Inspection on 22/05/08 for 23 Duston Road

This inspection was carried out on 22nd May 2008.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

23 Duston Road 04/01/07

23 Duston Road 30/01/06

23 Duston Road 31/01/05

23 Duston Road 06/05/04

Similar services:

Trevayler Residential Care Home

St Marys Nursing Home

Thornham Grove

Thistle Hill Hall

Chater Lodge

Conifer Lodge

Tixover Care Home

Toynton College (Cluster Five)

Extracts from inspection reports are licensed from CQC, this page was updated on 12/03/2009.

CARE HOME ADULTS 18-65 23 Duston Road Duston Northampton Northants NN5 5AR Lead Inspector Ansuya Chudasama Unannounced Inspection 22nd May 2008 11:00 23 Duston Road DS0000043835.V364978.R03.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 23 Duston Road DS0000043835.V364978.R03.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. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Duston Road Address Duston Northampton Northants NN5 5AR 01604 754559 01604 588276 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) The Richardson Partnership for Care Mr Brian Richardson, Mrs Jacqueline Richardson, Miss Laura Richardson-Cheater , Mr Gregory Richardson-Cheater Ms Michele Shalini D`Souza Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (1) of places 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No person falling within the category MD can be admitted where there are already 7 persons of category MD already in the Home. The Home can accommodate 1 Service User within the category MD who also has needs within the category PD. No person under 22 years and over 52 years may be admitted to the Home. The Service Users admitted to the home who fall within the category MD must have an Acquired Brain Injury 28th February 2008 Date of last inspection Brief Description of the Service: 23 Duston Road is a care home providing personal care and accommodation for 10 service users with Mental Disorder (Acquired Brain Injury) one of whom may have an additional Physical Disability. The Home is located in a suburb of Northampton close to the local shopping centre of St. James and near to local pub and other amenities. The Home can be easily accessed by public transport and is approximately a mile and a half from Northampton Town Centre. The Home consists of a three-storey building offering single bedroom accommodation to all Service Users. All bedrooms have en suite facilities. The ground floor bedroom has an adjacent, specially adapted bathroom to cater for one Service User who may have additional physical disability. The Home does not have a lift and Service Users accommodated on the upper floors must be able to negotiate stairs. There are two lounges and a separate dining room. The Home has disabled access, parking to the front and Service Users are provided with a rear garden. As from 1st of April 08 the basic fee levels start at £2,043 per week but are dependent on the complexity of the service users needs and the level of support required to meet the needs. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has one star rating and this means that the people using the service receive an adequate service Two inspectors Ansuya Chudasama and Andrea James went to the home without telling any one that they were going to visit on the 22nd of May 08. This was the first time they had visited the home. We spoke to the staff, the manager of the home and there was another manager from a sister home supporting the manager with the inspection. One of the managing partners Greg Richardson –Cheater had also visited the home to meet the inspectors. We talked to some of the residents, and looked at information about policies and procedures, which tells the staff how to do things in the home. We looked at the training that they do to look after the people living in the home. We looked at information about some of the people who live in the home to find out how their needs are being met by the staff. This is called case tracking. We watched how the young people and staff living in the home got a long together. A complaint was received by the CSCI in November 07 and it was decided that a Random inspection would be carried out by CSCI on the 22nd of November 07 to monitor compliance with the Care Standards Act 2000. Four requirements, that were unrelated to any issues that were raised in the complaint were made at this inspection. These requirements were checked at this inspection and evidence showed that they were met. We would like to thank the staff, and the people living in the home for their time in helping with this inspection. This inspection report should be read alongside the National Minimum Standards for Younger Adults. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 6 What the service does well: Some of the people living in the home say they: • • • • • • • • • • ‘like living at the home’ ‘the quality of care as excellent’. They know who to tell if they are unhappy. They go on holiday ‘staff treat me well’ as they helped to prepare my food and take me shopping Sometimes ‘cook with staff’ and ‘like spaghetti bolognaise’ Go shopping to buy new clothes for the holiday ‘a kind lady takes me out shopping’ ‘like the food’ Everybody who lives at the home has their own bedroom The staff spoken to say: • • • • • That they enjoy working at the service. They attend training to help them meet the needs of the people they look after. They have meetings called supervision with their management to discuss how they are getting on at work and meeting the needs of the people they look after. They ‘help people look after themselves’ and ‘like to see them improve’. They help people living in the services to learn skills to help them become more independent The Inspectors observed: • • • • • Staff were talking to the people living in the home in a positive and caring manner. The home was clean and tidy People are encouraged to help with household chores and do as much of their personal care as possible. Medication records were well maintained Records, observations and discussions with people using the service demonstrated that they can make some decisions about their lives and independent lifestyles are encouraged. For example one person was able to form a relationship with another person with the support from management and staff. Professionals spoken to stated that the home was friendly and the staff were approachable, they also commented that the home was clean and tidy and smelled fresh • 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 7 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. 