Inspection on 24/05/07 for 2a Waterloo Street

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

2a Waterloo Street 16/01/06

2a Waterloo Street 24/06/05

2a Waterloo Street 06/09/04

2a Waterloo Street 07/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 2a Waterloo Street Cockermouth Cumbria CA13 9NB Lead Inspector Liz Kelley Unannounced Inspection 24th May 2007 10:00 2a Waterloo Street DS0000022556.V327436.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 2a Waterloo Street DS0000022556.V327436.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 Older People and 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. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2a Waterloo Street Address Cockermouth Cumbria CA13 9NB 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) 01900 827749 West House vacant Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 10 people over 18 years of age with a learning disability (LD), some of whom may be over 65 years of age (LD(E)). The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 16th January 2006 Date of last inspection Brief Description of the Service: West House are the Providers of the services and care at 2a Waterloo Street for ten people who have a learning disability, the majority of whom are older adults. The home is situated in a quiet side street near to the centre of the town of Cockermouth. The home blends into the surrounding community and there is level access to local amenities and facilities. 2a Waterloo Street operates as two units for five people on both the ground and first floors. Private bedrooms are situated on both floors and access to the upper floor is by either stairs or chairlift. The home has good facilities for assisting older people, such as an assisted bath and electric beds. There is a small garden to the rear of the home that includes a public footpath. There are car-parking facilities adjacent to the home. The current scale for charging is £563.32 per week. A Handbook is available for prospective residents, and the latest Commission for Social Care Inspection report is made available on request. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection where all the key areas of the National Minimum Standards were checked. Residents, and their families, and members of staff had given their opinions regarding the service and care to the inspector. Their comments and the observations made by the inspector have informed the judgements made in this report. The inspector also: • Received questionnaires from professionals and other people working with the home • Interviewed the registered manager and staff • Visited the home, which included examining files and paperwork • Received a self-assessment report/questionnaire from the manager. • Visited the Head office of West House to check on staff recruitment files. The overall picture gained by the Inspector was that people living at the home are being offered an individually tailored service that promotes choice and a good quality of life. What the service does well: What has improved since the last inspection? What they could do better: 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 6 There are no issues identified for improvement, and evidence from the inspection demonstrates that any areas would be identified by the homes own quality monitoring practices and would be resolved very quickly. 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. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The Home has robust and well-established procedures in place to introduce new residents in a manner which ensures successful placements. EVIDENCE: Resident’s files demonstrated that information and assessments were available which assisted in ensuring a successful introduction to the home. Close working relationships have been developed with social workers and other professionals to ensure that placements are reviewed closely over a trial period. These assessments form the basis of the individual’s plan of care and include any potential restrictions on choice, and limitations due to risk as agreed with the resident and their family. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 9 A prospective resident was viewing the home the week of the inspection, they had already met the manager, who had visited the person at their previous home. The visit to this home had included a trip into town to chose wall paper for their bedroom, a visit to a café and to meet the priest of the local church that the person was intending on becoming a member. They had also been given the chance to make a snack in the kitchen. The residents said they were really looking forward to moving in next week and had been delighted with having free access to the kitchen. The manager ensures that they provide plenty of information for prospective residents. For example the homes Statement of Purpose and Service Users Guide contain relevant details to assist residents, relatives and professionals in making an informed choice on the appropriateness of the home. The latest Statement of Purpose includes pictures of all staff, photographs of the house and symbols which make the document user friendly. The home does not offer intermediate care referred to in point 6 above. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) 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 excellent. This judgement has been made using available evidence including a visit to this service. Staff work hard to encourage residents to take control and make informed choices, that are carefully monitored through a well-developed system of care planning. EVIDENCE: Each resident has a plan of care that is prepared on admission to the home. The plan is agreed with the resident and their family members (with the resident’s agreement) and reviewed on a regular basis. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 11 The resident plan is developed in partnership with the resident, and based on an thorough assessment on the persons needs. The plan clearly sets out how specialist requirements will be met through positive and planned interventions. Residents are well supported through these individually tailored support plans that promote positive interactions and experiences. The emphasis of these plans is to focus on the positives and what a person can achieve and build upon these achievements. Staff are due to attend person centred planning training that has been arranged for all West House services. Staff were observed already have a good understanding of the principles of a person centred approach through the choice and control they attempt to give to each person. This is recognised good practice in working with people with a learning disability. The plans were found to be very informative, with details of the care needs, healthcare visits and appointments. Reviews were up to date with the family members being involved wherever possible. The manager includes a pen picture and a typical daily routine for each person to ensure that care is tailor made to the individual. Individual care plan files are well organised and laid out in a format that clearly identifies needs and how they are to be met. These are supported by additional information such as profiles, pen pictures called “All about me” and photographs to aid greater understanding and knowledge of the individual. The care plan is a working document being reviewed regularly with appropriate amendments. This includes risk assessments with the emphasis on addressing safety issues whilst also promoting a better quality of life. The manager has introduced a good system to measure risk and to give staff clear information on the levels by using a numbered risk rating score. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 13 12,13,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal development and making informed decisions is a key feature for individuals, with the staff team being skilled at enabling residents to get the most out of life. EVIDENCE: Residents were observed interacting in a positive manner with staff and other residents. There was lively conversation and an interest in the welfare of others in the home. Care plans examined contained in-depth instructions for staff to enable and promote positive relationships with relatives and friends. Good relationships have been built with neighbours and supportive friendships have been formed by residents. This is helped by the home being in the heart of the local community, the town centre being just a short walk away. For example one resident was planning a 60th birthday meal out with friends at a top local hotel. Residents are enabled to make informed choices through one-to-one keyworker support and many examples were found and identified as good practice in this field. Each person has a different weekly routine geared to their needs and choices. For example attendance at the local day centre is optional, and there are sufficient staff on duty to allow for the flexibility of people staying at home instead. Families have expressed their satisfaction with the contact with the home and have said that communication is excellent. Menus are planned with residents and a communal evening meal is encouraged. Although there is a weekly big shop for the house where residents choose to take part, individual shopping is also encouraged to develop independence and daily living skills. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Excellent systems have been developed to monitor individual’s health and medication to ensure residents receive effective and timely health care. EVIDENCE: Staff have a good understanding of the support needs of residents, and issues relating to old age and offer a responsive and supportive approach in assisting people to maintain their health. Health and personal care issues are well managed and residents are supported to make informed decisions, and to take responsibility for their own well-being. For example one person is able to are for their own catheter with advice and prompting support given by staff. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 15 Staff have also developed good working relationships with health care professionals and behaviour specialist, which have benefited residents by the approach and strategies used. MAR sheets, which record medication given were examined and were kept in good order. Medications are kept in a secure locked cupboard. All staff have recently undertaken a Managing and Safe Handling of Medications course through a local College, to Level 2 as is recommended and Level 1 for new staff as part of an Induction programme. The staff team sensitively handles the ageing process, as appropriate for some people, and offers support to minimise any impact on independence, including training and equipment. They also enable people at the end of their life to die with support and dignity. As demonstrated recently when a residents received full care at home up to the point of going into hospital, were staff remained with him until he passed away. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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. Residents, and their families, know action will be taken to resolve any concerns and that their well being is safeguarded by the open approach of the home. EVIDENCE: The home has a satisfactory complaints system with residents being able to express their views on the home, and these are acted upon. Residents were observed freely expressing opinions to the manager, they said that they would feel able to speak to the manager, or staff about issues they had. The open atmosphere created within the home ensures that residents feel free to express their opinions and are confident that they will be listened to and concerns acted upon. Residents had been given a brochure with ways to make complaints and this was available in various formats to aid understanding. All residents have regular contact with other people outside the home with whom they can discuss any problems, for example each person has a link with a day centre or college placement or have regular contact with an advocate. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 17 The manager has introduced a document called “Restraint in Practice” which is completed for each resident and describes the various forms of restraintphysical, chemical, mechanical and financial. This gives clear guidance to staff of good practice in safely supporting residents without infringing on their rights. Financial transactions on behalf of the residents are all documented and receipts and signatures gained to approve and authenticate the transaction. Staff receive training in de-escalating any challenging behaviours. This ensures that staff have the appropriate skills and use positive approaches to help people when they may become upset or agitated. Policies and procedures regarding Safeguarding Adults are available to staff and give them clear guidance about what action should be taken. Access to external agencies or advocacy services is actively promoted. The manager and staff team demonstrated a good awareness of different forms of abuse and the rights of the individual. The Home has induction training that covers adult protection issues and the various forms of adult abuse, and action to take if an allegation were made. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. It is open and transparent when discussing incidents with external bodies. These areas, and training in Adult Protection safeguarded residents from abuse. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well kept and safely maintained home that is adapted to meet their needs. EVIDENCE: The home is a large converted church building that has been adapted to a residential dwelling and to suit the specific needs of residents. The home is situated in a quiet side street near to the centre of the town of Cockermouth. The home blends into the surrounding community and there is level access to 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 19 local amenities and facilities. 