Inspection on 18/01/07 for 1a White Ladies Close

This inspection was carried out on 18th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

1a White Ladies Close 11/01/06

1a White Ladies Close 11/10/05

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 09/07/2008.

CARE HOME ADULTS 18-65 White Ladies Close, 1a 1a White Ladies Close Little London Worcester Worcestershire WR1 1PZ Lead Inspector S Davies Unannounced Inspection 18 January 2007 10:15 th White Ladies Close, 1a DS0000064298.V318260.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 White Ladies Close, 1a DS0000064298.V318260.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. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Ladies Close, 1a Address 1a White Ladies Close Little London Worcester Worcestershire WR1 1PZ 01905 27271 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) www.macintyrecharity.org MacIntyre Care David Joseph Bunn Care Home 5 Category(ies) of Learning disability (5) registration, with number of places White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 1a, White Ladies Close is registered to provide residential care for up to 5 adults who have mild to moderate learning disabilities. The premises is a large, detached, purpose built house, situated in a residential area, close to the centre of the city of Worcester, and with easy access to various amenities and facilities. The Registered Provider is MacIntyre Care. The property is leased from the Sanctuary Housing Association. The stated purpose of the organisation is, ‘to be recommended and respected as the best provider of services for people with learning disabilities throughout the United Kingdom.’ The main aim of the home is to encourage service users to achieve optimal personal independence in their lives, both within and outside the home, with supervision, support and assistance from staff where needed. Fees are currently £806.00 weekly White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine, unannounced key inspection was to look at how well the service is achieving good outcomes for service users in key areas of the National Minimum Standards, and to follow up previous requirements and recommendations. This was done through talking with service users and staff about daily life in the home and their experience of the service, touring the premises, looking at service users plans and examining records. Care records were seen in detail, and staffing and staff training records and sample records kept in respect of safe working practices were checked. Planning for the inspection involved looking at previous reports and the service history, and at a pre inspection questionnaire returned by the manager. Surveys about views of the service were sent out to the service users, their relatives, social and health care professionals and GPs. Comments received are incorporated in the report where appropriate The inspection took approximately 4 ¾ hours, and time was spent talking with the registered manager, staff, and the 5 service users living at the home. Everyone indicated they were happy to be living and working at White Ladies Close. The assistance and co-operation given throughout the inspection was very much appreciated. . What the service does well: The home is warm and comfortable, has a friendly and happy atmosphere, and service users take a full part in the daily routines within the home. The home very obviously revolves around them. Everyone goes to college, work or attends day placements, has good contact with family and friends and enjoys a varied programme of leisure activities. There are good links with the local community. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 6 The home is very well managed, maintained and cared for.The manager and staff carry out their responsibilities sensitively and fulfill them effectively, enhancing the well being of everyone living and working in the home. Detailed records are maintained. Service users are safeguarded by a rigorous approach to staff recruitment. Each service user’s individuality is highly valued. The staff are strongly committed to a person centred approach, supporting and enabling service users tolive life as they choose. They work positively with each individual to help them master challenging issues and achieve real progress in their lives. Service users privacy is respected, they are aware of their rights, and are encouraged to voice their opinions. Service users and staff respect each other and get on well. Service users views are actively sought and used to plan the way the service develops as part of the quality assurance process. What has improved since the last inspection? What they could do better: Service users are encouraged to speak out about any problems and the service responds promptly to spoken concerns. There have been no formal complaints for some time. Recording and analysis of such concerns and comments would contribute to service monitoring and quality assurance. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 7 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. White Ladies Close, 1a DS0000064298.V318260.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 White Ladies Close, 1a DS0000064298.V318260.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): Standards 2,4,5 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users needs are carefully assessed, and they can take the time they need to get to know the service before making a decision about moving in. They have a copy of their contract. EVIDENCE: No new service users have joined the home since the last inspection. Service user plans contain evidence of full needs assessments and there is evidence of a careful, individualised and user needs led approach to the introduction and admission process. For the latest service user who was leaving her family home for the first time in later life, this process continued for several months until she was comfortable with the decision to move in. Service users have a copy of their contract signed and dated by the service and themselves. White Ladies Close, 1a DS0000064298.V318260.