23 Duston Road DS0000043835.V364978.R03.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 23 Duston Road DS0000043835.V364978.R03.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): 1,2,3,4 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Evidence suggests that prospective residents have a needs assessment undertaken before they are admitted to the home to ensure their needs can be met. EVIDENCE: The home’s Statement of Purpose was combined with the service user guide. Which had information about the aims and objectives of the home. The document was revised in April 2008. However the information on staffing needs reviewing to ensure that it reflects current staff working at the home, alternatively the home could remove individual names of care staff and staff the number employed with the range of qualifications. The above document is given to people interested in coming to the home. One new user who had recently been admitted to the home said that they ‘liked it here’. There was evidence to suggest the user was able to choose the furnishings and fittings for their bedroom. Evidence showed that the people 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 10 were able to visit the home for a trial before they made up their minds about living at the home. Information in the files of people living at the home showed that there were detailed social work assessments and assessments completed by management prior to the admission of the resident. This information was documented in a ‘ratings tool’ that has been devised by the home. The information is then expanded onto a more detailed document that is completed with the individual to whom it concerns. We noted that for one person the more detailed document was not available in their file. The manager was asked for this information but said that a member of staff was working on this and it was not made available. The home needs to ensure that these documents are available for inspection purposes. 23 Duston Road DS0000043835.V364978.R03.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): 6,7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are generally well met EVIDENCE: All people living at the home had care plans, however some of the activities such as preparing a meal and carrying out laundry facilities was not happening (See standard on life style for meal and laundry services). The care plan documentations seen suggested users needs were kept under review and updated on a regular basis these records were a satisfactory standard and they identified risks and hazards and how best to deal with them. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 12 Intervention guidance for example personal care and crisis prevention was also seen, along with various health action plans. We spoke with some people and observed others that were not able to communicate verbally. Support workers demonstrated how they communicated effectively with people that have minimal verbal communication skills. People confirmed that they were involved in the review of their care plans along with their family or representatives. These occurred on a regular basis or as needs changed. People received support from family, friends and professional representatives at reviews. Records have clear processes for decision-making and advocates are used appropriately. People are further assisted in making decision within the home during house meetings at which minutes are taken. Issues raised during these meetings are acted upon. People’s cultural needs are fully met by a staff team that reflects the ethnicity of the people living at the home and Individual needs are well met. An issue concerning one person that can become racist is managed positively. Staff spoken to stated that they understood the policy on confidentiality. Staff recruitment records seen showed that all staff had signed the confidentiality document to ensure that information is handled appropriately. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15,16,17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are offered a healthy diet but meal times need to be more comfortable with staff being proactive in meeting the needs of the people being looked after. EVIDENCE: Residents had good opportunities to access community activities of their choice. We observed one person being supported by staff so they could read the newspaper. Another person said that they liked ‘spaghetti bolognaise and had cooked this with staff’. Another person spoken to stated that they were working towards going out on their own, and a ‘nice lady that takes me out’. It was also said that they were getting on ok and staff were ok. They helped 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 14 out with housework, hoovering, and they liked the food. They’ chilled out’ in their room, and were happy. One person had been out shopping to buy clothes for their holiday and said that they were very excited to go on holiday. We were informed by staff that people did activities like painting, make cards in the house and went for drives, shopping, ate out and went to the cinema. Both staff and people living in the home spoken to stated that more activities were required’. The manager stated that a new summer activity was scheduled to be implemented soon. There were concerns as to how some people were restricted in their day-to-day living choices. These restrictions included the ability to take