Inspection on 08/06/07 for 23 Mount Pleasant

This inspection was carried out on 8th June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

23 Mount Pleasant 06/11/06

23 Mount Pleasant 10/11/05

23 Mount Pleasant 13/07/05

23 Mount Pleasant 15/10/04

23 Mount Pleasant 04/06/04

23 Mount Pleasant 05/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 23 Mount Pleasant Chesterton Newcastle Staffordshire ST5 7LH Lead Inspector Mr Berwyn Babb Key Unannounced Inspection 8th June 2007 02:00 23 Mount Pleasant DS0000004983.V342664.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 23 Mount Pleasant DS0000004983.V342664.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. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Mount Pleasant Address Chesterton Newcastle Staffordshire ST5 7LH 01782 565437 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) mntpleasant@choiceshousing.co.uk Choices Housing Association Limited Susannah Jane Chard-Beech Care Home 8 Category(ies) of Learning disability (8), Physical disability (4) registration, with number of places 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th November 2006 Brief Description of the Service: 23, Mount Pleasant is registered to provide care for eight Adults with a learning disability, four of whom may have a physical disability. This is one of a group of homes managed by the Choices Housing Association that is based in North Staffs. It is situated in the midst of local residential properties, close to shops and other neighbourhood facilities. It is not distinguished by signs or other means as a care home, and is in keeping with other adjacent properties. This accommodation is purpose built and situated on two levels. Each level provides a self-contained unit, which accommodates four service users. Access between the two floors is via a staircase. The ground floor comprises of four single bedrooms, spacious lounge, spacious kitchen/diner, assisted bathroom, separate toilet and laundry. The first floor comprises of four single bedrooms, spacious lounge, spacious kitchen/diner, assisted bathroom, separate toilet and an office, which also serves as the staff sleep-in room with en-suite facilities. [Currently night staff are watchful waking, and the facility is retained for anyone who wishes to be accommodated during the terminal phase of the life of someone who uses the service to whom they are very close, such as a parent] The grounds are compact but well maintained, with a private and enclosed patio area to the rear accessible to all service users. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place during the afternoon of Friday the eighth of June 2007 and was conducted by one inspector alone. The registered care manager was on duty throughout the whole of the inspection, and she, the people who use the service, and staff on duty in the home were all helpful and hospitable. During the course of the inspection contact was made with each of the people who live in the home, though unfortunately due to their lack of meaningful verbal communication it will not be possible to include any quotes from them in this report. However, two of the people who use the service were able to indicate by use of gesture positive or negative responses to questions put to them, and these have been recorded. The home was clean, warm, and tidy throughout, and was vibrant with activity, with people who use the service coming and going from day opportunities in the community, and moving from one part of the home to the other to take part in whatever activities (such as the evening meal) were going on, or to have some private time for themselves in their room. Information was obtained for this report from a provider dataset, from observations and discussions at the time of the visit to the service, and from a formal interview with a member of staff on duty. It was established that the current rate of fees charged at this home range from £870 to £890 per week, with no charges being made for the normal extras that are incurred in everybodys life. What the service does well: This home continues to provide a mixed level of care (those people who have a greater degree of disability inhabiting the ground floor, whilst those who are able to mobilise on their own living on the first floor with a greater degree of independence and support and guidance, rather than physical intervention), and in a domestic style of property located in the heart of the local residential community. The home outwardly displays no signs of being a care institution, and the services providers states that they seek to stimulate the inclusion of the people who use this service into the normal activities of daily living, in order to become valued members of their neighbourhood. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 6 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 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. The quality outcome for this group of people who use the service was good. This judgment was made using all the available evidence including a visit to the service. People who use the service were seen to have their needs and choices assessed prior to admission, and to receive written confirmation of the ability of the service to meet these. The service users guide and statement of purpose had been updated, and provided in a format that made them accessible to prospective users of the service and their supporters. EVIDENCE: The statement of purpose had been finalised in a form with lots of pictures to enable it to be relevant to the people who use this service. So had the service users guide which showed that the home complied with the Our Lives programs that was being adhered to advise the care team following the initial assessments. Reference to the care plans of two individuals who use the service showed that the providers had undertaken full multi agency/multidisciplinary assessments of their needs and choices prior to their admission, and that they had been informed in writing of the ability of the service to meet these. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 9 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, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service had comprehensive plans written about their assessed and changing needs and personal goals, and every effort had been taken to determine what decisions they wanted to make about their lives. Positive steps were being taken to encourage them to experience the highest degree of independence that they could readily achieve. EVIDENCE: The person centred care plans of two of the people who use the service were reviewed as a sample, and these demonstrated a 24-hour plan of care that was founded upon the original assessment, and was regularly reviewed as a result of which any changes in needs of choices of that person were reflected. Some of these reviews reflected the inclusion of relatives, whose signatures appeared on documents. The manner in which the desired outcomes of care intervention were achieved was recorded differently according to the individual. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 10 For example, in the care plan of one person who historically experienced negative associations with touch, there was a programme to expose her to tactile activities so that she could become accustomed to physical contact in a positive sense. In the same persons care plan, there was an example of diversion techniques being used with other people who use the service, to ensure that she does not become distressed by having her personal space invaded. This entailed staff being sensitive to the seating plan at mealtimes, and during such times as trips out. Discussion with the care manager about the use of such things as Makaton and pictures in care plans to make them more accessible to people who use the service, revealed the long-term intention of providing audio tapes for those people who would benefit from them, rather than a written presentation. In the area of responding to decisions made by individual people who use the service, there was good evidence of steps taken to determine these in the production of a communication plan that indicates what certain sounds and actions have come to be understood to mean from that individual. In this manner, whilst the majority of the people who use this service are unable to communicate verbally, their likes and dislikes can be recorded as a determinant of the decisions that would make. An example of this was one person who is unable to ask to be taken to bed, but whose pattern of behaviour has become so well-known, that staff now know when to assist her to retire. In the room of one of the people who use the service there were many examples or steps being taken by staff of the home to minimise the risks to him of such environmental equipment as the lights, his bed, his radiator, and the curtains at his window. All of these had been replaced in such a manner that he was able to continue using his room on his own, to have privacy, and to be as comfortable as his pattern of behaviour would allow. The care plan showed that an element of his pattern of behaviour was interfering with and destroying fixtures fittings and furnishing, and the manner that these had been replaced to ensure his safety will be commented on in the appropriate section later in this report. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 11 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, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service were able to maintain family and other relationship ties, to have their rights and responsibilities respected to take part in appropriate activities, and to access the local community. Their likes regarding food were known, and every effort was made to respect these. EVIDENCE: The physical limitations experienced by most of the people who use this service have not been a barrier to them engaging in appropriate activities. The care plan of one person noted that they needed to be ready to be picked up at 10 minutes to nine each morning during the week to go to Day Services, and in a personal profile of someone else, there was a daily diary of activities participated in, both inside the home, and also outside the home. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 12 One of the people who use the service had received numerous cards on the occasion of his birthday the weekend prior to the inspection, one of which was from the people he met in the various groups he attended that Day Services. His personal profile seen in his care plan recorded these visits there on Monday, Tuesday, and Thursday, and also of regular visits that he received from close members of his family. Unfortunately this person does not have any verbal communication, and when asked if he thought it was good to live at 23 Mount Pleasant, he put up both thumbs, smiled, and nodded enthusiastically. Similarly when he asked if people looked after him in the way that he wanted, he kept on smiling broadly, and again put up both his thumbs and nodded repeatedly. In discussion with the care manager about another person who uses the service, it was revealed that they prefer their own company, though not always to retire to their own room. They particularly enjoy being in the lounge late at night and after all the other people have gone to bed, to watch video’s and current television programmes at this time. During the course of an inspection of the service, the needs of people who use it was seen to be addressed in accordance with any restrictions that their health placed upon their natural choice, and their care plans recorded not only these restrictions that staff needed to be aware of, but also their particular likes and dislikes. For example, in the profile of one lady who was unable to communicate for herself, it stated that she adored coffee with a passion, was quite happy to have juice and cordials, but required time to finish her drinks. Also stated was that she needed to sit upright in her wheelchair for all meals, and to have a food mashed or blended to avoid her choking. In respect of her dislikes, it asked for her not to receive chilli con carne, as: I hate it . 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service was seen to receive personal support that was both sensitive, dignified, and within the boundaries of what they would have chosen, to have all the appropriate provisions made for them to receive the health care they needed, including relevant medication and other treatment regimes. EVIDENCE: During the course of the visit to the service, those people who use the service were seen to receive personal care in a dignified way with respect to their privacy and sensitivity. Before personal care tasks were carried out they were spoken to by the support workers in a manner that respected their privacy, before being moved to either their own room, or the bathroom or toilet. In the PCP of one of the people who uses the service though was detailed advice about exposing her to tactile activities to assist her in becoming accustomed to physical contact in a positive sense, because her assessment had indicated that she had always previously drawn away from physical touch which might have been because of negative associations. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 14 When reviewing healthcare records, it was seen that a record was kept of PRN medication sent with, and received back from, people attending day-care, and this was reviewed on a weekly basis. There was also a reminder in this PCP to staff during sunny weather to remember to send appropriate barrier cream to Day Services. In addition to the input of hospital consultants, GPs, and specialist learning disability health professionals, there was evidence in the care plans of a range of liaisons with other appropriate healthcare professionals such as the continence adviser, the diabetic nurse, the dietician, occupational therapists, audio clinicians, and physiotherapists. Each person was registered with a local GP, and benefited from regular Well Man or Well Woman annual health checks. Dental, foot, and eye care were arranged on a regular basis, and one of the ladies needed and enjoyed regular massage. There were also records of assessment being carried out for the provision of appropriate moulded support pods for use in the wheelchairs of people who were not able to support their own body weight, and of the provision of these through the appropriate health agency. The registered manager was advised that the home should review their policy on medication to ensure that the facilities they provided for storage were in line with current recommended best practice. This was with particular regard to the construction of the medication cabinet, and the manner of it being affixed to a solid wall. Protocols were in place for the use of liquid medication for someone with a propensity to choke, and for the use of the rescue treatment referred to earlier, and there were as evidence of regular and appropriate review of medication plans. There was a written daily record of the medicine cupboard temperatures together with a policy that if it exceeded 26°, ice packs could be used to return it to the recommended temperature range. Examination was made of the Medication Administration Record with no discrepancies being found, and it was reported by the care manager that they received excellent support from their local pharmacy. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. People who use the service were seen to have an appropriate complaints procedure that had been produced in a more accessible format, and to be protected from abuse by the policies of the providers, and culture of employees, of the home. EVIDENCE: The registered care manager for this home has been accredited as the trainer for the parent organisation for the safeguarding of vulnerable adults. She has developed the recently strengthened policy so that it now includes the involvement of some families, and where they are able, people who use the service, in taking the most robust steps possible to ensure that people were not subject to abuse. In a formal interview undertaken with a member of staff, the carer involved was correctly able to identify the range of people who could be responsible for abusing someone who uses this service (Anybody), a range of things that would be abusive if they were to happen to someone in the home, including things that would constitute abuse if that person did not receive certain things, and concluded by correctly identifying that should she suspect abuse was taking place, the policy of this provider in line with that agreed with all appropriate agencies locally, was that she should immediately inform her line manager or any other person in charge of the home at that time. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 16 No complaints have been received by this service, or by CSCI about this service, in the period being covered by this inspection. During the course of the visit to the home, the dynamics observed between support workers and those people who use the service displayed sensitivity and dignity, with good humour that in no way crossed acceptable boundaries. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use at this service were seen to live in a facility that was not stigmatised as being the care institution that was well maintained, that had a good standard of fixtures and furnishings, that had communal and private space, and benefited from policies that ensured the best possible containment of any infection or more of noxious odour. There were sufficient toilets and bathrooms, and aids and equipment in the home had been provided as a direct result of the assessment of the need of the individual using it. EVIDENCE: This home is situated in a local residential community, within walking or wheelchair distance of a range of shops and other services, and less than 2 miles distant from the centre of Newcastle where there are more extensive facilities such as hospitals and entertainment complexes. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 18 The home is not distinguished as being a care institution, and blends in with other properties in the locality. A cursory visual examination of the exterior revealed no items to cause concern, and in the enclosed rear garden, there was evidence of the commitment of the home towards reducing their carbon footprint through a wide range of recycling. Garden furniture was evident for the use of people in the home during good weather. One of the people who use the service met the inspector and immediately took him on tour of the environment. This included his bedroom and with reference to another person who was able to nod in agreement, a second bedroom, and to see upstairs bathroom which was in process of being converted to also contain a walk-in shower. Although this person (like all the current users of this service) was unable to communicate verbally, he made it clear that he was very excited about the improvements being made, and was not embarrassed by pointing out things that had been done to improve his safety in his own bedroom, because of his tendency to destructive behaviour. His windows had been replaced with Perspex opaque safety glass which gave him both privacy and light, and his electric light had been replaced by one recessed into the ceiling so that he wasnt exposed to danger of electrocution. The providers had made plans to purchasing a new bed in line with his personal choice to have nothing between him and the floor, though this has not yet arrived at the home. The tour reveals that the lounge was well appointed with new looking, and good quality furnishings, as similarly was the kitchen/dining room where preparations were in hand for tea. There was a separate laundry where work required by the last report has now been completed, with only putting finishing touches to the paintwork remaining. The area was tidy and free from obstruction, the machines were seen to be in good order and fairly new, with a sluicing facility included in the wash program, and there was appropriate signage for containment of substances hazardous to health. A tour of all the communal and service areas of the home, and of two bedrooms, did not find there to be any offensive odours, and systems were seen to be in place, such as separate collection bins, for soiled or infected materials and clinical waste. Washing facilities were available for the care staff throughout the home at appropriate points, and care plans showed suitable programmes of bathing and continence management to maintain the dignity of the people who use this service. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service were seen to be supported by staff who were appropriately skilled and qualified, with the necessary experience to ensure that they had the very best quality of life. EVIDENCE: The matrix of staff training provided by the care manager during the visit to the service showed that over 50 of the current staff house achieved NVQ level 2 or above, and that two further members of staff were undertaking the training at this time. It also showed a complete record of everybodys training needs and achievements, together with dates for impending refresher training where this was indicated. The range of subjects covered by this document included first aid, Food Hygiene, Fire Safety, Person Centred Care Planning, Moving and Handling, Lone Working, Personal Safety, Management of Actual and Potential Aggression, Origins of Behaviour, Sexuality, Abuse, Medication, Bereavement and Loss, and second level medication training for the use of Rescue Medicine. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 20 During the course of the unannounced visit to this service the number of people on duty were seen to be adequate for the needs and wishes of the people in the home, and it was established in discussion and confirmed by reference to staff rota that during the night there is a member of staff who is watchful and waking, and that all other times there is a duty manager and three members of support staff. It was also seen that during activity days and evenings when social outings had been arranged, the staff group was strengthened. There is a staff nurse development post in this home, and the person occupying the post was on duty at the time of the visit, and took part in discussion with the inspector. A formal interview was conducted with a member of staff during which she confirmed that appropriate measures had been taken during her recruitment to ensure that equal opportunities legislation was met, and thats proper safeguards were in place to ensure that the people who use this service will not be exposed to people whose background could not be vouched for. She stated that she had received appropriate induction and refresher training, and that full two-way supervision was undertaken by the care manager, with support staff able to influence the agenda, and that further, the managers of this particular home were open and inclusive in their style of leadership. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use this service were seen to be protected from dangers to their health, safety, or welfare, by the policies and procedures adopted by the providers, and to live in a home managed by somebody appropriately competent, qualified and experienced, and where every effort was made to ascertain their views. EVIDENCE: Both the Registered Care Manager and the deputy manager of this home are qualified nurses who have completed the Registered Managers Award. In discussion the care manager showed herself to be forward thinking and proactive in her approach to providing an holistic service to her residents. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 22 She appeared competent in all she did, and to be running the home following the best principles of current thinking in good practice for people with learning disability. As the majority of people who use this service have no useful verbal communication it is only through the knowledge of the non-verbal signs that they present, that staff are able to determine their views on the acceptability of the service being provided. The home is visited at least monthly by a Principal Officer of the providers, and a written report on the quality is prepared, this being copied and sent to CSCI. There was evidence in the care records of the input of family members and professional health supporters at reviews, and their views were also used to help monitor the opinion on the quality of the service. Care plans also demonstrated a raft of risk assessments to insure the greatest degree of independence commensurate with safety, including those aimed at determining which of the range of therapies or interventions available was going to be most beneficial to the person using the service. Staff input could be traced in these documents towards supporting individuals through physical assistance, guidance, and or training and education, so that they gained the maximum benefit for their independence and quality of life. Discussion took place with the Registered Care Manager about the implementation of advice given by the fire officer, and areas of good practice were confirmed from the comments that he had made. The dataset in the AQAA received from the provider confirms that all necessary inspection and servicing of equipment used in the home had been undertaken at the appropriate intervals, including testing of fridge and freezer temperatures, and that of hot water available in the home. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 23 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 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 X 28 3 29 X 30 4 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 4 3 x 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 3 X X 3 X 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA42 Good Practice Recommendations There should be a review of the medication storage arrangements to ensure that they meet currently recommended best practice Radiators within the home must be assessed for the risks they present to the people who use the service, and action taken to minimise any identified risk. 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Local Office Dyson Court Staffordshire Technology Park Beaconside STAFFORD ST18 0ES 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 23 Mount Pleasant DS0000004983.V342664.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!