Inspection on 22/11/07 for 3 Moultrie Road

This inspection was carried out on 22nd November 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Moultrie Road 14/11/06

3 Moultrie Road 27/01/06

3 Moultrie Road 30/09/05

3 Moultrie Road 10/11/04

3 Moultrie Road 19/05/04

3 Moultrie Road 22/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 3 Moultrie Road 3 Moultrie Road Rugby Warwickshire CV21 3BD Lead Inspector Jo Johnson Key Unannounced Inspection 22nd November 2007 09:00 3 Moultrie Road DS0000004314.V355068.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 3 Moultrie Road DS0000004314.V355068.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. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Moultrie Road Address 3 Moultrie Road Rugby Warwickshire CV21 3BD 01788 547585 F/P 01788 547585 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) www.rethink.org Rethink vacant post Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: 3 Moultrie Road is a large, three-storey, Victorian town house, close to the centre of Rugby. It is owned and managed by Rethink. The Home is domestic in nature and is indistinguishable as a care home from the neighbouring properties. The rooms are large and airy and generally well maintained. The home caters for six people with enduring mental health problems, providing 24-hour support and encouragement to enable service users to regain their independent living skills. The Home is within walking distance of the town centre; there are accessible gardens to the rear of the property. The inspection report is given to all of the people living at the home and a copy is available in the entrance hall for visitors. The range of fees was not available at the time of inspection. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were sent to all of the people living at the home and all were returned. All were positive about living at the home. Surveys were also sent to all of the staff working at the home. Information from surveys has been included in the report. The inspection was unannounced (we did not them know we were coming) and took place on 22nd November at 9.00 am. The acting manager was not present during the inspection. A telephone discussion was held with the acting manager on 23rd November at 10.00 am to clarify areas that the staff member on duty did not have knowledge of. The inspection involved; • • Observations of and talking with the people who live at the home and the ‘bank’ staff on duty. Three people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • The inspector would like to thank the people who live at the home, and staff for their hospitality and cooperation during the inspection visit. What the service does well: 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 6 The philosophy of the home is to support the people to develop and maintain skills, gain confidence and become independent with a view to progressing from residential care into a supported living or an independent living environment. People have clear ‘recovery’ plans that they are involved in developing and setting achievable goals. The staff have a good understanding of the people’s needs and aspirations, they adapt the levels of support that they provide to reflect the individuals needs, abilities and the progress that they have made. People continue to receive support from the relevant health and social care professionals. People are able to participate in a broad range of activities that reflect their personal preferences, promote their independence and that they enjoy. People are encouraged to access community based activities in the evenings and at weekends and to attend a resources centre. The home is comfortable, clean and homely and reflects the individual needs and personal preferences of the people, the atmosphere in the home is welcoming. There are regular house meetings, which means that people are actively involved in the running of the home. What has improved since the last inspection? Most of the requirements from the previous inspection have been met. Staff have now completed ‘safe handling of medication’ training. This means that they have a better understanding of medication. Staff have attended adult protection training and other mandatory training. This means that they know how to recognise, report any allegations of abuse, and have been trained in health, safety, and mental health awareness. The management of peoples’ finances has been reviewed and new systems put in place to make sure that they are safeguarded. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3 Moultrie Road DS0000004314.V355068.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 3 Moultrie Road DS0000004314.V355068.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 adequate Peoples’ needs and aspirations are assessed but the shortfall in relying on just professional assessments means that the person cannot be sure that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were six people living at the home at the time of the inspection. One of the people spoken with had moved in two weeks before the inspection, other people spoken with had lived there for longer; one person was a long term resident. The aim of the home is to promote people’s independence and to support people to move on to alternative accommodation. All of the people admitted within the last year spoken with were clear that this is the purpose of the service. Full assessments of three people’s needs were seen in their care records. One person said “XXX came to see me at the hospital and there then was delay between my assessment and admission to the here”. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 10 The person who had recently moved in said that their admission to the home had been arranged through their CPN (community psychiatric nurse) key worker. The only assessment of the person’ need in their care records was completed by their CPN. There was not any assessment completed by the home seen in the records. Assessments must be completed before a person moves into the home. This is to make sure that the home and the individual can be sure that they can meet their needs. The person who had recently moved in said that they had an introduction into staying at the home and had been given an information pack. The home induction checklist was seen in their care records. 3 Moultrie Road DS0000004314.V355068.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, 9 Quality in this outcome area is good. The people living in this home are involved in decisions about their lives and are playing an active role in planning their care and the support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four people’s care plans were seen with their agreement and three of the people were happy to discuss their plans and support. Three of the four care plans seen included a ‘recovery’ plan. The newest admission said that their recovery plan was in progress and “staff have gone through my plan with me”. All of the people spoken with were positive about their ‘recovery’ plans that that the setting of short and long terms goals supported them in gaining their independence. The plans seen were of good quality and people had clearly been involved in the setting and reviewing of their plans. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 12 The risks to three of the people in their day-to-day lives have been assessed. Again, people have been involved in the development of these assessments. These have been reviewed and updated as needed and following any changes in people’s well being. There is a culture of positive risk taking to promote people’s independence. This is good practice. The newest person did have a risk assessment in place; again, this was completed with their CPN and related to their time as a voluntary patient in hospital. Staff must complete a risk assessment for all people moving into the home. This is to make sure that any risks are assessed, managed and minimised where possible. People have a weekly one to one session with their key workers and the daily recording seen was of a good quality and reflected people’s support given. People spoken with were happy with the recording in their care plans. All three people’s surveys show that they ‘always’ make decisions about what they do each day. Comments on surveys included: ‘I stick to a plan and that helps me make decisions’ and ‘the home encourage each resident to have at least one activity away from the home’ The staff member on duty was a ‘bank’ member of staff who had started the previous month. They confirmed that they had read everybody’s care plan during their induction. They had a good understating of each person and was able to describe their needs and the support they need. Staff surveys show that they are ‘always’ or ‘usually’ given up to date information about people. There are a number of checklists and a ‘confirmation that staff have read care plan’ sheet in individuals’ files. All of these checklists were either out of date and staff had not signed to show that they had read people’s care plans. The purpose and value of the checklists and confirmation that staff have read or completed information should be reviewed. This is to make sure that if such paperwork is needed that it is followed up when staff have not completed it. Discussions with the people and staff member, and observations during the inspection confirmed that people are actively encouraged to make decisions that affect their everyday lives. 3 Moultrie Road DS0000004314.V355068.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, 14, 15, 16, 17 Quality in this outcome area is good. The people living in this home are supported to make choices about their lifestyle and to develop life skills. Daily living activities promote independence and opportunity for people to live ordinary and meaningful lives in the community where they are living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two of the three people’s surveys show that they can choose how to spend their time during the week and that can do what they want at the weekend. Comments on surveys included: ‘ I get up, have breakfast then get dressed and do my own things’ and ‘ on Sunday it’s someone’s turn to make Sunday lunch and communal housework takes place. Housework also takes place on a Saturday morning so is quite difficult’. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 14 From discussions with people they spend their days in varied ways including: college courses, voluntary work, meeting up with friends, shopping and following elements of their ‘recovery’ plans. Everyone has a key to their room and people said that staff do not enter until they let them in. People said that they can have visitors to the home until 9.30pm and this was observed during the inspection. People chose where to spend their time and were free to come and go in and out of the home. People spoken with said there are not any restrictions as to what time they can come and go. One person chose to spend their time in their bedroom and did not wish to be spoken with. The staff member on duty respected this but offered them support throughout the day as detailed in their ‘recovery’ plan. Lifestyle choices and people’s diverse needs are consulted on during the assessment process. However, this part of the assessment does not include personal relationships and people’s sexual orientation. From discussion with the acting manager, information provided on the AQAA and people’s surveys show that this is not always considered. People should be consulted during the assessment process as to whether they wish to express their preferences in terms of personal relationships. This is to make sure that people’s preferences are acknowledged and that any specific needs identified can be met. Staff attend ‘anti discrimination’ and ‘race awareness’ training as part of their mandatory training. The manager said, that it is planned for staff to complete the ‘equality and diversity’ distance learning course. Staff surveys show that they have enough information, support and experience to meet peoples’ diverse needs. Each person has their own kitchen cupboard and space in the fridge to store their food. The home provides each person with a food budget at the beginning of each week. Staff support is provided if this is required for budgeting and preparing a menu and shopping list. During the inspection, the staff supported two people to plan their weekly shop and menu. They were encouraged to plan a healthy balanced diet. All the people spoken with were positive about the support given by staff to menu plan and support them with budgeting. One person said, “I’ve always lived at home and staff are helping me to be more independent. I go shopping on a Friday and staff help me go through my menu”. Each Sunday the staff and people prepare a traditional lunch. The people said that the home also organises ‘take-away’ and ‘fish and chip’ suppers. 3 Moultrie Road DS0000004314.V355068.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, 20 Quality in this outcome area is adequate. The health and personal support that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. The lack of some self –medication assessments and the medication recording practices may place some people at risk of misadministration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were positive relationships and interactions observed between the staff member and the people who live at the home. The staff member observed provided support in private and was sensitive and discreet when supporting people with any aspect of their ‘recovery’ plan. People living at the home do not require any hands on personal care but some may need some prompting from staff to maintain personal hygiene. This is identified in ’recovery’ plans if necessary. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 16 People’s health records and care plans showed that their right to good-quality physical and mental health care is being promoted. The records show that as part of promoting their health people make regular visits to a dentist, optician, specific health consultants, physiotherapists, speech and language therapists, learning disability nurses, their GP and a chiropodist when needed. The acting manager confirmed, on the telephone, that since the last inspection staff have attended medication training and that a majority have completed ‘the safe handling of medicines’ course. From information provided on the AQAA and evidence in ‘recovery’ plans, there has been a focus on promoting peoples independence in the management of their medications. Four people self-administer their medication on a weekly or planned daily basis. However, a self-administration risk assessment and plan was only seen for one person. This was of good quality and the individual had been involved at all stages of the assessment and planning. There are good risk assessment and plan templates and systems in place that are not routinely being used. This may place people at risk of self-misadministration if they have not been properly assessed. Medication self-administration risk assessments and plans must be completed. This is so any risks associated with self-administration are assessed and minimised and that there is a clear plan as to how staff are to support people with their medication. Medication records were seen of all of the people living at the home. There were two different types of medication administration record in use, one from the dispensing chemist and another from North Warwickshire PCT. The different administration records and lack of risk assessments and plans meant it was confusing to assess whether people had had their medication administered correctly. There should be just one type if medication record used that reflects peoples’ plans. This is so staff know how to complete the medication records correctly. Two people’s medication administration records had gaps and one person’s record, who self administers, had not been completed since the first day of their admission to the home. Staff must sign medication records to show whether medication has been administered as detailed in their plan. This is so there is record of whether people have been given the correct medication as prescribed. 3 Moultrie Road DS0000004314.V355068.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, 23 Quality in this outcome area is good Complaints procedures make sure that peoples, relatives and representatives concerns and complaints are listened to and acted upon. A staff team who have a good knowledge of how to respond to any suspicion of abuse and to keep people safe from harm support the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints made to the Commission for Social Care Inspection about the home since the last inspection. There is a written complaints procedure that is available to people and their families or representatives. All of the people spoken with and surveys show that they know how to complain. All of the staff surveys and the staff member spoken with show that they know how to support people how to make a complaint. From information provided on the AQAA, five complaints were received by the home since the last inspection. However, following the telephone discussion with the acting manager, three of these related to the supported housing scheme that the manager is also responsible for. These complaint records should be kept separately. This is so it is clear which complaints are about which service. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 18 Staff have attended adult protection since the last inspection. This was provided by Rethink and is part of staff’s mandatory training. Two people’s financial records were looked at with their consent. The staff member on duty was confident of how to administrate the records and each person’s individual monies. The records and monies kept were checked and they balanced. Two people spoken with receive support from staff in the management and budgeting of their finances. One person said “I go to the bank and staff help me budget, they give me money each day…otherwise I’d spend it all at once”. The procedures for the monitoring of the management people’s finances kept by the home have been improved since the last inspection. The acting manager said that only she has access to the safe and that she balances the homes and peoples accounts every Friday. It is recommended that monthly regulation 26 visits also be used as an additional way of checking people’s monies to ensure that people’s finances are safeguarded. These have not been happening every month and must be undertaken as part of the quality monitoring systems of the home. 3 Moultrie Road DS0000004314.V355068.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, 30 Quality in this outcome area is good The home is well maintained and furnished so that people live in a homely, clean, comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home found that the general décor, carpets, furniture and fittings were of good quality and domestic in nature. The home was clean and free from unpleasant odours. Communal areas include a good-sized garden, large lounge, a smoking room and a large kitchen diner. People chose whether they wished to spend time in the communal areas or in their own rooms. 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 20 People spoken with were happy with their bedrooms and new furniture had recently been provided for one person. Communal bathrooms and toilets were clean and had toilet rolls and facilities for washing and drying hands. People take responsibility for the cleaning of their own rooms and there is a shared rota for the communal areas. People spoken with were happy with sharing the domestic cleaning. People do their own personal laundry and staff wash the towels and bed linen. There are enough washing and drying facilities. 3 Moultrie Road DS0000004314.V355068.