Inspection on 04/07/06 for 28-30 Woolston Road

This inspection was carried out on 4th July 2006.

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 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

28-30 Woolston Road 06/09/05

28-30 Woolston Road 19/04/05

28-30 Woolston Road 01/12/04

28-30 Woolston Road 26/07/04

28-30 Woolston Road 09/03/04

28-30 Woolston Road 07/01/04

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Flint House

Hillview Farm

Dalewood Respite Care

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REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 28-30 Woolston Road Butlocks Heath Netley Abbey Southampton Hampshire SO31 5FQ Lead Inspector Isolina Reilly Unannounced Inspection 4th July 2006 09:00 28-30 Woolston Road DS0000055425.V298622.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 28-30 Woolston Road DS0000055425.V298622.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. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 28-30 Woolston Road Address Butlocks Heath Netley Abbey Southampton Hampshire SO31 5FQ 01428 601618 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) Robinia Care Limited TO BE CONFIRMED Care Home 8 Category(ies) of Learning disability (8), Physical disability (3) registration, with number of places 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One named service user (date of birth 28 November 1986) may be accommodated at the home Service users with physical disabilities must also have learning disabilities All service users must be between 18 and 50 years of age Date of last inspection 6th September 2005 Brief Description of the Service: 28-30 Woolston Road is a care home providing personal care and accommodation for eight younger adults with learning disabilities. Up to three of the beds can be used to accommodate people with physical disabilities, though it is a condition of the registration that these people must also have learning disabilities. The home is owned and operated by Robinia Care Limited, an organisation that has been a registered care provider since 1995. Robina Care limited employs a manager who has yet to register as manager with the commission. All residents are accommodated in single rooms. Six of the rooms are situated on the first floor and have en-suite facilities. The two rooms on the ground floor share an assisted bathroom. The home has a large lounge with adjoining small room, used as a quiet area. There is a large enclosed garden to the rear of the property, which is situated in a quiet residential area of Netley Abbey, close to local amenities. The manager states in the pre-inspection questionnaire he completed on the 20th May 2006, fees vary between individuals from £2,069.76 to 2,652.46 a week though services users pay for their own hairdressing and reflexology. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit took place over one day. In the past service users have become distressed when people they are not expecting arrive at the home. There is an agreement with the home that the inspectors would telephone the home the night before so that staff are able to prepare the service users and reduce their anxiety. On this visit the inspector phoned the home at 19:15 hours the evening before and arrived at the home at 09:00 hours. The inspector looked around the home, viewed records and procedures, spoke with all the service users, four relatives and one Adult Services care manager by phone, three staff and observed the interaction between them. The manager helped the inspector during the visit. Currently the home has three service users in residence. Information has also been taken from the pre-visit questionnaire filled in by the manager, correspondence with the home and monthly reports on how the service is doing, sent in by the area manager. The manager informed the inspector that Robinia Care Limited are planning to temporarily close the home for a major refurbishment for reopening at a later date. The current service users are being helped to find good homes to move at their own pace to make their move as to lower the stress and anxiety of the individuals. This means a date for closure has not been set. What the service does well: The service users all showed in their own way that they liked their home and feel comfortable. Staff were observed being attentive to service users throughout the day, encouraging and fully involving them in all tasks and activities on a one to one basis. The home has a good system in place for assessing if it can meet the needs of service users before they come to the home and makes good records. This includes medical and personal care needs. Everyone spoken with confirmed that staff are caring and respectful. They encourage independence and are mindful of peoples need for privacy and dignity. The staff help individuals to make decisions about their lives and service users are fully involved in planning their days and care. There is an excellent attitude towards service users personal development expressing their own opinions and participating in activities as well as accessing the local community. The service users are fully involved in menu planning, reparation and cooking of meals. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 6 The home has an open and good process in place for dealing with complaints, concerns and compliments. The staff team at the home is skilled and receive regular training to be able to care for the residents. The home has a logical and detailed process for recruiting new staff. There are good systems in place for making sure that the service is run in a safe manor for residents. The residents stated they all feel safe and comfortable at the home and their opinions are sought by the home. The organisation has a good system in place for monitoring the quality of the service being delivered at the home. 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. 28-30 Woolston Road DS0000055425.V298622.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 28-30 Woolston Road DS0000055425.V298622.