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): Standards 6,7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users plans are fully person centred. Every service user is being well supported to understand and manage risky situations, and play their full part in making plans and taking decisions about their own lives. EVIDENCE: Each service user has a service user plan which is fully person centred. This plan is based on a comprehensive assessment of their needs, regularly reviewed and updated with them from when they first moved in. All staff have training in person centred planning, and there is ample evidence of person centred working following the principles of Valuing People. Service users needs and personal preferences in the way they are supported and enabled, are recorded with them in these plans, which show clearly how staff work with them in a person centred way. One service user showed her White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 11 plan, which she and her keyworker have created together. Each section is written in straightforward language from her own point of view and is full of photographs and mementoes of the events, people and activities important to her. It clearly shows her needs, hopes and goals and how she is being supported to meet them as these change. Talking to service users and staff shows service users’ plans are used as working tools to make sure all staff understand what is important to help the people they support to live individual, fulfilling lives. Risky situations are assessed and the plans show how staff will help service users manage these so that each is able to lead a fulfilling life in their own way. In a plan seen staff look at this often with the service user and record any changes, noting and responding particularly to this person’s own perception of changing abilities. This helps the service user, by making sure everyone keeps up to date with how they manage risks and can give them consistent support. This is helping maintain confidence and as much independence as possible. The plans show how staff help service users to be as involved as they are able to be in making decisions about their life. One example shows how staff are helping someone who was very independent but who has been ill, keep up as many former activities as they feel comfortable doing. Talking to staff showed they are highly committed to working with each service user as an individual. They are well trained to help service users communicate and contribute to writing their plans from their own point of view. They make sure the plans are kept up to date by reviewing them with service users regularly, and whenever there are changes. They believe strongly in the importance of helping service users to have the information they need, and to manage risks in a balanced way, so as to make their own decisions and be as independent as possible. This enables them to skilfully support the very different needs and aspirations of the five people who live here so that each is able to live the life that is right for them. White Ladies Close, 1a DS0000064298.V318260.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): Standards 12,13,14,15,16, and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users generally have good contact with friends and families, and enjoy a variety of individual and group activities both within and outside the home, which are appropriate to their age and interests and offer the chance to try new experiences as well as sustaining those that are important for a continuing sense of well being EVIDENCE: Each service user is being supported to develop a fulfilling lifestyle based on who they are and how they want to lead their life. Service users here have made a home together and have got to know their local community well. Staff support them to explore further the range of opportunities available to them for widening their circle of friends and acquaintances, through meeting neighbours and using local services and facilities. All five people have very different needs and ability levels, and the lifestyles and activities they talked about are equally varied, but it is very clear all enjoy White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 13 their life and feel it suits them. Service users who are increasingly able are helped to build on their skills while others are gaining more self assurance and the confidence to broaden their interests. Those who need more support receive this in a way which helps them continue to make the most of life. Staff described each service users’ interests and abilities with a good understanding of what is important to them. They were able to show how each person has different, well planned support to lead the life they choose. Examples given show how this is working well for each service user. They spoke enthusiastically about future living plans, holidays abroad, funding and following a personal dream, keeping up with friends and busy activities, and getting all they could out of life. Activities include college and day centres, Top Barn, paid and voluntary employment, clubs, eating out, music, going to the pub, shopping, trips out, and seeing friends and family. One service user is looking forward to a family holiday soon, and staff were alert to and prepared for any extra support the family might need to make sure the holiday goes ahead smoothly. There is a balanced approach to meals planning and preparation so that each service user has the chance to plan and cook a meal each week, after choices have been discussed at the weekly service users meeting. Service users confirmed this approach worked well for them and that they enjoyed their meals. As service users get older, they have sensitive support to deal with changes associated with ageing. This is helping them keep up with activities and valued relationships they enjoy, through the continuing security and support of people who know and understand them well. Staff are creative in finding ways to do this, for example a loss of one activity was balanced by finding a similar opportunity amongst a group of friends so that the service user was able to transfer an interest without loss of confidence. White Ladies Close, 1a DS0000064298.V318260.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): Standards 18,19,20 and 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users are being supported to take charge of their personal and health care. There is some very good practice, and staff show they have a sound knowledge and understanding of service users general and specialist personal and health care support needs. They receive training in a timely way as needs are identified. This has progressed beyond support to promote service users’ personal awareness and skills development in a systematic way, to help them develop or retain control over their lives. The service uses and liaises well with specialist personal and health care agencies. EVIDENCE: Service users’ plans show that they have the support they need to understand and take real responsibility in decisions about their own personal and health care. Where they need help this is discussed and agreed with them. Service users plans each have detailed records about their personal and health care needs and a health action plan, and they work with staff to make sure their records are written from their own point of view and are up to date. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 15 Service users can make sure this way that staff can understand what matters to them, so that they get the right support to keep themselves as well and active as possible. Service users are supported by staff who have a sound knowledge and understanding of what is important to keep people well, physically and emotionally. Staff are well trained and well supported by their manager, and there is some very good practice. This means individual service users have good support from staff when they need it, but staff use their knowledge skilfully to help them gain more understanding and control over their own personal and health care. Service users are becoming more self assured and independent, showing that staff are working very well with them. Where service users need more help as they get older, staff understand how to do this while still helping them to stay as independent as possible. Service users explained how they hold and use their own health action plans, taking them to appointments and sharing with staff the task of keeping them up to date. They are supported to keep routine health appointments and have regular check ups with dentists, opticians and for hearing and foot care. Each service user faces significant challenges of their own, this can mean their behaviour challenges staff too. All staff have specialist training in managing challenging behaviour, and discussion shows they know how to respond and support service users well at such times. Service users can be confident about managing challenging incidents and health developments, because staff are keeping a careful watch over these things through good records and monitoring. This helps everyone understand and deal with these things better, and get more help when it is needed. Staff seek help and guidance from other agencies and specialists when this becomes necessary. This includes the behaviour support team, psychiatric, psychological, social work, medical and nursing specialists. Survey answers from two of these people shows they are entirely satisfied that the service liaises well with them and follows their guidance. Agreements are made with service users and recorded in their plans, to show how they want to be supported. For different people, this means supporting progress towards more independent living, managing anxieties and developing confidence, better overall control over their lives, and making adjustments to changes in health and ability. For example, where age related illness means more staff help is needed, specialist training has been arranged and staff are listening carefully to anxieties, so as to reassure and keep personal control for as long as possible. Service users are safeguarded by a sound approach to medication. A monitored dosage system is used, staff are fully trained in handling and administration of medication, and a pharmacist visits regularly to monitor and support. Service users manage aspects of their own medication wherever White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 16 possible and are being supported to take over more responsibility where this is appropriate. Although staff are responsible for handling and administering most service users medication, this is done sensitively with the aim of making sure service users are as fully involved with decisions as possible. For example staff are particularly aware of the implications for service users of taking medication to alter their behaviour, and aim to make sure they understand and take part in decisions about this. Sometimes decisions about medication need to be taken quickly as a difficulty develops, but staff still involve service users in making this decision, and record this carefully with them at the time. One service user has been helped to understand medication options the medical specialists have offered, and make a personal decision about this. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Robust procedures for safeguarding service users and protecting their interests are in place, and staff receive extensive training on safeguarding people which is kept up to date. The complaints procedure is accessible to service users in different formats. No complaints have been received but the manager plans to review how concerns and comments are recorded as part of the quality monitoring system. EVIDENCE: Service users have a reliable system for making sure any concerns they have about the service are brought to the attention of staff and are put right. The complaints procedure is available around the home and each service user has copies, in suitable formats such as easy read and a postcard system. Staff talk to service users to make sure they understand the procedure and encourage regular discussion about concerns, one to one and in service users meetings. There were no complaints recorded but after discussion, the manager is to consider ways of recording all comments on the service in a way that will contribute to quality monitoring. Service users know they can trust staff to safeguard their wellbeing. Staff are trained to understand what constitutes abuse and how to safeguard service users. The home has information about local procedures and staff know what to do if there is any concern or allegation of abuse. Training and information about local procedures is kept up to date, and staff have attended training White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 18 provided by the adult protection coordination team as well as on their foundation and National Vocational Qualification programmes. Staff are also encouraged to access e-learning materials on this topic provided by MacIntyre. Staff recruitment records are held at the providers’ head office. Following discussion with the manager he provided written evidence before close of inspection, to show that the provider’s robust recruitment practices are being rigorously followed before new staff are appointed. He undertook to ensure that an appropriate record showing the right checks are made, will now be retained in the home for all staff. Relationships between staff and service users are characterised by warmth, courtesy and mutual respect. The manager is strongly committed to the principles of person centred working and has in place a sound and well managed staff training programme, supervision and support system designed to promote this. Service users are both empowered and safeguarded by this approach, and this is strengthening as the service continues to develop. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The accommodation is in a good location, spacious and suited to the needs of people living here. It is clean, fresh, comfortable and well maintained, and service users are involved in looking after their home and making decisions about it. EVIDENCE: Service users enjoy living in this home that has been designed and purpose built to suit their needs well. It is in a residential area but only a short walk from the city centre. This means service users can get to know neighbours and use local shops and services, but can easily get to all the extra city facilities. Service users have made sure their home is about themselves with ornaments, pictures and very many photographs of friends, families and happy times. They have chosen the décor and the home is in good order, warm and welcoming. Communal areas are spacious and varied. There is a very large White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 20 kitchen dining room, separate utility room, a large comfortable sitting room and a smaller, cosy room known as the