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, 35 Quality in this outcome area is good Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, and to support the smooth running of the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As the inspection was unannounced, the manager was not present so the staff recruitment files were not available for inspection. Recruitment standards were met at the last key inspection and information included on the AQAA, staff surveys and the bank staff member on duty spoken with show that they staff go through recruitment checks before they start work at the home. On the day of the inspection, there was only one member of staff on duty as the second member of staff had phoned in sick. The acting manager was on a training course. A second member of staff came on duty at 2pm. Copies of the homes staffing rota were seen during the inspection. The rotas showed that as on the day of inspection shows that there are occasions when there is only one member of staff on duty. A majority of the time there are 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 22 two staff on duty plus the acting manager during the week. Observations during the inspection and examination of records relating to the people confirmed that this level of support is adequate for the needs of the current people living at the home. The acting manager confirmed, during the telephone discussion, that there is now flexibility within the budget to increase staffing to meet individual’s specific needs and that staffing can be increased if someone becomes unwell. People spoken with spoke highly of the staff and the support given to them. Surveys from people showed that staff ‘always’ treat them well and that they act and listen to and act on what they say. Comments included: ‘I feel I can talk to everyone to make my opinion or problem heard or better’. The training file for staff was seen. Only the training schedule for the deputy manager was up to date. There were the details of staff in the file that have since left the home. The information provided on the AQAA and the acting manager confirmed that all staff and new staff have completed their mandatory training, which includes POVA (protection of vulnerable adults), mental health awareness, health and safety, Infection control, antidiscrimination and race awareness and safe handling of medicines. The training schedule and file should be updated so that there is an accurate record of what training staff have completed. There are monthly staff meetings and the minutes were seen. 3 Moultrie Road DS0000004314.V355068.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, 42 Quality in this outcome area is good People benefit from living in a well maintained and managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager returned from planned leave in March 2007. She has not yet applied to the commission to be registered. An application to be registered as the manager of the home must be submitted to the commission. This is to make sure a suitable and registered person manages the home. The organisation completes its own internal quality audits for which the service achieved a green status and a score of 97 . Each month the manager completes a health and safety checklist and provides a copy to the 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 24 organisation. There is a quality assurance tool in place for the manager to complete which will include surveys for people who live at the home. She is committed to undertaking a formal consultation with the people who live at the home. Regulation 26 monitoring visits are currently undertaken by a service manager but these are happening infrequently. The last regulation 26 visit was in July 2007 and the one previous to that was in March 2007. These monitoring visits must be completed on a monthly basis. This is because they are an integral part of the quality assurance and monitoring systems. There are monthly house meetings. One of the people showed the inspector the minutes from the last meeting. They said, “we talk about things in the house and what we want to do”. People spoken with felt they are invovled in decisions about the day to day running of the house. Information provided before the inspection, by the manager in the AQAA (Annual Quality Assurance Assessment) indicates that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. 3 Moultrie Road DS0000004314.V355068.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 2 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 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 3 x 3 Moultrie Road DS0000004314.V355068.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 YA2 Regulation 14 (1) Requirement People’s assessments must be completed before they move into the home. Timescale for action 01/02/08 2 YA9 13(4)(b) This is to make sure that the home and the individual can be sure that they can meet their needs. Staff must complete a risk 01/02/08 assessment for all people moving into the home. This is to make sure that any risks are assessed, managed and minimised where possible. 01/01/08 Medication self-administration risk assessments and plans must be completed. This is so any risks associated with self-administration are assessed and minimised and that there is a clear plan as to how staff are to support people with their medication. 3 YA20 13(2) 4 YA20 13(2) Staff must sign medication records to show whether medication has been administered as detailed in their DS0000004314.V355068.R01.S.doc 01/01/08 3 Moultrie Road Version 5.2 Page 27 plan. This is so there is record of whether people have been given the correct medication as prescribed. 5 YA37 8(1) 9 (1) An application to be registered, as the manager of the home must be submitted to the commission. This is to make sure a suitable and registered person manages the home. People and their representatives must be formally consulted about the quality of the service. This is so people are involved and consulted about the running of the home. Requirement amended at this inspection, previous timescale 28/02/07. 7 YA39 26 Regulation 26 visits must be undertaken on a monthly basis. This is because they are an integral part of the quality assurance and monitoring systems. 01/02/08 01/02/08 6 YA39 24(3) 01/04/08 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 Refer to Standard YA6 Good Practice Recommendations The purpose and value of the checklists and confirmation that staff have read or completed information should be reviewed. This is to make sure that if such paperwork is needed that it is followed up when staff have not DS0000004314.V355068.R01.S.doc Version 5.2 Page 28 3 Moultrie Road completed it. 2 YA15 People should be consulted during the assessment process as to whether they wish to express their preferences in terms of personal relationships. This is to make sure that people’s preferences are acknowledged and that any specific needs identified can be met. There should be just one type if medication record used that reflects peoples’ plans. This is so staff know how to complete the medication records correctly. The homes and supported living service complaint records should be kept separately. This is so it is clear which complaints are about which service. Monthly regulation 26 visits also be used as an additional way of checking people’s monies to ensure that people’s finances are safeguarded. The training schedule and file should be updated so that there is an accurate record of what training staff have completed. 3 YA20 4 YA22 5 6 YA23 YA35 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 3 Moultrie Road DS0000004314.V355068.R01.S.doc Version 5.2 Page 30 - 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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