Inspection on 14/06/07 for 220 Preston Road

This inspection was carried out on 14th June 2007.

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

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

Other inspections for this house

220 Preston Road 17/01/06

220 Preston Road 07/09/05

220 Preston Road 03/03/05

220 Preston Road 20/09/04

220 Preston Road 26/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 220 Preston Road 220 Preston Road Hull East Yorkshire HU9 5HF Lead Inspector Christina Bettison Unannounced Inspection 14th June 2007 09:30 DS0000000922.V343255.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 DS0000000922.V343255.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. DS0000000922.V343255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 220 Preston Road Address 220 Preston Road Hull East Yorkshire HU9 5HF 01482 706988 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) mansfieldm@hullcc.gov.uk North British Housing Association Limited Mrs Marjorie Mansfield Care Home 9 Category(ies) of Learning disability (9) registration, with number of places DS0000000922.V343255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That registration is approved with the condition that a clear CRB disclosure for the Manager is received by the CSCI. 17th January 2006 Date of last inspection Brief Description of the Service: New Leaf a subsidiary of North British Housing own 220 Preston Road. And it is managed in partnership with Hull City Council. The councils social services department are responsible for the care and providing the care staff. New Leaf is responsible for its upkeep and provides ancillary staff. The home is registered to provide care and accommodation for up to 9 adults between the ages of 18-65 who have a learning disability. The home is located to the east of Hull city centre and is purpose built. It is a 2 storey building divided into 2 main units with a central linked area that includes the reception area, office accommodation, the laundry room, relaxation room and kitchen. Each unit has a lounge and dining room with kitchenette area. One unit has 5 bedrooms and one has 4, and a sleep-in room for staff. All bedrooms are singles. There are a number of bathrooms and toilets on each floor. Two bedrooms are downstairs. There is no chair or passenger lift. There is a car park area to the front and a pleasant garden to the rear and sides. DS0000000922.V343255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and the unannounced site visit took place over 1 day on 14th June 2007. Two relatives’ surveys were returned, nine service user surveys were returned, (service users were assisted by staff to complete these), eleven staff surveys were returned and one health and social care professional survey was returned. The registered manager, two senior care officers, three care officers and the cook were spoken to on the day of inspection. Observations of care practices were undertaken to check if service users were receiving appropriate care to meet their needs. The inspector looked around the home and looked at records. Information received by the CSCI since the previous inspection was also considered in forming a judgement. A relative commented, “I have no complaints whatsoever. ……….is well looked after, well fed, taken out and brought to see me. He looks well and is always clean and smart. Now that I am old and ill it gives me peace of mind to know that………….is well looked after and happy. The care staff are wonderful people and I’m sure………would say so if he could talk”. Anther commented “ the home always make a point of letting me know if there is a problem with our son. Whenever a problem has occurred I have only to mention it to the staff for them to sort it out to everyone’s agreement. My son is very happy, so we can assume the home is well run, clean and general atmosphere of “home from home”. The feeling of friendliness and relaxation is prevalent. The situation of the home, lack of space and the dual carriageway outside is a worry however the staff do extremely well to keep the clients safe” A visiting health professional commented, “The staff and manager appear warm, friendly and committed. Constantly motivated to meet clients health and social needs and striving to progress.” Seven staff were spoken to and without exception they all commented that they enjoyed their job, worked with a friendly effective staff team that all work well together, they have a good management team that runs a tight ship and ensures that things get done with the main aim of the home being that everyone is there for the good of the service users. Prior to the visit the inspector referred to complaints received and notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre- inspection questionnaire. The site visit was led by Regulation Inspector Mrs.C.Bettison and the visit lasted seven and a half hours. DS0000000922.V343255.R01.S.doc Version 5.2 Page 6 Weekly fees are £886 per person per week. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report What the service does well: Service users and their relatives are provided with information that is easy to read so that they know what to expect from the home. Service users have an assessment so that the staff know what they need to do to meet their needs. New service users are able to visit the home and stay overnight to help them to decide if the home will be able to meet their needs or not. Each service user has a range of plans that help the staff to know how their needs must be met. All service users have a single room that is nicely personalised to their own taste, providing them with an area where they can spend private time or receive visitors. Service users are helped to enjoy a wide range of activities both in the home and in the community and holidays that meets their diverse needs. Relatives are very involved in the home and service users are helped to go and visit their relatives, making sure that they can keep in contact. The kitchens are kept clean and service users are helped to eat a healthy diet. Each service user now has a health action plan which helps to make sure that their health needs are met. Service users medicines are looked after well and staff assist service users to take their medicines safely. Service users and their relatives concerns are listened to and staff make sure they take action to sort problems out quickly. The staff and managers know that they need to make sure service users are protected from harm and what to do if someone is harmed. A good recruitment policy is in place so that staff employed are safe to work with the service users and they are protected from harm. DS0000000922.V343255.R01.S.doc Version 5.2 Page 7 The staff are very committed, caring and competent and treat service users with respect and dignity. More than half of the staff have got a certificate (NVQ Level 2) which says they know how to work with the service users in the home and how to meet their needs. The registered manager is qualified and competent to fulfil her role as the manager. The home is safe, comfortable and meets service users individual needs. 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. 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. DS0000000922.V343255.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 DS0000000922.V343255.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): 1,2 and 4 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed in full by a range of professionals and service users and their families are given sufficient information about the home so that they can be assured that the home can meet their needs EVIDENCE: The home has a statement of purpose and this details all of the information required by this standard and Schedule 1 of the Care Homes Regulations 2001 for adults 18-65 years. A service user guide is available and this contains all the information required by National Minimum Standard 1.2. and is provided in a format that to help service users understand it. The care files of two service users were examined, one of these being a new admission to the home. This contained a copy of the Local Authority Community care assessment and care plan and a range of assessments carried out by a variety of professionals. DS0000000922.V343255.R01.S.doc Version 5.2 Page 10 In addition to this the manager undertakes her own assessment to ensure that the home can meet the service users needs and that they will be compatible with the other people living in the home. A short transition from the service users previous home was planned but the service user is autistic and it was felt that a phased introduction would be more unsettling therefore a quicker move was arranged. The staff team had enough information on the assessed needs of the service user and this enabled them to provide an individually tailored service to meet the service users complex needs and ensure their emotional stability. Staff members informed the inspector as to how they are continuing their assessment of the new service user in a variety of areas, i.e mobility and personal care and making changes to their approach to ensure that they meet the service users needs and provide support in the way they like it. However the recording of actions/plans and outcomes needs to be improved to ensure that the home can evidence the good work that they are doing and demonstrate how the service users needs are being met and how individuals are developing. DS0000000922.V343255.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 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the provision of service users plans, risk assessments and a knowledgeable, skilled staff team. EVIDENCE: Two care Files were examined as part of the inspection process. Each file contained a pen picture which gave staff a quick overview of a service users needs. Although all of the assessment information was available to ensure that all of the service users assessed needs were identified and met, the care planning process and paperwork was a little disjointed and spread all over the file. DS0000000922.V343255.R01.S.doc Version 5.2 Page 12 The home used a service user plan format that contained very little information in one service users file, however in their other file were lots of plans of care that were very detailed and covered most of the areas required by this standard. Behaviour management guidelines, communication passports and risk assessments supported the information. The home need to decide which format to use and ensure that plans are clear and easy to follow. Plans did not include any detail of cultural and religious needs and as previously stated the recording of actions/plans and outcomes needs to be improved to ensure that the home can evidence the good work that they are doing and demonstrate how the service users needs are being met and how individuals are developing. Feedback from professionals and discussion with service users evidenced that service users and relatives were happy with the service and that there needs were met and independence promoted in many ways. Both service user files contained copies of their care review coordinated by the care management team, In addition to this the service users had benefited from a person centred plan meeting, actions from these plans need to be met, kept under review and incorporated into the care planning process making it more comprehensive and cohesive. A number of risks had been identified, assessed and were being minimised by the production of risk assessments that staff were familiar with and followed and a number of these related to measured risk taking allowing service users to develop and maintain their independence. All service users had a key worker. Staff and service users confidential information was observed to be securely kept and handled in accordance with the Data Protection Act. Lockable facilities were used and service users are consulted about when and where there information can be shared. Staff were observed to knock on doors and to ask permissions to enter bedrooms. DS0000000922.V343255.