music room. This means there is opportunity for service users to spend time or see their visitors in private, without needing to use their own bedrooms unless they wish to do so. There is a good size, attractive private garden with outdoor furniture, lawn, vegetable plot and barbeque area. Service users enjoy using their garden space in good weather. Staff facilities are separate and provide adequate space for them too. Service users all have a single bedroom, and some proudly showed their rooms. Bathroom and toilets are shared and there are no ensuite facilities. Bedrooms are comfortable and a reasonable size. Service users are supported to look after their own space themselves and to personalise this as they wish, including their own furniture. They choose their own décor, and are consulted and their views listened to about any changes to be made to the accommodation generally. Service users can be sure their home is clean, fresh, comfortable and well looked after. This is because there are very good hygiene and maintenance arrangements which all staff understand and follow well. Records show staff are attentive to regular routines and repairs needed, and make sure the right action is taken to put things right quickly. One service user explained how the washing machine needed to be repaired, and that this was done straight away. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users benefit from a stable staff group, which consists of a mixed group of younger and more mature staff providing for a good balance of experience and energy on the team. There is a well designed training programme. Staff are very well supported by their manager to work effectively with service users, to achieve the quality of life they choose for themselves. EVIDENCE: Service users can be confident in the staff who work at the home and can be sure there are always enough staff to support them in the way they need and wish, to live the life they choose for themselves. Staffing is arranged around their needs, interests and timetables so that they can make the most of opportunities for personal development and interests, seeing friends and family and taking part in their own community. There is a strong staff team of both men and women, of mixed ages and experience with enough staff to offer choice and flexibility for service users to White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 22 be supported in the way they wish and need. For example as a service user’s needs change staff look with them at the implications for their lifestyle and make sure they have extra support so as to keep up with the things that matter to them and they enjoy. Service users can be confident that staff who work with them can be trusted to treat them well. This is because robust recruitment procedures are followed, and proper checks are made before new staff start work. Staff respect service users and treat them with dignity, and relationships between them are warm and friendly. Service users can be sure staff have the knowledge and skills they need to support them properly in the way that suits them best. The manager takes a proactive approach to staff training, and is responsible for taking the lead on training for all local services in the group. Under his direction this service is currently piloting the providers’ impressive e-learning programme. Staff spoken to were highly enthusiastic about the benefits of this programme, finding it gives them access to a much greater range and depth of knowledge while being fun and easy to use so motivating them to extend their learning in an enjoyable way. Sampling this confirmed the programme is well designed to promote systematic and effective, sustainable learning. Staff training needs are assessed as a team and individually, and good training records help to make sure this is kept up to date. There is a full, well planned training programme. This makes sure staff have mandatory and basic care practice skills, keep up to date with emerging needs, and continue to build on their expertise. It takes all staff from induction linked to Learning Disability Advisory Forum standards, actively encourages them through National Vocational Qualification programmes up to levels 3 and 4, and this is complemented by the e-learning programme. The aim is to provide staff with the knowledge and skills they need to support service users in the way they choose, and to actively work with them to take real responsibility for themselves and their own lives. Service users’ very individual, personal lifestyles here shows this is effective. Staff receive regular individual supervision and support, and the manager works closely with and alongside them to promote good practice. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Service users benefit from a service that is well run, with their own choices and interests the foremost priority. Service users and their key people actively contribute their views as part of the quality assurance process, and with support service users have a role in planning and developing the service. The manager is creative in taking service development forward. The annual service development plan takes service users views as its starting point, and shows what action the service will take to meet the aims they identify. White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 24 Management responsibilities in this service are carried out sensitively and fulfilled effectively, and enhance the well being of everyone living and working in the home. The manager provides sound direction and leadership, has confidence in his staff, and delegates effectively. There is an open, inclusive management style which makes sure everyone who lives and works at the home contributes to the decisions and routines. Everyone shares and takes very seriously the responsibility for sound management of health and safety in the home. Health and safety records sampled included risk assessments, fire safety procedures, water temperature and legionella checks. Sound and up to date systems and records show these are carried out to a good standard. The manager is well respected within and outside the service, and contributes to wider service development through supporting colleagues and taking on some delegated responsibilities from the area manager. The area manager visits monthly and reports on this to the Commission, as required to fulfil regulatory requirements White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 x 32 4 33 x 34 4 35 4 36 3 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 3 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 4 4 x 4 x x 4 x White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA22 Good Practice Recommendations It would be good practice to record all comments on the service, including those resolved in the course of day to day support, and link these to the quality assurance process White Ladies Close, 1a DS0000064298.V318260.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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