2a Waterloo Street operates as two units for five people on both the ground and first floors. Private bedrooms are situated on both floors and access to the upper floor is by either stairs or chairlift. The home has now been running for over 10 years and over this time the relationship with neighbours and the local community has steadily strengthened, with residents now very much part of the local community. Resident’s individuals bedrooms are of a good size and individualised to each persons tastes and interests. A written programme of planned maintaince and renewal was available and areas recently up-graded were bedroom carpets, and a full redecoration for a new residents. The home has good facilities for assisting older people, such as an assisted bath and electric beds. The home is well lit, clean and tidy and smells fresh. There is a good infection control policy in place; and the manager seeks advice from external specialists, e.g. infection control, and encourages staff to work to the homes’ policy to reduce the risk of infection. An example of this is the use of the “redbag” system for soiled materials in washing machines and a related policy and practice guidance for staff. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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. Staff recruitment, training and supervision practices are well developed which ensures that residents’ well-being is promoted, by staff that have the qualities, aptitudes and skills to work in social care. EVIDENCE: 2a Waterloo Street has a core group of staff with a good mix of skills, experience, age, and gender, which reflects the profile of the residents. There has been a significant amount of staff movement in the last 18 months, including the manager leaving. This has not unduly affected residents as staff have worked hard to provide continuity of care. A new manager has been 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 21 appointed in February, who has experience of running a similar type of home. Staff have already reported that the manager has had a positive influence on the home and are feeling well supported. All staff are clear regarding their role and what is expected of them. Relative comment cards stated that staff know what they are meant to do, and that they are able to meet their needs. This leads to good levels of confidence and satisfaction from residents, relatives and professionals with the care that is delivered. “The care is wonderful” said one relative. The Home follows the recruitment procedures of West House. Staff files are held in the home, and contained all the relevant documentation, being clearly sectioned and well-organised. The selection procedure includes obtaining two written references, a formal interview and an informal interview involving residents, wherever possible. All staff had CRB disclosure checks and applications are subject to equal opportunities monitoring. Upon appointment staff were issued with a handbook, which includes job descriptions and terms and conditions. Appointments are subject to a six-month probationary period. West House has a code of conduct and all members of staff have a statement of terms and conditions. A member of staff interviewed confirmed these practices. These are all good practices and ensure that residents are supported by a carefully selected and vetted staff team. The home has a framework for supervisions and appraisals, and these have been carried out to good standards; staff reported that these are helpful and they feel well supported by the manager and the organisation. Staff training continues to have a high profile in the home and staff are keen to gain new knowledge and skills that will assist them in supporting residents. For example all staff have recently completed a Safe Handling of Medication training course, and have had training on swallowing difficulties. The numbers of staff who have a qualification in care has been affected by the loss of trained staff, however new staff have quickly gained qualifications and five are registered to take part shortly. This means they are above the 50 minimum as required by this standard. Staff also receive varied training to equip them with skills and knowledge to support residents. A rolling programme of training includes first aid, abuse and neglect, fire wardens, moving and handling, health and safety and physical intervention training. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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. Residents and staff are benefiting from a period of greater stability brought by the experienced and competent leadership of the new manager. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager promotes an open, positive and inclusive atmosphere in the home through a variety of ways: regular staff meetings; regular supervision; and by inclusion of residents in the use of feedback and encouraging participation in users groups. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. Staff had received the required training to ensure the health and safety of residents and themselves. Advice is taken from the local environmental health and fire officers regarding maintaining a safe environment. The working practices in the home are safe and there are no preventable accidents. The home has a full range of policies and procedures to promote and protect residents’ health and safety. Staff consistently follows these. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. The home proactively consults other experts and agencies about health and safety issues. There is a good understanding of risk assessment and this is taken into account in all aspects of the running of the home. The quality assurance system confirms that the findings from risk assessments have been actioned and the home continuously improves its systems for health and safety. Spot checks and quality monitoring systems provide management evidence that practice reflects the homes policies and procedures. The provider, West House, appoints an operations manager to carry out Quality Assurance checks (regulation 26). These are sent into the Commission for Social Care Inspection on a monthly basis. The registered persons within the organisation have extensive knowledge and are highly confident in both strategic/ financial planning and review and have developed a detailed business and financial plan which gives a clear indicator of the success and efficiency of the business arrangements. The manager, in turn, has sound knowledge of both strategic and financial planning and review, and provides value for money through effective management. The administration systems within the home were found to be up-to-date and in good order, ensuring the home is run in an efficient and effective manner. Record keeping is of a consistently high standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. These are all features of a well run home. The manager is currently undergoing registration with the Commission for Social Care Inspection. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 23 4 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 Standard No Score 37 3 38 x 39 3 40 x 41 x 42 3 43 x 3 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2a Waterloo Street Score 4 3 3 4 DS0000022556.V327436.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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. 2a Waterloo Street DS0000022556.V327436.R01.S.doc Version 5.2 Page 27 - 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!