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Inspection on 01/08/07 for Dallimore House

Also see our care home review for Dallimore House for more information

This inspection was carried out on 1st August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector spoke to a number of service users, and only one service user was able to tell the inspector how she feels; all were cheerful and happy they were well dressed and staff stated service users needs are being met. Observation by the inspector was that service users and staff have a good rapport. The inspector spoke with five members of staff on duty on the day of inspection; staff commented they feel supported by the new manager; however, some staff commented morale is low with the constant changes of management in the home. The inspector had a discussion with the manager and the manager was able to identify the action that has taken to improve the service. A number of staff have moved to other locations and therefore the majority of staff working in the home are new. The manager also stated she Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 plans to have a number of meetings with staff to ensure all the staff work as a stable team and reassure staff and service users to improve the standards in the home. The communal areas of the home were homely having recently been decorated. A number of service users bedrooms have also been decorated.

What has improved since the last inspection?

There were twenty-seven requirements made at the previous inspection and three requirements are still outstanding. Information taken from the Annual Quality Assurance Assessment (AQAA) states, the home has implemented and reviewed the weekly menus with input involving the service users and planning the menu. This is now on display on the notice board and there are other items of interest for the service users for example a choice of activities also displayed on the notice board. Supervision for all staff has been implemented and key worker meetings have been undertaken to ensure that staff views and wishes are sought as well as day-to-day service provision including activities, holidays etc. Two empty bedrooms are in the process of being decorated and all the service users are being supplied with two new pillows. The manager stated they are currently waiting for new bedding and curtains for each bedroom to arrive.

What the care home could do better:

The majority of the requirements made at the previous inspection have been actioned except for three. The management of the home needs to ensure any requirements made as a result of a site visit must be met, if the timescales for any requirements are not suitable these should be discussed with the inspector. The garden needs attention; there was a considerable amount of rubbish in the garden and some has been in the garden for some time. It was also noted that several panes of glass in the green house had been smashed and glass was everywhere inside and outside the green house, this is a health and safety hazard and needs to be cleared immediately. The manager informed the inspector the service users are not able to use the garden at the present time because of the broken glass. The garden needs to be attended too and cleared of rubbish to enable the service users to enjoy the garden during the summer months and good weather. The inspector would advise the management of the home to review the laundry facilities; currently there are three service users who are doubly incontinent and the management to consider a washing machine, which has a sluicing facility.Guildford Road (2a)DS0000013481.V338988.R01.S.docVersion 5.2The inspector would also advise the management of the home to keep up to date with the many changes of the Commission for Social Care inspection (CSCI) and to check on the website on a regular basis. The management of the home also need to ensure a copy of the Care Homes for Younger Adults, National Minimum Standards and the Care Homes Regulations are available in the home to enable staff to use as a working tool.