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,and 17 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assisted to continue their personal development and access a range of leisure pursuits of their choice. Family contact and personal relationships are maintained and all service users enjoy a healthy diet. EVIDENCE: Service users at 220 Preston rd have autism and significant needs and all require a high level of support from the staff team. Therefore none of the service users have work placements. DS0000000922.V343255.R01.S.doc Version 5.2 Page 14 The home employ two programme workers to specifically support service users to access outside activities of their choice and they also provide an in house activity programme. In one of care files examined the service user activity plan identified swimming, bowling, walks, shopping, relaxation, listening to music and in the other the service user plan consisted of country and coastal visits, shopping, gardening, arts and crafts, baking, flower arranging and some domestic chores with staff support. There was evidence in the file and staff spoken to confirm that these activities take place regularly and it was apparent that service users individual diverse needs and wants were being met be a very motivated and flexible team of staff. Service users holidays are being planned for this year with two service users going to a caravan in Mablethorpe, they had tried a cottage last year but staff had assessed this as being too quiet for them as they like discos and swimming and a more active lifestyle, another two service users are going on walking holiday as this is something that they enjoy. One of the service users who had gone away for five days lat year had found the experience too much and so this year the staff are taking them out for days. Letters were seen from relatives thanking the home and staff for the good work they do and for one service user whose parents are older and suffering ill health at the moment the staff team support the service user to go and visit their parents regularly, the parents are very grateful for this. The manager, staff and cook promote a healthy eating menu. Breakfast is cereals and toast. The lunch menu consists of quiche, jacket potatoes, soup, toasted or ordinary sandwiches, and omelette and chicken burgers and followed by homemade puddings. The evening meal menu consists of beef cobbler, shepherds pie, curries, fish and chips, pasta, and fish cakes and on Sundays a full roast dinner. The cook was spoken to and was knowledgeable about service user likes and dislikes and special diets and all staff spoken commented on what a good cook she is. On the day of inspection she had made homemade biscuits for the service users. Any restrictions regarding meals and/or lack of choice where clearly documented in the service user plans and guidelines and recommendations from psychologist and speech therapists where being incorporated. Staff said there were always biscuits, crisps and drinks in for service user to have when they wanted them. DS0000000922.V343255.R01.S.doc Version 5.2 Page 15 DS0000000922.V343255.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies and a caring and professional team of staff that promotes their privacy, dignity and respect. However this could be improved by better identification, planning and recording of outcomes to meeting health needs. EVIDENCE: Records examined confirmed that service users health needs were met by GP, dentist, chiropody and that they had access to a wide range of other health professionals e.g. psychiatrist and psychologist and speech and language therapist. However there needs to be some improvement in the screening, identification and planning to meet health needs. Health action plans had been produced but these were basic and did not cover all areas of health need. In addition to this the recording of outcomes to health appointments were in the general daily DS0000000922.V343255.R01.S.doc Version 5.2 Page 17 recordings and did not sit alongside the health action plan, this could made it difficult to track if health needs had been met or not. Discussion with staff and observations confirmed that the staff promoted service users dignity, privacy and respect. Staff were observed to behave in an appropriate manner towards service users. A visiting health professional commented, “staff have always appeared caring towards individuals, considered their wishes and respected their dignity.” Hull City Council has medication policies and procedures that include receipt, storage, administration and disposal of medication. Medication systems appeared to be well managed in the home, there was no one self medicating and at the time of the visit there were no controlled drugs in the home. Medication is provided by Lloyds pharmacy and is in a monitored dosage system. The manager and senior staff regularly audit, stock check and ensure that the medication is safely managed. All staff are given medication administration training which includes the completion of a workbook assessed by Lloyds pharmacy, however the manager needs to evidence that she has assessed staff to ascertain their competence. Some service users are prescribed medication for pain relief and for behaviour management purposes. The protocols for the administration of medication on a “as and when required” basis need to be clearer so that staff know when to administer PRN medication and when second doses can be given. DS0000000922.V343255.