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good admission process that is well managed and prospective service users’ individual aspirations and needs are assessed. EVIDENCE: The relatives spoken with said that they and their loved one had been made welcome when they first came to live at the home and they were able to look around an visit various times including stopping for a meals and overnight stays. One relative stated that they were pleasantly surprised that their loved one had settle into the home so quickly and always looks forward going back to the home when on home visits. The service users were observed to be relaxed and content. One service user said is very happy here. The relative spoken with also confirmed this and felt they are fully involved in the support their loved one is receiving. The inspector tracked the three service users’ records and each file contained a detailed assessment. The records showed individual aspirations, educational, training and work needs, potential restrictions, choice, freedom, information on family and friends, their cultural and faith needs, physical and mental health care, treatments and methods of communication. Written assessments and 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 9 relevant risk assessments on files were relevant and reflected care needs assessments completed by Adult Service’s care managers. The home is working closely with the proposed placements and supplying relevant information for a detailed assessment. Records were seen the confirmed this. One service user is in the process of completing their person centred plan with the placement in mind. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. 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. The home has good systems in place that fully involves service users in decision-making, taking reasonable risks, assessing changing needs and meeting personal goals. EVIDENCE: The service users have difficulty with verbal communication and comprehension. However, staff were observed communicating appropriately and respectfully with the individuals. They have a good knowledge of the service users and the key worker roles that work well with trusting and mutually restful relationships. One staff member (a key worker) spoken with stated that it had taken a long period of time to establish a good level of mutual respect, trust and understanding between them and the client. This is now showing great benefits as the individual is expressing their opinions and having them understood and has enable the range and level of activities to increase greatly whilst significantly reducing in appropriate displays of behaviour. One service user had a good knowledge of their goals and care 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 11 plans held within the home. The other service users were observed undertaking tasks and being supported in accordance with their care plans. The relatives spoken with confirmed that they were fully involved in planning support for their loved one and felt the home was doing an excellent job in helping the service user to have a fulfilling life. They also stated that the social and recreational time with their loved one was incorporated and part of the whole plan. The plans seen give information on assessed and changing needs and personal goals. There were separate sections for personal and health care plans. One service user was clear about the way and support they would receive. Records seen are regularly reviewed and updated as necessary with the service users. The staff spoken with confirmed this. Service users formal reviews were seen on the files involving the service user; Adult Services care manager, health professionals, family or advocate. The individual care plans and centred planning record see reflect outcomes, activities and instruction specified on the care management reviews. The staff spoken with stated they assist service users to update their care plans are have a good knowledge of the individuals’ needs and aspirations. One staff member said that the home was very flexible and providing an appropriate risk assessment and actions had been undertaken, recorded and followed the service users are able to follow their wishes. Risk assessment seen were informative and contained clear instruction to staff. They covered all aspects of support and personal care provided both in and outside the home. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. 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. The service is good at providing support for individuals to take part in age appropriate, peer and cultural activities with the local community. They encourage appropriate personal, family and other relationships whilst respecting and empowering individuals rights and dignity. The service users enjoy varied balanced meals in a relaxed atmosphere. EVIDENCE: On the day of the visit, the inspector observed that one service user who enjoyed walking had gone for a long walk and key workers were observed undertaking one to one tasks and activities throughout the day. One service user stated that they enjoyed reading picture books, colouring and watching the football on TV. The also confirmed that they regularly visiting the local library and sensory room. Another service users was seen doing crafts on a one to one and the key worker confirmed that the individual also likes swimming, going out to buy their own clothes as they are interested in fashion and being pampered by having their nails and hair styled. This was confirmed 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 13 in the care plans seen. The home keeps separate records of activities completed and how the individual enjoyed them. These, the daily records and care plans showed that all service users were involved in many suitable activities and were part of the local community. The service users confirmed that they take part in the cleaning. These tasks were recording in their files. All the service users had a turn at taking part with meal preparation. They all enjoyed the occasional eating out at the pub and takeaway meals. It was observed that service users are relaxed when preparing and eating meals. Service users were seen having snacks including fresh fruit, hot and cold drinks during the day. They stated that they like the food and Copies of menus were sent with the pre-inspection information and found to be variable balanced and many examples of individuals’ choices. Similar menus were seen at the home working on a four-week rota. Records of food prepared were available. There was a large colourful information board in the hallway that included a picture system of the meal for that day. One service user likes to sometimes eat in their bedroom, which they choose on the day of the visit and another service eats at a separate table with a staff member due to identified anxiety issues. An appropriate risk assessment and care plan was seen on the file. The lunchtime experience was observed to be unrushed and relaxed. There were various health and safety procedures in place within the kitchen including colour co-ordinated chopping boards, cleaning rota, gloves, temperature recording including probing of food, fridges and freezers. The manager confirmed Environmental Health Officer had visited in January 2006 and the report seen stated that the service was assessed as being good. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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. The service users’ health and personal care needs are being met ensuring are support is given in the way they prefer. The home medication practices, policies and procedures supports and protects service users. EVIDENCE: The service users spoken with confirmed that the staff are supportive prompting them with their personal care in respectful and dignified way. This was observed on the day. The relatives spoken with confirmed this. One service user stated they were able to look after themselves but staff reminded them when it was bath time. The service users, relatives and staff spoken with stated that individuals lives and daily routines were flexible and they were fully involved in planning their activities and daily routine. On the tour of the home one service user showed the inspector around their rooms were there was evidence of personal effects including. The other two rooms seem also reflected the individuals choice and personality. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 15 One service user stated that they could visit their doctor when they needed. The staff and manager confirmed that if they wish to the service users can go in on their own without staff, although they preferred to have a member of staff come with them. This was documented in the care plans seen. The staff and one service user confirmed that individuals visit the dentist, opticians and chiropodist regularly. Medical correspondence, records of outpatient appointments and health care checks were seen in the files. The manager and staff confirmed that one older service users has had Records seen in individuals’ files held risk assessments and instruction for staff on personal and health care support needed. There is a satisfactory medication policy and procedures and the home uses a blister pack system from the local pharmacist. The medicines were correctly stored in an appropriate cupboard that was clean and reasonably orderly with medication stored correctly in date and in sufficient quantities. There were no control medicines at the home on this visit. All residents need assistance with their medication. The records for receipt, disposal and administration were seen and found to be satisfactory. The home uses the ‘Medicine Administration Record Sheets (MARS) system for recording the administration of medication and medication received in the home. The staff spoken with stated they had received training in the safe handling of medicines. The manager confirmed that he regularly assessed the staff when administering medication. Staff training records seen that confirmed this. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users, relatives and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues that protects residents from potential abuse. EVIDENCE: The service users, staff and relatives spoken with stated that they would go to the manager or a staff member if they had a concern or complaint. They confirmed that the staff are good and listen to their concerns and the inspectors observed this during the day. The service users and staff spoken with were aware of the home’s complaint procedure. The home’s complaint procedure includes the various stages; the address for the Commission and complaints will be dealt within 28 days. An easy to read complaint procedure was available on the service users’ notice board. The home has received four complaints in the last twelve months that have been investigated and resolved by the home within the timescales. Two of the complaints were specific to one service user’s inappropriate behaviour when out in public. This was upheld and a strategy for managing the care was developed including care plan and risk assessment. The third complaint was from neighbour who complained that clinical refuse collection at three o’clock in the morning was very noisy. This was resolved and contract for collection time amended. The fourth complaint was regarding the positions of the home’s waste bin and these were relocated. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 17 The service users spoken with stated that they felt safe at the home and the relative also confirmed this. The staff spoken with confirmed that they have received instruction and are aware of the protection of vulnerable adults from abuse. The home has an out of date copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure and it’s own policy and procedures reflecting the guidelines from Hampshire County council’s own policy. The manager stated that he would order an recent copy as a matter of urgency. There is a clear whistle blowing procedure and the manager has encouraged an open and fair ethos within the home. The staff spoken with confirmed this. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a clean, homely, comfortable and suitable environment for the service users. The standard of the décor within the home is satisfactory. EVIDENCE: The manager showed the inspector around the home, explaining that due to the anticipated closure for major refurbishment only repairs and emergency redecorating was taking place. All the service users liked their bedrooms and the inspector observed that they had been personalised. There is a secure garden at the rear of the house that one service user was seen making use of. The staff and relatives spoken with felt there were enough toilets and bathrooms. On the tour it was noted that the communal toilets had disposable hand towels and liquid soap. The home was found to be clean and tidy with no 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 19 clutter or obstacles in corridors. The service users and staff confirmed that they all have cleaning tasks and rotas. The home has a supply of gloves and aprons that staff use when necessary. The staff confirmed that they have received training on infection control. The laundry room is accessed of the ground floor corridor and within easy access to the garden. There is a washing machine and tumble dryer. The service users spoken with stated that help their with their laundry. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. 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. The service users are supported by competent and qualified staff that undertake regular training. There are now satisfactory recruitment procedures that ensure service users are not put at risk. EVIDENCE: The service users and relatives confirmed that the staff treated them with respect and they felt comfortable with them. The inspector observed staff interacting with the service users listening, focused and interested in what the service users were doing and saying. During the day it was observed that the individual staff spend their whole time with the service user, fully integrating their tasks with the service users activities and wants. It was noted from the staff rotas seen that there are normally three staff throughout the day and two waking night staff each night. The staff spoken with stated that they received regular training and had a good knowledge of each individual. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 21 The manager explained that all new staff complete an organisation induction on starting work at the home that meets the Skills for Care Council minimum standards for induction. All the staff are in the process of undertaking the Learning Disability Awareness Framework (LDAF) induction and foundation course. Three staff out of the seven hold a National Vocational Qualification (NVQ) in care level 2 or 3. Staff files seen on this visit confirmed this. Three new staff will commence NVQ level 3 in care once they have completed their LDAF. Three staff files were seen and these held the necessary documentation including two satisfactory written references, identification, criminal record bureau and protection of vulnerable adult list checks prior to starting work. The staff and manager confirmed that each staff member had their own copy of the General Social Care Council’s Code of Practice. Signed contracts of employment including terms and conditions were seen on the file. The staff explained the various training and learning they had recently undertaken these included moving and handling, health and safety, medication, supervision and appraisal, fire safety, infection control, first aid, food hygiene, abuse, epilepsy and autism. The Adult Service care manager stated that the home could improve its understanding on Autism. The staff spoken with and observed on the day of the visit had a good understanding of autism and stated they had recently completed their training on this subject. Certificates and the home’s staff training matrix were seen and confirmed this. The written information in the home’s pre-inspection questionnaire also confirmed this. The manager confirmed that the organisation has achieved Investors In People Award (an independent training quality assurance) and the certificate was seen displayed in the office. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. 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 service users benefit from a well run home where their view are listened to and their health, safety and welfare are promoted and protected. The home has a satisfactory quality monitoring system for reviewing and developing the home’s performance. EVIDENCE: The home has a history of changing managers. The previous manager has been promoted within the organisation and the current manager in post is not yet registered with the commission. The relatives and Adult Services care manager spoken with stated that it was a little confusing with so many managers coming and going. However, they all expressed that they had confidence in the current manager and felt both the current and previous managers were knowledgeable, approachable and good at their jobs. The 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 23 staff confirmed that they felt the current manager has the necessary experience and skills and manages the home well. The manager confirmed that he regularly undertakes training to maintain and develop his own skills these courses include person centred planning, health and safety, infection control, food hygiene, leadership training, supervision and appraisal, budget setting, first aid and abuse. Staff files seen and staff spoken with confirmed that they have regular supervision sessions that at appropriately recorded. The home seeks the views of the service users on a regular basis and these are recorded in the individuals’ files. Service user, relatives and care manager’s quality surveys are sent out two weeks previous to the visit, to assess quality of the service being provided. These will be collated and a summary of outcomes be made available. The manager completes a monthly performance monitoring report for the organisation and he confirmed that policies and procedures are reviewed annually and amended as necessary. The organisation undertakes annual health and safety audits and the area manager undertakes monthly monitoring visits. Written reports of these monthly visits are generated that meets the Care Homes regulations 2001, regulation 26 reports. The specific communication issues with the individual service users are prohibitive for holding service users meetings. Staff confirmed that they attend regular meetings and minutes were available in the office. The inspector was able to seen various up dated risk assessments for the environment, fire safety and activities. The service users, staff and relatives spoken with stated that they felt safe at the home and confirmed that the fire alarms are regularly tested. They participate in regular drills and evacuations. The inspector viewed the records for fires safety maintenance, evacuation and visual checks and found them to be satisfactory. However, they have had fire safety instructions in the past but not one recently. There were no records of staff fire safety instruction in the home. This was discussed with the manager who stated, as a matter of urgency would ensure that all staff had completed a fire safety instruction in the next two weeks. The staff spoken with were clear on what action to take if a fire in the home was suspected. The commission has received confirmation that this training has been completed. It was also noted that regular visual checks on fire extinguishers had lapsed. However, records show and staff confirmed they participated with the service users in regular drills and evacuations. Individual fire safety risk assessments and instruction were available in each service user’s care plan. The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) with information leaflets for each chemical being utilised within the home and chemicals were securely stored. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 24 The home’s records for reporting injuries and incidents were appropriate. The incident records matched the Care Homes Regulation, regulation 37 reports. 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 26 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. 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. Refer to Standard Good Practice Recommendations 28-30 Woolston Road DS0000055425.V298622.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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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