CARE HOME ADULTS 18-65 Guildford Road (2a) 2a Guildford Road Chertsey Surrey KT16 0QA Lead Inspector Vera Bulbeck Unannounced Inspection 1 August 2007 10:45 st 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 Guildford Road (2a) DS0000013481.V338988.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. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Guildford Road (2a) Address 2a Guildford Road Chertsey Surrey KT16 0QA 01932 568553 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) Welmede Housing Association Ltd To be confirmed Care Home 12 Category(ies) of Learning disability (12), Physical disability (4) registration, with number of places Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. It is a condition of Registration that of the twelve people accommodated in the home, up to four may be PD 25th May 2006 Date of last inspection Brief Description of the Service: 2a Guildford Road is a detached property situated off of the main road and within walking distance of Chertsey town centre. The home is owned and managed by Welmede Housing Association, with the staff team employed by North East Surrey Primary Care Trust. The home provides accommodation and care for up to twelve people who have a learning disability, four of whom may also have a physical disability. The accommodation has communal facilities on each floor so that service users are able to live in smaller groups. There are currently six service users living on the first floor and four on the ground floor. The ground floor is wheelchair accessible throughout and has an assisted bath. Each floor has its own lounge, dining room, kitchen, laundry, toilet and bathing facilities. All bedrooms are single occupancy and none are en-suite. The first floor can be reached by two sets of stairs; there is no passenger lift or stair lift. The home has the use of two vehicles to access activities and local amenities and has limited parking to the side of the building. All the staff need to attend equality and diversity training to ensure all the service users needs are being met. The fees for the home are £1,375.00. Items not covered by the fee, include hairdressing, personal items, clothing, toiletries and some holidays. Activities are paid out of the amenity fund. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over six hours and fifteen minutes commencing at 10.45 and ending at 17.00pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. Two care plans were sampled and the care observed for the two service users. The inspector observed the care provided on the ten service users, three service users have limited communication, only one service user was able to communicate with the inspector. Five members of staff were spoken to during the visit and a number of records were observed. The inspector was able to speak with an Assistant Psychologist who is monitoring a service user. The purpose of the visits is to establish if the home is the most suitable place for the service user and if the home is meeting the needs of the service user. The inspector was also able to speak with an Advocate who is involved with another service user. The advocate informed the inspector that the staff are helpful and she is able to speak with the manager regarding any issues, and action is taken to rectify any problems. The home has been operating for some time without a registered manager on site. The current manager has been in post a short time and is in the process of submitting her application of registration. There were ten service users living in the home on the day of the site visit and there were two vacancies. The inspector would like to thank the service users and staff for their cooperation and hospitality during the inspection. What the service does well: The inspector spoke to a number of service users, and only one service user was able to tell the inspector how she feels; all were cheerful and happy they were well dressed and staff stated service users needs are being met. Observation by the inspector was that service users and staff have a good rapport. The inspector spoke with five members of staff on duty on the day of inspection; staff commented they feel supported by the new manager; however, some staff commented morale is low with the constant changes of management in the home. The inspector had a discussion with the manager and the manager was able to identify the action that has taken to improve the service. A number of staff have moved to other locations and therefore the majority of staff working in the home are new. The manager also stated she Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 6 plans to have a number of meetings with staff to ensure all the staff work as a stable team and reassure staff and service users to improve the standards in the home. The communal areas of the home were homely having recently been decorated. A number of service users bedrooms have also been decorated. What has improved since the last inspection? What they could do better: The majority of the requirements made at the previous inspection have been actioned except for three. The management of the home needs to ensure any requirements made as a result of a site visit must be met, if the timescales for any requirements are not suitable these should be discussed with the inspector. The garden needs attention; there was a considerable amount of rubbish in the garden and some has been in the garden for some time. It was also noted that several panes of glass in the green house had been smashed and glass was everywhere inside and outside the green house, this is a health and safety hazard and needs to be cleared immediately. The manager informed the inspector the service users are not able to use the garden at the present time because of the broken glass. The garden needs to be attended too and cleared of rubbish to enable the service users to enjoy the garden during the summer months and good weather. The inspector would advise the management of the home to review the laundry facilities; currently there are three service users who are doubly incontinent and the management to consider a washing machine, which has a sluicing facility. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 7 The inspector would also advise the management of the home to keep up to date with the many changes of the Commission for Social Care inspection (CSCI) and to check on the website on a regular basis. The management of the home also need to ensure a copy of the Care Homes for Younger Adults, National Minimum Standards and the Care Homes Regulations are available in the home to enable staff to use as a working tool. 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. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New admissions to the home are only admitted following a needs assessment to ensure that the home can meet the service users identified needs. The home does not offer intermediate care. EVIDENCE: All service users entering the home have a pre needs assessment carried out to ensure the home can meet the service users needs. The staff on duty explained that full details of any potentially new service user would be undertaken before the service user enters the home. Also when the service user enters the home. The manager explained the admission procedures and criteria to reflect the principles of admission and assessment appropriate to the home. The pre assessment document was seen and it was noted that service users are involved in the assessment, prior to admission to the home. The manager informed the inspector the pre assessment form is in the process of being up dated. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 10 The staff on duty informed the inspector that a copy of the service users guide is provided to each service user and the document is provided to relatives. This document was not checked on this visit, the inspector was informed it is updated on a yearly basis. The statement of purpose was also not checked on this visit, however the document needs to be changed with regards to removing the sensory room and changing the facility to a staff office. The home does not offer intermediate care. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. 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, personal and social care needs are set out in an individual plan of care, to demonstrate needs are met in accordance with the homes philosophy. However, service users confidential information needs to be stored in a locked facility. Systems are in place to enable service users to make decisions and to promote independence. EVIDENCE: Two service users care plans were sampled and there was evidence that service users health, personal and social care needs had been identified and assessed. Care notes were detailed to include service users daily routines. Some service users are able to be involved with their care plan. The care plans hold all the relevant information, however they are not user friendly to enable staff to use as a working tool. The manager explained that she is in the process of changing the plans to be person centred. The care plans are kept in the manager’s office, and staff has access to the care plans. Service users care plan should indicate who are unable to hold a key to their bedroom; care plans must be documented to include the reasons Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 12 for not holding a key. Reviews need to be undertaken on all service users, currently there are no care managers involved with any of the service users. Staff stated that service users are supported to make decisions affecting their lives in a number of ways. Each person has an allocated key worker, who is trained to offer one to one support and who knows the service user well and understands his or her needs. The majority of service users have limited communication and staff has the experience to enable service users to make some decisions and choices. Holidays, menu planning and outings are mainly with staff support and interaction and generally knowing the service users well. Staff advised that information is provided to service users to assist with decision- making and this is in a format to suit their individual needs. Observation by the inspector, staff are respectful to the service users. It was also noted that service users and staff have a good rapport. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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 users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. EVIDENCE: Service users are supported to make choices in their everyday lives as far as they are able. Families of service users are consulted and encouraged to be involved in the decision making process. Any service user who does not have family or friends an advocate should be involved. The ten service users attend various activities; for example, bowling, shopping, and most service users enjoy pub lunches. Four service users went to Hayling Island for the day prior to the site visit with three members of staff. They had fish and chips for supper on the sea front. The service user spoken to confirmed she had a nice day. Staff take service users shopping and for car rides, and visit other places of interest. One service user is on one to one Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 14 support for the morning and the service user is able to attend cookery classes or play bingo. One service user goes to church on Sundays. The majority of service users will be going on holiday, the upstairs part of the home service users will be using a holiday cottage sometime in October. The down stairs service users have not decided where they will go. An arts and craft activity group visit the home on Wednesdays and the inspector was able to see some of the work undertaken by service users displayed on the dining table to dry. The staff informed the inspector a musician visits every Friday to play music. The home has two vehicles for the service users use and a number of staff are able to drive the vehicle. The manager stated she ensures at least one member of staff is able to drive the vehicle on each shift if possible. The vehicle is sometimes used by other homes during holiday time when some service users go on holiday. The evening meal was in the process of being cooked and was observed to be nutritional and well balanced. The meals are cooked in both kitchens on the ground floor and the first floor. A member of staff informed the inspector who was cooking the evening meal, that service users have a good appetite. Staff informed the inspector that service users are involved with the menu planning. The menu is displayed on the notice board in picture symbols in the hallway of the home. Staff supports service users to ensure they eat healthily. Food intake and nutritional content is monitored and all service users are weighed monthly. All members of staff who are undertaking the cooking have undertaken training on food and hygiene and have a certificate. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 15 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. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. EVIDENCE: The inspector was informed by staff that service users are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. There are regular visits to the local G.P and service users have an annual health check. The medical team as well as other professional health care people, including the dentist and optician when required, constantly observe the health needs of all service users. A number of risk assessments were in place for each service user, and the manager explained the process is updated on a regular basis. However, there are plans to up date all the service users plans to be more person centred. The system for medication administration was seen and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 16 were seen for the two service users who were case tracked and it was noted that there were no gaps on the recording records. The manager monitors the medication and the MAR sheets. Any recurring gaps or errors would be discussed with the member of staff. Staff stated that the member of staff making the entry, signs any additional entries to the MAR sheet that have been handwritten. A record is kept for all medication coming into the home. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. Only staff that have received medication training are allowed to administer medication. There are no service users who are able to self medicate. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. All staff have received training in protecting vulnerable people and are aware of the procedures and practices, to ensure that service users are safeguarded, as far as reasonably possible, from harm or abuse. However, a number of staff needs updates to the training. EVIDENCE: There were four recorded complaints; which had been handled appropriately the manager informed the inspector one complaint is still in process. Records seen indicated that complaints would be responded to within the guidelines. The Commission for Social Care Inspection (CSCI) have not received any direct complaints. There were two complaints referred to the Safe Guarding Adult team for investigating one has been completed and one is currently under investigation. The homes complaints procedure for service users is in pictorial form and staff stated that some service users would be able to use it when necessary. The complaints form is written with widget symbols and easy for service users to understand. A copy of the complaints procedure is displayed on the notice board in the hallway of the home. There are several new members of staff, some have moved from another home. The inspector was informed that staff have undertaken the training for the protection of vulnerable people at the time of induction. The majority of staff has completed the vulnerable adults training. However, some staff need updates to the training. The manager confirmed that staff cover training on induction but need more in depth training for the new members of staff. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 18 Some staff spoken to stated they had undertaken training in the protection of vulnerable adults and were aware of the whistle blowing policy. Staff said they would be willing and able to report any concerns and “would go to any level to protect service users”. Welmede Housing Association are in the process of changing service users bank accounts, all the service users accounts were registered under the previous manager’s name, who no longer works in the home, therefore accounts have to be changed and this seems to be taking a long time. In the meantime Welmede Housing Association are financing service users any money they may need, and when the bank accounts have been changed the money will be refunded to Welmede. The service users have a bank account and regular statements and receipts were available. Staff checks the records on a daily basis. The finances held in the home of two service users were checked by the inspector and found to be correct and the money balanced against the records held. The receipts were available and matched the records. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are in need of attention including the garden, to ensure service users have a safe, comfortable and homely environment to live in. EVIDENCE: The main communal areas in the home were found to be clean and well presented. Service users bedrooms were found to be personalised and nicely decorated. Some of the service users had televisions and music players along with other personal items. It was noted in some of the bedrooms that the light over the mirror was not working. The carpet in bedroom number four was badly stained and had a mal odour. There were other areas in the home that require attention for example the toilets and bathrooms were without soap, toilet paper and hand drying facilities. Each bathroom should have a dispenser for rubber gloves; at the time of the visit the boxes of rubber gloves are left in areas for easy access. There needs to be an indicator on the door of bathrooms and toilets to inform people that the bathroom or toilet is in use. Bathrooms require some form of cupboard or shelving to store pads etc. It was also noted in the upstairs Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 20 bathroom that the bath panel was missing off the bath, the velux window was refusing to open and the fan is so noisy it wakes service users up when they are asleep in bed. The service users would benefit with a shower room as there are six service users sharing one bathroom, which can be quite hectic at times the inspector was informed. The kitchen is in need of being deep cleaned on the ground floor, the cupboards were found to be dirty and the lights are in need of cleaning. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 21 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. Recruitment and vetting practices are good and the service is committed to safeguarding the welfare of service users. EVIDENCE: The home has recently appointed a new manager and the staff spoken to on the day of the site visit commented that the manager has an open door policy and staff are able to discuss with the manager any issues. Staff confirmed that regular supervision takes place. The present staff team are mainly new staff, which has caused some anxiety amongst service users and relatives. However, the proprietors of the home are very positive with regards to the staffing arrangements. Recruitment files were seen and found to be in order. Staff files held all the relevant documentation as required under Schedule 2 of the Care Homes Regulations 2001, amended version July 2006. Training is currently being up dated and a number of staff requires updates to their training, all staff needs to attend equality and diversity training which is not on the current training programme. The inspector would advise the Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 22 management of the home to ensure all staff attends makaton training as some of the service users use this method of communication. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. The management in the home provides an open, positive and welcoming atmosphere. The home has been operating without a registered manager for some considerable time. The manager should be given more supernumerary time to undertake some of the management duties that need to be in place. EVIDENCE: The present manager who is to apply for registration has completed NVQ Level 4 April 2007. The manager informed the inspector that she has three units to complete of the Registered Managers Award, and hopes this will commence this year. There are a number of areas that need to be addressed in the home. The manager is currently working four days a week on management and one day a week on shift, and one weekend a month on shift. This practice needs to be reviewed. The manager has already identified her objectives and completed Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 24 an action plan to meet the targets. The manager should be given more time to complete these tasks. The manager has delegated the control of the homes budget to the two deputies to manage, but the overall responsibility lies with the manager. The management of the home to ensure a copy of the Care Homes for Younger Adults National Minimum Standards are available in the home and a copy of The Care Homes Regulations 2001 and the updated amended version should be available for the staff to use as a working tool. Regular monitoring Regulation 26 visits take place and the reports seen were informative and the person undertaking the visit is clear regarding the content of the report. The manager stated that she intends to undertake an annual survey very soon this will include service users, relatives, G.P.’s and professionals. A number of records were checked these include fire records, service users meetings and staff meetings. The maintenance book was seen to be signed and dated of work undertaken in the home. It was noted in the kitchens there were several opened packets of cereals; all dried foods must be stored in a sealed container once opened. Guildford Road (2a) DS0000013481.V338988.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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 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 X 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 X X 3 X X 2 X Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 26 Yes 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 YA20 Regulation 17 Requirement To produce training records for staff administering rectal diazepam and diabetic injections. (Timescale 23/06/06 not met). The hallway carpet upstairs with iron burn marks on needs replacing. (Timescale 28/07/06 not met). Management to produce an emergency contingency plan. (Timescale 30/06/06 not met). A number of areas in the home require attention. As detailed in section Environment. The kitchen on the ground floor is in need of having a deep clean, the cupboards were found to be dirty and the lights are in need of cleaning. The garden needs attention; there was a considerable amount of rubbish in the garden. The green house must be removed from the garden; several panes of glass had been smashed. This is a health and safety hazard. Training to be up dated including more specialists training. All dry foods including cereals must be stored in a sealed DS0000013481.V338988.R01.S.doc Timescale for action 31/08/07 2. YA24 23 31/08/07 3. 4 5 YA42 YA24 YA24 13 23 & 13 23 & 13 31/08/07 28/09/07 31/08/07 6 YA24 23 & 13 31/08/07 7 8 YA35 YA42 18 13 28/09/07 09/08/07 Guildford Road (2a) Version 5.2 Page 27 container. 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 YA24 YA30 YA39 Good Practice Recommendations The service users would benefit with a shower room. The management to consider a washing machine which has a sluicing facility. A copy of the Care Homes for Younger Adults, National Minimum Standards and the Care Homes Regulations 2001 should be available in the home. Guildford Road (2a) DS0000013481.V338988.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 - 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. 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