadow Way Jaywick Clacton On Sea Essex CO15 2SF Lead Inspector Gaynor Elvin Final Key Unannounced Inspection 9th May 2006 11:00 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 178 Meadow Way Address Jaywick Clacton On Sea Essex CO15 2SF 01255 431301 01255 431301 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) Mr S T Lewis Mr S T Lewis Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th November 2005 Brief Description of the Service: 178 Meadow Way is a small care home, which is registered to provide accommodation, support and personal care to three service users with a mental health disorder. The home is located in a residential area in Jaywick Sands, within close proximity to the beach, shops, cafés and public house. A local bus service provides access to the nearest town of Clacton on Sea, approximately 2 miles away, for local amenities such as day centres, local hospital, sports centre, swimming pool, library and colleges and the town centre. Information about the service is provided to prospective service users in the homes Statement of Purpose. The current scale of charge is £525.00 - £580.00 per week, all-inclusive. This information was included in the Pre Inspection documentation submitted to the CSCI, by the provider, in February 2006 and confirmed by telephone on 18th May 2006. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place early in May 2006, over four hours. All of the Key National Minimum Standards for Young Adults and the intended outcomes were assessed in relation to this service during the inspection. The inspection process included pre inspection documentation, discussion with the Registered Person, Mr Lewis, who is also the Registered Manager, examination of staff files, service users care management files and associated documentation and other records required to be kept in the home. The Manager later submitted further documentation requested during the inspection visit. The home is registered to provide accommodation and care to three service users who have mental health needs. Currently the home has two vacancies. The inspection process was unable to engage with the one service user accommodated and therefore views and experiences of the service were not obtained on this occasion. What the service does well: What has improved since the last inspection? What they could do better: The scope and range of this inspection was limited on the basis that only one service user was accommodated. Based upon the information obtained at this inspection, the care outcomes were adequate in terms of service users safety and welfare. However it is anticipated that the next inspection of the home, following admission of potential service users, will reflect further improvement and development in the following areas: 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 6 • • • • Care management, assessment, planning and review remains an area for improvement. Supporting service users to make decisions about their lives and encouraging a more independent lifestyle. Development of a functional, pro-active approach to quality monitoring and quality assurance focusing on care practice and quality outcomes for service users. Staff training and some associated aspects of staffing. 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. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Written information is provided for prospective service users and their families, enabling them to make an informed choice. The home promotes the opportunity to visit the home as an essential part of the pre admission process. Pre admission assessment documentation prospective service users needs. EVIDENCE: Only one long-term service user was accommodated and the home is currently in the process of admitting two prospective service users. The practice of the admission process will be fully assessed within the next inspection process. The Statement of Purpose and the Service User Guide documents contained all the relevant information required to enable prospective service users to make an informed choice with regard to the services and facilities the home offers. The service currently has two vacancies and prospective service users are offered the opportunity to visit the home and stay on a trial basis. provided information of the 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 9 Only one service user is currently accommodated and has been resident for many years, he was not available for comment. The service user was referred through Care Management arrangements and a copy of a pre admission assessment of needs was included in the service users file. Confirmation to the service user, in writing, that the care home was able to meet the individuals assessed needs was not included. The registered manager described a thorough pre admission process, through which an assessment would be carried out to ensure the home was able to meet the individual’s needs and ensure compatibility with the current service user. Adequate evidence of the standard was demonstrated. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality outcome in this area is adequate. Service users were not consulted on their assessed and changing needs and personal goals were not reflected in their individual plan. Service users were consulted on, and participated in aspects of their daily life within the home. EVIDENCE: Care plans had not progressed any further since the last inspection. Although they provided information to assist staff in meeting basic needs, further improvement is required with regard to introducing a person centred approach and identification of progress towards the service users personal goals and aspirations. The care plan inspected was appropriately detailed in the areas it covered to guide care staff on care delivery. However, the plan only focused on the main presenting needs rather than adopting a person centred approach to the quality of daily living; identifying strengths and aspirations. Specified risks 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 11 acknowledged within the care plans were under developed particularly with regard to behaviour management strategies, refusal to take medication and lack of motivation. There was no clear evidence seen of clear strategies to address the more complex and challenging issues related to mental health problems and little evidence of meaningful consultation with the service user regarding care-planning arrangements. An holistic approach to planning care and support would be expected to take into consideration emotional, social and psychological needs of service users and would encompass occupational, leisure and recreational care objectives agreed with the service user. Reviews contained relevant information with regard to progress or no progress made towards outcome, however the new information did not prompt change to the existing care plan where necessary. Care must be taken to ensure reviews are part of the ongoing care planning process and that the plan of care/support continues as a current and active document reflecting a clear progression towards outcomes. Service users were supported in the decision making process relating to day to day choices but further development is required in assisting and recording decisions about their life. Documentation indicated that regular formal resident meetings were offered to service users providing an opportunity for service users to participate and voice their views on the day to day running of the home, but on the last two occasions these were declined. The Manager indicated that this was probably due to one service user being very unwell and the other not wanting to participate alone. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to the service. Service users benefited from flexible routines and staff support to engage in leisure activities. Service users were encouraged and supported to maintain family relationships, which contributed to a fulfilling lifestyle. Mealtimes were flexible and prepared to the individual’s choice. EVIDENCE: The care/support plan examined did not reflect a planned approach to support and motivate the individual to their potential and optimal independence. The inspector advised the manager about adopting a more person centred approach to how service users spent their time, so that that their personal strengths, interests, aspirations and goals were part of their support plan and regularly evaluated. In the cases where motivation is difficult, contributing factors and various management strategies should be addressed and explored 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 13 with the individual and recorded appropriately. This approach would benefit the service users and extend the individuals potential and aim for a purposeful life. The one service user currently resident at Meadow Way was in bed for the duration of the inspection. The Manager explained that the resident had returned from a long weekend break in Blackpool during the early hours of the morning and was catching up on sleep. The member of staff who had accompanied the service user in Blackpool described a full and active time that was thoroughly enjoyed by the service user. The manager confirmed that the cost of the break and support was fully inclusive and covered by the home. Social inclusion within the community was promoted and the manager indicated that the service user attended a club weekly and went to the pub and restaurants. Whilst there was no opportunity for the inspector to directly observe the style and type of support provided to service users, it was noted that staff frequently knocked on the service users door to enquire after his well-being and offer refreshments. Service users were provided with a key to their own bedroom and lockable storage facilities for their valuables. From discussion with the manager and staff it was evident the home promotes a policy of ensuring flexibility, individual choice and freedom of movement for service users. From discussion and documentation it was evident that the service user accommodated was in regular communication with family and visited them each weekend. It was difficult to fully assess the standard relating to meals and mealtimes in the home as there was only one service user, however, adequate evidence of this standard was demonstrated. The manager indicated that due to the current situation of only one service user accommodated, meals were served to the individual as and when required, according to personal choice; although support was offered to make informed and healthy meal choices. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. Healthcare needs were generally recognised and addressed, service users were supported in receiving continuing care and attending follow up appointments. Service users were protected by the home’s policies and procedures for dealing with medicines. Further training for staff incorporating the purpose, side effects and effective monitoring of any problems in the use of medication, particularly with regard to mental health problems would further benefit service users. EVIDENCE: As previously stated there was no opportunity for the inspector to observe or discuss the style or type of support provided to service users; and support arrangements reflected in the care plan examined were brief and provided little evidence of meaningful consultation with the service user. There was little reference to the need to monitor mental health difficulties, particularly with regard to care management in the event of refusing medication. The Manager described a positive and professional approach, recently taken, in a sensitive and proactive manner, to encourage a service 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 15 user to take their medication. Providing information about the consequences and enabling the service user to make an informed decision. However this was not reflected within the care plan for care staff to provide the same approach. There was plenty of information available for service users with regard to voluntary, charity and NHS support and counselling groups for people with a mental health problem, but no indication, in the care plan sampled, Statement of Purpose or Service User Guide as to how the service user would be supported or encouraged to access these facilities should the need arise. The home had initiated contact with appropriate health professionals for additional assessment and guidance to inform practice and work collaboratively to meet service users specific needs in relation to continence. Records reflected regular appointments and follow up attended with the Psychiatrist and GP for management and medication administration and reviews. The care plan did not contain information relating to annual general health checks (unrelated to primary mental health care needs). The current service users did not self medicate. Policies and procedures relating to the safe administration and handling of medication were in place to guide staff. Staff had received medication training accessed from the local pharmacist, focusing mainly on the supply system used. Care plans identified medication prescribed but did not make reference to side effects, adverse reactions or the need to carefully monitor and record the mental health of service users particularly with regard to medication side effects or noncompliance. An area of training to be considered for staff to broaden their understanding and practice in this area. The medication administration records for the sole service user were completed and dated accordingly. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Arrangements satisfactory. for responding and acting upon any complaints were The homes adult protection policy and procedure enhanced service users protection. EVIDENCE: The home has a detailed complaints policy and procedure and is included in the Service Users Guide for reference. No complaints had been received by the home or the CSCI in the last twelve months. Robust policies and procedures were in place to guide staff in responding to an allegation or suspicion of abuse to vulnerable adults incorporating Local policy guidelines. Staff had received training in this area although it was recommended for staff to attend the Essex Vulnerable Adult Protection Committee’s free training sessions regularly held locally. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. The home was suitable for its stated purpose, accessible, safe and maintained to a high standard, meeting service user’s individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were in keeping with the local community, domestic and unobtrusive, offering access to local amenities, local transport and relevant support services. The home provided a calm and homely environment, maintained to a high standard, clean and hygienic. The bedrooms had been refurbished to a high standard including new sinks with tile splash backs, individual door bells and locks and lockable wall safes, each room offered sufficient space and furnishings suitable to meet service users needs and lifestyles. Bedrooms promoted individuality, decorated 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 18 according to the individuals’ choice and personalised with service users belongings. An additional bathroom was recently installed to provide separate facilities for future prospective female service users. Communal areas included a lounge/dining area and a new large conservatory. The conservatory providing a pleasant and tranquil additional sitting room that overlooked the meadow at the back of the house. It also provided the added benefit of an unobtrusive, purpose built kitchen facilities for service users to prepare their own snacks and drinks. Central heating provided heat to the conservatory enabling continued use during the winter months. A small quiet room was also available if a service user wanted to be alone away from their bedroom. A loft conversion was now completed and provides an office and separate room for night staff to sleep and separate staff washing facilities and shower room. The laundry is housed in a newly built extension to the front of the house, equipped with a washing machine that has a disinfectant programme and two separate sink facilities; one for rinsing soiled clothes and one for hand washing. Mr Lewis was requested to obtain advice, and if required, building regulation approval and certification for the building works carried out in relation to the loft conversion and installation of the new bathroom and shower room to ensure the refurbishment meets regulatory requirements particularly with regard to health and safety and fire. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality outcome in this area is poor. This judgement has been made using available evidence including a visit to the service. Staff were appropriate in numbers to meet the needs of the current service user. Staff employed in this home are not appropriately trained to meet all the assessed needs of the service users although it is recognised that mandatory training and development opportunities have continued to improve. Planned formal supervision for staff is not consistent. EVIDENCE: One member of staff was on duty supporting the two current service users. The staff team was small and comprised of the Registered Manager, the deputy manager, one day support worker and one sleep in support worker during the night. The home needs to regularly review staffing levels in the case of changing needs of service users or when an additional service user is admitted. An annual training programme identified mandatory training received and planned for staff during the current year. A sample of staff files examined contained reference to training sessions undertaken by individuals during their 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 20 employment, such as first aid, food and hygiene, Health & Safety and fire safety. Formal training in Infection Control has yet to be covered. At the time of inspection, the service had not yet achieved an adequate proportion of carers having attained or commenced a National Vocational Qualification (NVQ) or a date by which this will be achieved. However, it was noted that the deputy manager had re commenced training in NVQ level four in care and management. Staff had recently received a days training in Mental Health Awareness, which provided an introduction and awareness of the factors leading to mental illness, behaviours linked to and the impact mental health problems have on daily living. This level of training is satisfactory as an induction level of training to support staff in the provision of a specialist care service. However, further development is required in the training programme to ensure that the basic level of mental health awareness is complimented by further initiatives in areas such as behaviour management, therapeutic approaches, medication used in mental health, person centred care, the Care Programme Approach and the Mental Capacity Act, as well as managing aggressive or challenging behaviour. The sample of staff files examined during the inspection contained appropriate levels of documentation in respect of recruitment to promote the protection of residents from abuse. The homes induction arrangements is mainly service focused and although it provided the support new staff required and informed them of the culture of the home, it was not in line with National Training Organisation specification. Discussion with the manager advised that all new staff must be registered on a Skills for Care programme, the newly formed occupational training council for the social care sector, as from September 2006. It was also recommended that existing staff not yet commenced NVQ should be considered for the induction and foundation programme. The sample of staff records confirmed they received formal supervision, which reflected most of the elements necessary to support staff in developing and sustaining their working practice, however these need to be more frequent, particularly for newly appointed care staff. Mr Lewis is yet to undertake individual assessment and profile of care staff to identify strengths and weaknesses, training needs or gaps in knowledge and skills. The manager was advised that this could be incorporated within the supervisory process. From discussion with the manager it was acknowledged that a small service and staff group where the manager or deputy works alongside staff often deal with issues informally as they arise during the course of a working day. It was advised that a formal one to one supervision in protected time and in a conducive environment has additional benefits for staff and management ensuring working standards meet the aims and objectives of the home. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 & 43. Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. The home does not have a formally trained manager in that he has not yet achieved the NVQ level 4 or equivalent in care and management. Quality assurance and monitoring systems have not progressed to meet this standard. Practices and procedures ensure that the health and safety of residents are protected. EVIDENCE: The Proprietor/manager position is unchanged and Mr Lewis has managed a service for people with mental health problems for many years. However Mr Lewis has yet to complete NVQ level 4 in care and management, and along with the staff group needs to continue to develop and update his 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 22 understanding and skills in meeting the needs of service users with mental health needs in line with evidence based practice and current guidance. It was evident throughout the inspection that the manager had a good relationship with his staff and the staff enjoyed working at the home and felt part of a good team. The home had still not progressed in addressing quality assurance and quality monitoring systems as required in the last inspection report. The elements of quality assurance were discussed with the manager, including the need for the process to focus and evaluate the quality of life for the people using the service, examining and measuring care practice and the outcomes for the service users. Service users surveys have been conducted in the past using basic closed question questionnaires, however the responses were not formulated and evaluated to inform future practice. The home had commissioned an independent consultant to provide an objective overview of the quality of the service provided as measured against the National Minimum Standards, results of the report was shared with the Inspector. The consultants report set out to identify, at a particular point in time, where the service was or was not meeting National Minimum Standards and Regulations. It was not a system for reviewing or improving the quality of care. The home should be considering effective internal quality assurance systems, combined with regular independent inspections to build on best practice and inform a development plan. External consultancy can be sought to help to provide guidance on how quality methods, systems and techniques can be used in planning, preparation, care practice, checking and recording actions that are necessary to achieve the standard required. In the main, measures taken to promote the health and safety of service users and staff were satisfactory and proportionate to the size of the home. Policies relating to health and safety and appropriate risk assessments were in place, reviewed, dated and signed. Inspection and maintenance certificates relating to equipment and services to the home were in place and updated as required. An electrical installation inspection and fire alarm inspection was carried out 01/05/06 and a gas safety inspection 06/06/05. An Environmental Health Inspection was carried out in November 2005. The CSCI is currently awaiting confirmation of a satisfactory building regulation inspection (including fire safety) in relation to completion of building works; loft conversion and installation of new bathroom and shower room. Mr Lewis, the proprietor/manager is in day-to-day contact with the home and therefore a monthly inspection visit in line with Regulation 26 is not required. There is no formal financial or business plan for the home. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 23 Employers public liability insurance was in date. 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 3 X 3 2 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 25 Yes 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 YA6YA19 Regulation 15 Requirement The Registered Person must demonstrate that service users are involved in their care plans and that care plans reflect all assessed needs, review and evaluation within the care planning process process. The Registered Manager must demonstrate appropriate consultation and ensure service users receive appropriate support and encouragement to meet aspirations and assessed needs, and take part in valued and fulfilling activities to reach potential and a purposeful lifestyle. This is a fourth repeat requirement not met within set timescales of 1st Dec 2004, 1st June 2005, 1st September 2005 & 1st March 2006. Timescale for action 01/09/06 2. YA11YA12 16 01/09/06 3. YA32 18 The Registered Manager must 01/08/06 ensure that service users are in competent safe hands. This is a second repeat requirement not met within the agreed timescale 1st March 2006. DS0000017724.V294406.R01.S.doc Version 5.1 Page 26 178 Meadow Way 4. YA35 18 The Registered Person must ensure each staff member has an individual training and development assessment and profile. 01/09/06 5. YA35 18 6. 7. YA36 YA37 18(2) 9 The Registered Person must ensure training and development are linked to the homes service aims and to service users needs and individual plans particularly with regard to the needs of people with mental health needs. The Registered Person must 01/09/06 ensure all staff receive structured induction training and foundation training to sector skills specification (Skills for Care). The Registered Person must 01/09/06 ensure staff receive regular recorded supervisions. The Registered Manager must 30/09/06 demonstrate that he has the qualifications and skills necessary for managing a care home. This requirement is carried over. The Registered Manager must ensure an effective quality assurance and monitoring system is in place to measure success in achieving care outcomes, incorporating continuous self monitoring, review and evaluation to project an annual development plan for the home and demonstrate development for each service user. A second repeat requirement not met within agreed timescale 1st March 2006. 01/09/06 8. YA39YA43 24 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that staff receive accredited medication training and the Registered Person is able to demonstrate staffs competence and understanding of medication prescribed for mental health problems including use, side effects and the need for monitoring. Service users should be offered annual health checks to promote general well being. 2. YA19 178 Meadow Way DS0000017724.V294406.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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