part in preparing meals, and carrying out laundry duties even though the care plans identified some of these tasks as daily activities for people living in the home. It was observed that the laundry facility is situated outside in the garden making it difficult for the people using the service to access this facility when the weather conditions are poor outside. In addition the laundry room is limited in size and it is difficult to see how staff and people living in the home would use the available space for to promote independent living skills. People who were wheelchair users would also have found it difficult to access this facility. The staff spoken to stated that people who live at the home are not able to use the laundry facility as a result the staff team mainly undertake these duties. The manager said that given the conditions of some people it could be difficult to motivate them to undertake these activities of daily living on a regular basis. The service user guide talks about ‘we will help you with your laundry on a daily basis’ however given the limited space and the conditions of the people living in the home this may be difficult to achieve. We were informed that the home did not have a cook but the manager said that the people who live at the home were going to get involved with meal preparation in the kitchen with staff. This was a good suggestion of getting people involved in learning skills in meal preparation. However on the day of the inspection this practice was not observed. Observation showed that the people were not encouraged to help with meal preparation and staff cooked the meals. It was stated by staff that it would be nice for them to have a dishwasher in the kitchen. At present the staff are doing the washing up in the kitchen. One person was observed eating their lunch. We observed that there were plates of food left on the table and these were not covered up. We were concerned that the food was getting cold and this was pointed out to the manager. The food was taken back to the kitchen to be reheated. A person using the service was observed using their tea shirt as a napkin. The inspector asked the manager if the person could have a tissue napkin to wipe their mouth with. The manager asked the person to get tissues from the toilet 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 15 whilst they were eating their meal. The nurses who had visited the home also stated that tissue napkins were required in the home. The manager was also observed telling staff how to support a person at mealtimes. Another person was observed being supported by staff on a one to one basis. We did not observe staff informing the person what food they were eating and very limited communication took place between the two people. It was also observed that the plate the person was eating from kept moving and making it more difficult for the person to get food on their spoon. One person who we understand is visually impaired was observed to keep asking staff to pour water in their glass rather than staff proactively ensuring that his needs were being met. One person got upset as they stated it was too stressful and noisy and ate their meal in the main lounge. It was said that they like to have their meal in peace. The mealtime was discussed with the manager who stated that she was embarrassed at what happened and would ensure tissues napkins would be available to people using the service. The manager also said that a non-slip mat would be purchased for people who require this equipment. The manager told us that a table used in one of the smaller lounges was broken and the person that was upset by the noise in the dining room normally used this table. The manager also said she was going to talk to the key working staff regarding the issues that occurred at mealtime. People are offered a holiday and we were informed that three caravans were booked in the summer months of June, July and August to go to Great Yarmouth seaside. Contact with families and friends depend on the individual, some people are visited at the home whilst others are supported to visit them in their own homes. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has robust systems in place to make sure that medication records are fully completed, contain required entries, and are signed by appropriate staff and regular management checks are recorded to monitor compliance. EVIDENCE: The staff spoken to explained how they gave personal care to people they cared for and said that they encouraged people to do as much as they were able to make them feel independent. It was also stated that they respected people’s privacy and dignity. One person spoken to said that staff knocked on their door before entering their room. People said that they went shopping and picked their own clothes with support from staff. People were appropriately dressed to their individual styles. The senior staff informed us how the medication procedures worked in the home. It was said that the senior staff in the home gave out medication. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 17 They had all received the accredited training on medication. These new procedures were introduced since the last medication error that was made on the 6th of March 08. The medication records inspected showed that all staff were signing these correctly. Medication profiles seen were good and explained what the medication was for. Medication temperatures were being monitored and there was intervention guidance recorded for staff to tell them what to do if a mistake was made. A medication induction form with one to one staff was carried out, as a way of monitoring staff competency and this was very good. The staff did medication audits on a regular basis. The senior staff gave examples of when people refused to take their medication and how she advised staff to take a cup of tea with the medication to encourage the person to take their medication. The files inspected showed that the health needs of the people living in the home were being met. Health professionals were involved in caring for the people’s health needs. The nurses spoken to at the home also confirmed this. The staff were maintaining good records of monitoring residents health needs and visits from the health professionals were recorded well. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People know who to complain to if they are not happy and staff understood what to do to ensure people who live at the home are protected . EVIDENCE: The home had a complaints policy and there was information recorded about how to make a complaint if people are not happy. We spoke to some people and asked them who they would speak to if they were not happy. They said that they would speak to staff or the manager if they were not happy. The manager stated that since the last inspection they have not received any complaints. The staff spoken to stated that they had done training on safeguarding of vulnerable adults. All the staff spoken to were able to give examples of how they would be able to tell if any people were being abused or were not happy in any way. Staff said they would be able to tell by the way the people behaved and they understood their behaviours. Evidence showed that in house training on safeguarding was booked for staff to attend this year. The home’s procedure for reporting safe guarding referrals to social services safe guarding team had improved since the last random inspection. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 19 23 Duston Road DS0000043835.V364978.R03.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): 24,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment that is clean and tidy. EVIDENCE: The home is well decorated and there is an ongoing maintenance programme in place. We were informed that new flooring and furnishings were due to be undertaken in the home by the 16th of June. The new dining room furniture had been ordered. It was also stated that new carpets were being fitted in 4 resident’s rooms and this was to be done when they were on holiday. The garden furniture was also due to be replaced to make it more userfriendly. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 21 People commented that they were happy with their rooms, which were seen to be personalised and comfortable. One person was due to receive new furnishings to her room in the colour and style they referred. The home had new fence put up in the garden, this was to keep people safe. It was stated by the manager that the electrics in the kitchen and front lounge would need rewiring in the future but that these were not a high priority and not a danger to any one. The laundry facility is limited in its ability to meet the needs of the people living in the home in relation to training for independence (see section on lifestyle). 23 Duston Road DS0000043835.V364978.R03.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has robust recruitment procedures in place to ensure that the residents living in the home are protected from any harm. EVIDENCE: The staff recruitment files showed that all staff were provided with job descriptions for the task they undertake. On the day of the inspection eight staff were on the rota, the manager said that the home can operate with 4 staff but extra staff are needed to assist people with activities in the community. The staffing rota showed that at the weekend staff worked very long hours. For example four staff worked 13 hours shifts and one staff worked five hours. We were concerned at the length of the shifts given the needs of some of the people. The home does not have a cook and at the weekend the staff also do the cleaning as the domestic staff only work Monday to Friday. We were informed that this meant one member of staff is taken away from direct care, 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 23 to undertake these domestic tasks. The manager needs to reassess the staffing working hours at the weekend to ensure that the staff working long hours are not putting the health and safety of people at risk and their needs are being met. A copy of the training schedule for 2008 was provided. It showed that 30 staff had completed equal opportunities training and 3 staff did CPI refresher training The manager of the home and two managers from the sister homes also had done in house training on infection control, petty cash and timesheets, care values and principles of care work and hoist training. Other training to be done by the managers for the rest of the year included care plans, risk assessments, manual handling, team building, mental health and capacity to consent, learning disability, data protection act, whistle blowing, makaton sign language, and safe guarding of vulnerable adults procedures. Fire safety, food hygiene, health and safety and first aid are obtained from external sources. The manager stated that 12 out of 18 staff had NVQ level 2 or 3 in care. It was said that those that did not have this qualification were either doing the course or were waiting to undertake the training. l The staff spoken to stated that staff had an induction book and they had supervision on a four to six weekly basis. It was also stated by staff that ‘most of the staff working at the home ‘had a heart of gold’. One staff stated that they were ‘enjoying it‘ at the home and they liked ‘helping staff to achieve the standards to provide consistency’. It was stated that the manager was supportive and they also supported the manager to change practices. Another staff stated that they ‘loved it’ at the home and they ‘help people look after themselves’ and ‘like to see them improve’. It was also stated that they ‘look after them alright’. Another staff stated that they work hard with the people using the service. It was stated that the home had a team building day once a year with another home. It was suggested that the home should have a team building day for the staff team in the home and this would be good for them. In discussion with staff, it was evident that they were not only very knowledgeable about the needs of individuals whom they were key workers for, but they were also aware of other residents needs that they supported throughout their shift. Staff spoke about the support they receive within the organisation, which includes regular recorded supervisions, team meetings, and support for training. They all agreed that the manager was both approachable and One person said staff are all OK but some are a bit bossy. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 24 Information on all training completed by staff was asked for but this was not available. After the inspection the manager provided details of the training planned for the year. The manager needs to develop a staff training and development plan (for all staff) to incorporate induction, mandatory, specialist and NVQ training. Four staff recruitment files were inspected in detail. Evidence showed that the company undertook interviews, two references, CRB checks, photography of the person, and 2 identifications. The terms and conditions of their employment were seen and all the staff signed a document called the service users confidentiality policy. The staff also confirmed that they did not start work until all the documentations required was received. 23 Duston Road DS0000043835.V364978.R03.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): 37,39,41,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People benefit from a well run home and the manager is aware of the improvements needed to meet the needs of the people living in the home. EVIDENCE: People living at the home, staff and external professionals spoken to all said the manager was approachable and managed the home well. The staff meeting notes detailed how staff were meeting the needs of people using the service. Although the manager had identified the improvements needed there were still a number of shortfalls resulting in requirements being made. The 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 26 manager must ensure that records to be kept in the home are available for inspection visits. Meal times must also be monitored to ensure that the needs of all the people living in the home are being met. We discussed with the manager regarding completing the CSCI regulation 37 Notification form. At present the manager was reporting this by writing a letter to us. However the information required needed to be more detail. It was discussed with the manager that they could use any format as long as the information required was included in the form. The manager informed us that they were going to rewrite the policy on accident and incidents. However in the mean time the manager stated that she would complete the CSCI regulation 37 notification forms. One of the people’s files looked at showed that the person had one incident/accident for 2005 and one in January 08. It was stated by the manager that there was another incident that occurred recently. The manager stated that a copy was sent to the CSCI, however this information was not available in the file and the manager was not able to find this information or information on any other incidents that occurred in 2006 or 2007. The commissioning team from Northampton social services also undertook two monitoring visits to the home in February 08. And had identified incidents that had not been reported to the CSCI under regulation 37. The home had some monitoring systems in place that sought the views of people using the service, however this needed further development to show how this home addresses issues and analyses their findings. This information should be displayed in the ‘service user guide’. The finance for one person was checked and this was correct with receipts kept. The staff stated that they supported people to get their own money from the bank and this money was then put in the petty cash in the office for safe keeping. Staff told us that the company paid for staff meal when they take people out for a meal or out for the day. The fire book was inspected and it showed that weekly fire drills and emergency lightening was being done on a regular basis. Staff spoken to stated that they did fire training last week and a fire drill was carried out in February 08. The names of staff and people living a the home need to be recorded. 23 Duston Road DS0000043835.V364978.R03.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 2 2 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 2 x 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 28 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. 1 Standard YA2 Regulation 14 Requirement All the documentation of the assessment of needs must be available for all service users admitted to the home All service users must be provided structured activities. Meal times must meet the needs of the people living at the home The Statement of Purpose must detail how people who live at the home are helped to use the laundry facilities. Introduce quality monitoring assurance procedures as specified by this standard and regulation. Records required to be kept in the home and for inspection purposes must be available Notifications as detailed in regulation 37 of the Care Standards Act must be made to CSCI. Timescale for action 22/08/08 2 3 4 YA12 YA17 YA1 12 and 16 18, 12 4 22/08/08 23/07/08 22/09/08 5 YA39 24 22/09/08 6 7 YA41 YA42 17 37 22/08/08 30/07/08 23 Duston Road DS0000043835.V364978.R03.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. 1 2 3 Refer to Standard YA17 YA17 YA33 Good Practice Recommendations Provide napkins Involve service users in meal preparation The manager should ensure that the long hours worked by staff at the weekend are not putting the health and safety of the residents at risk and demonstrate that the needs of the resident’s are being met. 23 Duston Road DS0000043835.V364978.R03.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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