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected from harm by a robust complaints procedure and a Protection of Vulnerable Adults policy and procedure that the staff and manager are aware of their responsibilities within this. However this would be further improved by the provision of appropriate training for helping service user when they present with behaviours that may harm themselves or others. EVIDENCE: Hull City Council have a well-developed complaints procedure. This contained contact details for the CSCI and the ombudsman and gave an assurance that service users and their families would not be victimised for making a complaint. There had been one complaint since the previous inspection which had been taken seriously, investigated and resolved appropriately. The manager checked the complaints log on a regular basis. DS0000000922.V343255.R01.S.doc Version 5.2 Page 19 The home had a copy of the “Multi agency Guidelines for the Protection of Vulnerable Adults” in respect of alerting, referral and investigation. Hull City Council have a separate whistle blowing procedure. There was evidence from the home’s recruitment and selection processes, staff training records, complaints log and the use of risk assessments that the manager ensured that on the whole service users were protected and safeguarded from abuse. Training records evidenced that staff had received training on the protection of vulnerable adults and the staff spoken to were clear about their responsibilities within the POVA procedures, however all staff spoken to commented to the inspector that they were concerned about a specific issue. On occasions some of the service users present with significantly challenging behaviour that may pose a risk to themselves, to other service users and to the staff. On these occasions staff have to use a minimal degree of restrictive physical intervention, i.e. holding a service users arms down by their side or escorting them to a safe place to protect them and others around them. Staff expressed concern that techniques of holding are not covered on the Therapeutic Crisis Intervention training provided by Hull City Council and it is not explicit stated what techniques can be used within the behaviour management guidelines. There is nothing to suggest that service user are being ill treated or abused however staff are being left in a very vulnerable position by the lack of appropriate training and guidelines in this area and this must be addressed as a matter of urgency. DS0000000922.V343255.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a well maintained home that is safe, homely and comfortable and is in the local community and meets their assessed needs. EVIDENCE: The home is located to the east of Hull city centre and is purpose built. It is a 2 storey building divided into 2 main units with a central linked area that includes the reception area, office accommodation, the laundry room, relaxation room and kitchen. Each unit has a lounge and dining room with kitchenette area. DS0000000922.V343255.R01.S.doc Version 5.2 Page 21 One unit has 5 bedrooms and one has 4, and a sleep-in room for staff. All bedrooms are singles and are personalised to the service users liking. There are a number of bathrooms and toilets on each floor. Two bedrooms are downstairs. There is no chair or passenger lift. There is a car park area to the front and a pleasant garden to the rear and sides. On the day of the visit the home was seen to be clean and tidy and provided a safe, warm and cosy environment for service user to live in. DS0000000922.V343255.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported by an extremely professional, competent and flexible staff team that promote the needs of service users as their primary concern. EVIDENCE: There has been one senior care officer leave the home as he emigrated since the previous inspection and there has been only one new appointment to the staff team since the previous inspection; this was a part time cook. A senior care officer has returned to the home following a secondment to another home. The staff team consists of;• 1 x registered manager DS0000000922.V343255.R01.S.doc Version 5.2 Page 23 • • • • • • • • 2 x full time senior care officers 2 x part time senior care officers (one of these is a vacant post covered by a care officer acting up) 6 full time care officers 6 part time care officers 1 x full time cook 1 x part time cook 2 x part time domestics (one of these is a vacant post) 4 x waking night staff The rota usually consist of a senior care officer and 2 care officers 7-3 and 311 and a floater 8-4, In addition to this Mon- Fri there are two programme workers to provide activities and sometimes a care officer on flexi shift. All staff spoken stated that staffing was adequate to meet the needs of the service users as they don’t always want to go out or be involved in activities and prefer their own company in their bedroom, the lounge or the relaxation room. Senior staff sleep in and there are 2 waking night staff. The home benefits from a consistent staff team as there have been very little change to the staff team for many years. Seven staff were spoken to and apart from the new cook they have all worked at the home for 7 to 8 years. Without exception they all commented that they enjoyed their job, worked with a friendly effective staff team that all work well together, they have a good management team that runs a tight ship and ensures that things get done with the main aim of the home being that everyone is there for the good of the service users. Observation of staff practices confirmed that they have developed appropriate relationships with service users and treat them in an age appropriate way and with the utmost of dignity and respect whilst offering guidance and support in a firm