Inspection on 14/11/07 for 218 Kingsway

This inspection was carried out on 14th November 2007.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

218 Kingsway 03/10/06

218 Kingsway 21/02/06

218 Kingsway 31/08/05

218 Kingsway 25/02/05

218 Kingsway 03/06/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 218 Kingsway St George Bristol BS5 8NS Lead Inspector Sandra Jones Key Unannounced Inspection 14 & 16th November 2007 10:00 th 218 Kingsway DS0000026582.V353115.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 218 Kingsway DS0000026582.V353115.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. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 218 Kingsway Address St George Bristol BS5 8NS 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) 0117 9476315 0117 9709301 max@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Ms Nicola Jane Josefowicz Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged between 18 and 64 years with Mental Disorder. 3rd October 2006 Date of last inspection Brief Description of the Service: 218 Kingsway is a care home for five younger adults of both sexes with mental health care needs. It is operated by Aspects and Milestones Trust and managed by Ms. N. Jozefowicz. The property is semi-detached, with an appearance of a domestic dwelling, which blends well with its local environment. It is adjacent to a shopping precinct and major bus routes. The fees range from £281.00 - £397.00 per week. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced over two days in November 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. The Annual Quality Assurance Assessment (AQAA) was sent to the home for completion, with “Have your Say” surveys for people at the home, their relatives and social and health care professional. The manager returned the AQAA and surveys from the people at the home. Feedback was received through the survey from five relatives and the GP. Prior to the visit some time was spent examining documentation accumulated through Regulation 26 reports, surveys, the AQAA and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. The five people living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered through face- to- face discussions. What the service does well: Through the “Have your say” surveys, four relatives made specific comments about what the home does well. These comments included “They look after them well and take them out on day trips, they take them where they like to go”, I am completely satisfied with all aspects of the care home also the social activity and trips they have, Excellent” and “ I have no complaints, and think my relative has improved since the admission to the home.” 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 6 Comments made by the people at the home through “Have your say” surveys include “ I love my home, I like the staff, I like my room and staff help me a lot” and “I don’t really ever want to move, I am happy here”. The people at the home named the person they would approach with complaints and their comments indicated confidence with the person resolving their concerns. The home operates above the NMS of 50 staff qualified to NVQ level 2, with the exception of one, staff at the home have NVQ level 3. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 7 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. 218 Kingsway DS0000026582.V353115.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 218 Kingsway DS0000026582.V353115.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) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is an effective admissions procedure in place, which ensures that the needs of the person can be met by the skills of staff skills at the home. EVIDENCE: ”Have your say” surveys from the people at the home say they were asked about moving into the home and comments include. “ Staff talked to me about the home and explained what is like and how it is run”, “ I came several times with my CPN and she asked me with the staff if I wanted to move in”, “ I was given three choices and I choose this one” and “ I didn’t really want to come but the hospital was closing down”. Surveys were also received from five relatives and four people said that they always receive information about the home and one person said it was usual. There are five people currently living at the home and there were no discharges or admission since the last inspection. A member of staff on duty said that there are no expected discharges. There is a prepared Statement of Purpose in place, which specifies the range of needs that can or cannot be met at the home. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 10 The procedure for admission includes an admission criteria and arrangements for introductory visits and trial periods. Through the Annual Quality Assurance Assessment (AQAA) the manager has acknowledged that the Statement of Purpose has to be reviewed and intends to review it. 218 Kingsway DS0000026582.V353115.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 adequate This judgement has been made using available evidence including a visit to this service. The care planning process sets an exacting framework for individuals to follow. Individual’s needs may not be met due to gaps in the care plans. People at the home make choices about aspects of their lives and are encouraged through the risk assessment process to take risk. EVIDENCE: Personal profiles that describe the persons preferred routines in terms of staying at the home without staff support, leaving the home unsupported, sleep patterns, hygiene, health care and domestic abilities are in place. A support worker on duty said individuals at the home have annual Individual Care Programme Approach (ICPA) meetings, which the person attends with the manager, health and social care professionals. It was further explained that before the meeting the manager will discuss the persons needs with the keyworker. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 12 Care plans are then reviewed and the person signs the care plan to indicate their awareness of the action plan. Personal profiles describe how mental health needs are manifested. For three people care plans and strategies are in place to meet the current need. While it is acknowledged that the care plans are up to date, issues identified within the ICPA are not always included within the homes care plans. For example, changes in behaviours and deteriorating mental health care needs. This means that a requirement made at the last inspection is not fully met. “Have your say” surveys from five relatives state that the home always meets the needs of their relative. People at the home said that they attend ICPA meetings and know they have a care plan. Members of staff giving feedback about their role as keyworkers said that they organise trips, accompany individuals on shopping trips and give personal care to individuals that they have specific responsibilities. Individuals at the home confirmed that they have a keyworker and they were able to describe the role of their keyworker. Reports of significant events describe the activities undertaken, incidents, and outcomes of visits. It is evident through reports that the boundaries set are exact and expects that people will adhere to them. However, staff must be careful of the language used to describe individual’s attitudes and behaviours. “Have your say” surveys from three people at the home state that they always make decisions about what to do each day and, one person said, this was usual. The member of staff on duty said that the people at the home are able to communicate verbally. It was further stated that people are able to make decisions for themselves. One person giving feedback said that they are able to make daily choices. While one person has visual impairments, it was stated that accessible formats are not necessary because of their literacy needs. It was confirmed by the staff on duty that written communications would be read to the person and checked to ensure their understanding. The manager will be undertaking Mental Capacity Act training and initially will be cascading the information to the staff through staff meeting. There is a risk assessment in place to limit one person’s choice and shows the reasons for imposing the restrictions, the professionals involved in the decisions, which is signed by the person and reviewed by the manager. Each person’s competency to undertake tasks such as crossing the road, using the kettle, smoking, bathing, ironing and household chores is assessed. Where the person is not competent to undertake tasks, risk assessments are completed. Action plans list the steps to be taken to reduce the level of risk. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 13 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (15), (16)& (17) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals at the home lead interesting lives and are part of the local community. EVIDENCE: Activities, education and occupation form part of the annual Individual Care Programme Approach (ICPA) meeting. The current activity and the way it will be met and by whom is included within the ICPA. However, care plans are not always developed to meet the needs in terms of the activities, educations and occupation. Comments received through the “Have your say surveys” surveys include “ I decided on which course I like at college and staff help me with walking the dogs from the dogs home”, I have a busy week attending activity day centre, I work as a volunteer and attend college. Two people giving feedback describe the activities undertaken which show that people at the home have opportunities to undertake community-based activities. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 15 Personal profiles state the person ability to stay at the home and leave the home without staff. Two people will stay at the home on their own and three prefer not to stay at the home without staff. Four people are able to leave the home without the staff and the staff accompany one person. Two people at the home said that they are independent in the local community. At the time of the inspection individuals at the home were going on an organised trip to the theatre with the staff. People at the home said that they have visitors and visits can take place in their bedrooms for additional privacy. “Have your say” surveys from five relatives state that the home helps their relative living at the home to keep in touch with them. The home’s visiting arrangements are included within the Statement of Purpose and confirm that there are no restrictions on visitors. Within the personal profiles, the individuals family network are described along with they way the person maintains contact with family. The manager was consulted about the way the people at the home are respected as individuals by the staff. It was stated that policies and procedure ensure that there is a set approach towards respecting individuals. Tenancy Agreements state the expectations of both parties and the Privacy and Dignity policy confirms that the home operates within the seven principles of care and through vocational qualifications staff become skilled to observe individuals rights. Regarding the staff approach the manager said that during induction staff receive the Trusts handbook and Codes of Conduct and through discussion during training staff are made aware of the home’s expectations. There is a “What we can offer” document developed by the manager which states that there is an expectation that people at the home undertake chores. The home’s Statement of Purpose purports that “clients are expected and encouraged to take responsibility and ownership of the home which means making decisions on their environment, homes procedures and keeping it clean and tidy.” However, the expectations on the person are not made clear in the information about the home. Information about the level of contribution from individuals at the home must be made clearer within the Statement of Purpose. The manager said that chores are allocated around the persons ability and use of the area. Each person has a designated house day when they are at home to clean their bedroom and do their laundry. Individuals at the home describe the chores they must undertake and confirmed that staff knock on bedroom doors before entering, staff usually respect their right to privacy and mail is handed to the person unopened. It was further stated that staff address the person in the correct manner and although keys to bedrooms are provided bedrooms are not always locked. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 16 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 17 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. Individuals can expect sensitive and prompt support for their personal and Health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: Within the individuals profiles the persons abilities to maintain their hygiene needs is described. A member of staff on duty the individuals personal care needs and how they are met. A was examined and the action plan shows the individuals likes, dislikes and preferred routines and guide the staff to meet the assessed need. Aids and adaptations are installed to maintain individuals levels of independence when their needs change. There are grab rails installed in the bathroom to maintain the person level of independence and an en-suite is provided for one person that has mobility needs. The people that were consulted during the inspections said that they did not need assistance from the staff with personal care. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 18 “Have your say” survey from the GP states that the health care needs of the individuals at the home are always met. The five relatives that responded through the surveys said that they are kept informed about important issues. Records contain information about people’s mental health needs and show that referrals for specialist support are sought from GPs through staff’s ongoing monitoring of the individuals health. A record of medical treatment is also kept and staff record the dates of appointments, reasons for the appointment and outcome of the visit. One person said that they visit the GP without staff support and members of staff said that two people are accompanied on GP’s visits. Staff described the way medical advice is consistently followed. It was stated that directions is passed through communications book and during handovers when shift changes occur. One person has sensory needs and support from the Royal National Institute for the Blind (RNIB) was sought on behalf of this person. A member of staff on duty said that the advice received has enabled the person to undertake tasks independently. Three people self-administer their medication and there are risk assessments that assess the person’s level of competency with an action plan that enables the person to be independent. Medications are administered to two individuals by the staff from a monitored dosage system. Records of administration examined cross-referenced with medications held at the home. “When required” medications are administered by members of staff and protocols are in place to guide staff when to administer the medications. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 19 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 adequate This judgement has been made using available evidence including a visit to this service. Individuals say that staff take their concerns seriously and act upon them. The manager must ensure that the people living at the home are safeguarded from abuse. EVIDENCE: “Have your say” surveys from the five people living at the home state that they know who to speak to if they are not happy. Their comments included “I would tell my keyworker or other staff”, “ I would go to a senior member of staff” and “ I know I would be happy talking to staff but I would find it hard with some members of bank staff.” The manager said that the same two bank workers are used and individuals reluctance to discuss concerns with these staff are more about familiarity and comfort with discussing personal issues. Four people said that they know how to make a complaint and one person said that they didn’t know. Relatives that completed the surveys state that they know how to make a complaint about the care service and two said that they couldn’t remember. The manager said that there is expectations that staff explain the complaints procedure to each person and to show their understanding individuals sign copies of the procedure. Individuals consulted during the inspection named the person that would be approached with complaints and their comments indicated their confidence that staff would take their concerns seriously. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 20 Members of staff explained the steps that would be taken when complaints are received, it was stated that complaints received are recorded and passed onto the manager for investigation. The manager said that members of staff have attended Safeguarding Adults training and Trust policies and procedures in place ensure the approach towards safeguarding individuals from abuse. The member of staff on duty was consulted about their responsibilities towards protecting individuals from abuse. Staff know the factors of abuse and the actions to be taken for alleged abuse. However, the manner that staff were observed addressing individuals, prompting them to undertake personal care tasks and discussions between them, in front of the person, is disrespectful and unprofessional. Information recorded by staff is subjective and leads the reader to make assumptions about the persons behaviour and attitudes. For example “she gave me an evil look.” Care action plans for one person state “staff must calmly repeat instructions and not get cross with the person” The manager said that the remark is to acknowledged that repetitive instructions may cause staff to react unprofessionally. The observations of the staff’s attitude towards the people at the home, the information recorded by the staff together with the expectations that people remain within the set framework has given rise to concern about the safety of the people at the home. The manager must ensure that staff behave in a professional manner and people at the home are not at risk of abuse. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained so that people at the home can benefit from living in a comfortable and clean environment. EVIDENCE: 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 22 Kingsway is a semi-detached property located in a residential environment, next to a small shopping precinct and close to bus routes. The property is arranged over two floors, with shared space on ground floor and bedrooms on the both floors. “Have your say” surveys from two people stated that the home is always fresh and clean, two people said it was usual and one person said it was sometimes clean. Their comments included “ Everyone helps to keep the home clean”, “I love my home” and “ Sometimes people have things around and this makes the place seem messy” Bedrooms are single occupancy, lockable and furnished with a combination of the home’s furniture and the person’s personal possessions. Each bedroom reflects the individuals personality and is suitable to meet the individuals lifestyle. One person said that their bedroom was due for decoration. One bedroom is fully en-suite with toilet, shower and hand basin to support one person with mobility needs. The upstairs bathroom has grab rails to maintain one persons level of independence. There is a lounge/dining room, smoking lounge and kitchen shared by the people at the home. The lounge/dining room offers sufficient seating for the group to sit together and watch television and dining space to eat their meals together. The smoking room is well ventilated with a large sofa, easy chair and desk. The kitchen is large enough for three people to sit at the small dining table. The home provides sufficient communal space for shared activities and for private use. The manager said that in January 2008 a separate smoking area would be provided. The laundry is sited away from the kitchen. The walls are painted and there is vinyl flooring for ease with cleaning. There is a domestic washing machine and tumble dryer with hand washing facilities. One resident is occasionally doubly incontinent and foul linen can be put through the washing machine. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (32), (34) & (35) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standards of care are delivered to individuals at the home by a competent and skilled staff team. EVIDENCE: “Have your say” surveys from three people said that carers always listen and act on what they say and two people said this was usual. Their comments include “ Different staff, different ideas” and “ I am able to discuss things with staff.” The personnel files of the staff working at the home were examined and notification of Criminal Record Bureau (CRB) checks obtained, application forms and referenced are held within the files. The manager said that the staff team are very stable and have not changed for seven years. It was further stated that there is a 25-hour vacancy and for more flexibility the vacancy will not be filled. The Annual Quality Assurrance Assessment (AQAA) states that the home operates under extablishment hours and a group of about 4 bank staff are used on a regular basis providing consistency during periods of sickness and leave. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 24 The manager said that members of staff attend training courses to maintain their level of skills with meetings individuals changing needs. Training for people that may self-harm and autism will be provided for the staff to ensure they have the skills to meet the needs of the people at the home. The staff training needs in Autism, Learning Disabilities, Active Listening and group work will be addressed through team days. It was further stated that that there is an expectation that staff are up to date with their statutory training and attend two additional training courses each year, which is decided through their Personal Development Plans (PDP). The staff training records show that staff undertake statutory training, which includes Manual Handling, Food Hygiene, Health and Safety. Other courses that staff have attended include medication, self-harm, diabetes, group work and person centred care. Staff working at the home are encouraged to undertake vocational qualifications and with the exception of one, all staff have NVQ level 3. The manager said that staff that do not undertake vocational qualifications must complete competency packs. The competency pack is a similar compressed version of the induction programme. The survey from the GP states that it is usual for the care staff to have the right skills and experience to support individuals with their social and health care needs. Four relatives stated through the surveys that the staff have the right skills and experience to meet their relative needs and one person said it was sometimes. 218 Kingsway DS0000026582.V353115.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): (37), (39) & (42). Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals live in a safe environment and can be reassured that the standards of care will be subject to constant monitoring. There are some concerns about the staff’s unprofessional practices. EVIDENCE: The fees at the home range from £281.00- £397.00 per week. Facilities exist for the safekeeping of cash and valuables and the records were checked against the balances held which cross-referenced with each other. 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 26 The staff rota shows that generally one person is on duty throughout the day and night, with overlaps when activities are organised. The manager is supernummery and works 34 hours per week. Fire Risk assessments are completed and include checking the fire alarm system, emergency lighting, fire fighting equipment and practices for the staff, which entail fire training and fire drills. The manager also ensures that the meets associated legislation by instructing a competent person to check the gas central heating and portable appliances annually. “Have your say” surveys from four people living at the home said that the staff treat them well and one person said it was usual for the staff to treat them well. Their comments included “ I’m happy with the staff’ “ I know I get me hair off sometimes can’t help that though” and “ sometimes I find them a bit strict”. The manager said that this comments refers to the expectations that people undertake chores and about addressing issues. Through the Annual Quality Assurance Assessment (AQAA) the manager stated that the role includes making sure that the residents physical, emotional, social and spiritual needs are met fully and that all the staff here are competent to do this. Policies and procedures are in place and followed so that residents best interests are foremost and staff are accountable. The manager said that the style of management used is led by the individulas needs. Individuals were consulted about the management of the home and the staff. One persons said that they are treated well by the staff and the other person said that the staff were “bossy”. Members of staff were also consulted about the style of management in place. They said that the manger is approachable and has respect for the people living at the home. The manager said that the external manager visits the home monthly and is supportive. The manager said that the first part of a two part audit has taken place with a manager from a similar service within the Trust. The purspose of the audit is to gather information about the standards of care and once complete the external manager and home’s manager will discuss the outcomes and set an action plan. Despite the above checks the disrespectful attitude of staff must be addressed. The manager must take responsibility for this and ensure people are safe from abusive practice. 218 Kingsway DS0000026582.V353115.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 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 3 x 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 (1) Requirement Current goals, activities and occupation must form part of the individuals care plans. Care plans must be kept under review. As individuals needs change action plans must be updated. Staff at the home must maintain good professional relationships with the people at the home The manager must ensure that the people at the home are safeguarded from abuse. The Statement of Purpose must be reviewed to make clear the expectations that individuals must undertake household chores and work within set boundaries. Timescale for action 30/03/08 2. YA6 15 (2) 30/12/07 3. YA16 12 95) (a) 01/12/07 4 5 YA23 13 (6) 6 01/12/07 30/01/08 YA1 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 29 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 218 Kingsway DS0000026582.V353115.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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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