but sensitive manner. A visiting health professional commented, “The staff and manager appear warm, friendly and committed. Constantly motivated to meet clients health and social needs and striving to progress.” A relative commented, “I have no complaints whatsoever. ……….is well looked after, well fed, taken out and brought to see me. He looks well and is always clean and smart. Now that I am old and ill it gives me peace of mind to know that………….is well looked after and happy. The care staff are wonderful people and I’m sure………would say so if he could talk”. DS0000000922.V343255.R01.S.doc Version 5.2 Page 24 Anther commented “ the home always make a point of letting me know if there is a problem with our son. Whenever a problem has occurred I have only to mention it to the staff for them to sort it out to everyone’s agreement. My son is very happy, so we can assume the home is well run, clean and general atmosphere of “home from home”. The feeling of friendliness and relaxation is prevalent. The situation of the home, lack of space and the dual carriageway outside is a worry however the staff do extremely well to keep the clients safe” Staff files were examined as part of the site visit and this evidenced that staff have CRB disclosures, all identity as required by regulation and references obtained prior to commencement in employment. Supervision records were examined and were in order and the current staff team are up to date with their mandatory training with the exception of infection control which all staff have been put forward for. Staff have undertaken other specialised training relevant to the needs of the service users, i.e. epilepsy, autism awareness and managing difficult behaviours (TCI). However as stated in the complaints and protection part of this report the quality of the TCI training needs to be looked at to ensure that it meets the needs of the staff and ensures that service users are protected from harm. The manager informed the inspector that she has been allocated a small budget for the provision of training and she is looking at providing some more tailored autism training, and some specialist bereavement training. The registered manager had a training and development plan for the staff team and all staff had an individual training and development action plan that was completed annually. All of the senior care officers have obtained NVQ level 3 and one has obtained NVQ level 4. All of the care officers have obtained NVQ level 3 except the two night staff who are planned to commence this soon. The cook has obtained NVQ level 3 in catering. DS0000000922.V343255.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 and 42 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is well run and managed by a very competent manager and senior care team. EVIDENCE: Mrs Marjorie Mansfield is the registered manager at 220 Preston rd. She has her NVQ 4 in care and management and many years experience of working with adults who have a learning disability. DS0000000922.V343255.R01.S.doc Version 5.2 Page 26 Regular staff meetings, staff supervision and the key worker system ensure that staff and service users have the opportunity to influence the way the service is delivered. Mrs Mansfield is a very effective manager and her staff speak very highly of her. They stated that she is very supportive both personally and professionally. Hull City Council have a Quality Monitoring system that includes surveys, audits and appraisals with the production of an Annual Review document. As part of the inspection all maintenance records were seen and were up to date and in order ensuring that the service users live in safe environment. DS0000000922.V343255.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 4 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 2 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 2 33 4 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 4 x 3 x x 3 x DS0000000922.V343255.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 15 Requirement The registered person must ensure that behaviour management strategies include detail of any restrictive physical intervention used by staff to protect service users The registered person must ensure that incidents of the use of RPI must be maintained and a record forwarded to the CSCI The registered person must ensure that service users health needs are met in full by the provision of health screening, comprehensive health action plans and robust record keeping of outcomes. The registered person must ensure that staff receive training in infection control. The registered person must ensure that the TCI training is tailored to the specific needs of the service users and provides specific restrictive physical intervention techniques to be used as a last resort and provided to all staff. Senior care staff to be trained as a priority and within the DS0000000922.V343255.R01.S.doc Timescale for action 30/09/07 2. YA7 37 15/06/07 3 YA19 13 30/09/07 4 5 YA32 YA32 18 18 31/08/07 31/08/07 Version 5.2 Page 29 timescale specified. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA6 YA6 YA6 YA20 Good Practice Recommendations The registered person should ensure that more robust recording of outcomes for service users is in place. The registered person should ensure that all documents specifically related to service users are provided in an accessible format. The registered person must ensure that service user plans include all aspects of service users diverse needs i.e. culture and religion, interests and hobbies. The registered person should ensure that Protocols for the administration of PRN medication are more detailed. DS0000000922.V343255.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000000922.V343255.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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