Inspection on 13/10/06 for 33 Station Road

This inspection was carried out on 13th October 2006.

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

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

Other inspections for this house

33 Station Road 14/12/05

33 Station Road 11/07/05

33 Station Road 23/02/05

33 Station Road 04/08/04

Similar services:

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

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

CARE HOME ADULTS 18-65 Station Road (33) Brimington Chesterfield Derbyshire S43 1JU Lead Inspector Tony Barker Announced Inspection 13th October 2006 09:05 Station Road (33) DS0000020099.V315820.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 Station Road (33) DS0000020099.V315820.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. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Station Road (33) Address Brimington Chesterfield Derbyshire S43 1JU (01246) 205801 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) None United Response Mrs Janice Ashmore Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14th December 2005 Brief Description of the Service: 33 Station Road is a large semi detached house congruent with the surrounding residential area and close to local amenities. There is a regular bus route to Chesterfield town centre. The Home has a large and well-maintained garden area that is accessible for residents. Accommodation comprises 6 single bedrooms and there are domestic style lounge and dining areas. The Home is satisfactorily resourced with bathroom and toilet facilities. Care programmes are developed with each resident and external specialist support obtained as required. The advanced age of several of the residents is assessed and necessary aids and adaptations provided. A passenger lift is also provided. The fees are currently around £318 per week plus a Primary Care Trust (PCT) grant. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8.25 hours and was a key unannounced inspection. The Manager, a senior support worker and a support worker and one service user were spoken to and records were inspected. There was also a tour of the premises. Two service users were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the one requirement made at the last inspection. The pre-inspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? What they could do better: A written policy concerning continence promotion should be provided and a written complaints procedure should be displayed for visitors to the Home. The floor covering should be replaced in one bathroom. Further staff should Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 6 achieve a National Vocational Qualification (NVQ) to level 2. Records of required monthly visits to the Home should be maintained. 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. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs were being assessed so that staff could provide individually tailored care. EVIDENCE: The five service users, accommodated at the time of this inspection, had lived in this Home for several years. A full assessment of their needs was made prior to their admission, as confirmed by detailed examination of care records at a previous inspection. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from having high quality care plans setting out goals to meet their needs. They were making decisions about their lives, with staff assistance, and participating in all aspects of life in the Home, in order to empower them. Service users were being supported to take responsible risks. EVIDENCE: The care files of the two case tracked service users were examined. These were well laid out, very comprehensive and person-centred. One case tracked resident’s file was personalised with pages of photos and recorded comments from the service user. The files included all the individuals’ needs and the potential risks to which they were exposed. Helpful Support Plans were in place to guide staff in their care of service users. There was a sheet with each Support Plan which staff had signed to confirm they had read and understood the Plan. The Manager said new staff are expected to read the relevant Support Plan/Risk Assessment before supporting a service user in a particular activity. All recorded guidance for staff was found to be explicit and detailed. All documents in the care files had been reviewed by the Manager during 2006. She stated that care plan review meetings were being held every six months, Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 10 with the service user and their relatives, even if there was no care manager involved. The Manager said she monitors staff keeping to the guidelines in the care files and the staff who were spoken to said they regularly read these files as well as keeping service users’ details up to date. Care files included service users’ ‘Likes and Dislikes’ and their individual preferences on issues, such as ‘Lifestyle’ and ‘Social Activities’ were comprehensively documented. The Manager added that service users’ ‘hopes and dreams’ had also been noted and that holiday locations for two service users had been based on these – Disneyland and Scotland. One staff member spoken to said she pays attention to the care file of the service user for whom she is key worker – “to make sure I am doing things as (the service user) prefers”. There was plenty of other evidence of service users being enabled to make decisions about their everyday life. Service users were involved in the recruitment of new staff, in periodic review of the Home’s menu, in organising social events at the Home and in a local self-advocacy group. One case tracked service user, who chaired this group, said, “I’m in charge of Spire Voice...we organise things...I enjoy this”. (See Standard 39 in this report) It was clear from discussion with the Manager, support staff and service users, and from observation, that service users had high levels of participation in the Home’s routines and events. In one service user’s bedroom there was a certificate displayed that stated, “Congratulations for Taking Part in the ‘Choosing Staff’ 3 Day Course”. The Manager explained that there were group interviews of job candidates that were videod so service users could look at these and give their opinions. She said the majority of service users were involved in this aspect of staff recruitment and had had training for this and were paid. Support staff spoke about service users’ involvement in staff induction/training and in fire drills and there were certificates supporting this. The Inspector was asked by a service user, on the day of this inspection, if he wanted to stay for lunch. Again, this highlighted service users’ participation in the Home’s routines. Recorded risk assessments documented a comprehensive range of activities to which service users were exposed to risk. These indicated the measures taken by the home to minimise these risks. Support staff gave several examples of service users being enabled to take ‘responsible risks’ in order to develop their independence. All the service users were over retirement age and had varying degrees of physical disability so many activities involved a degree of risk. Such activities ranged from carrying a basket of laundered clothes to one service user, who wore leg callipers, being enabled to swim in a local pool. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were involved in fulfilling and age-appropriate activities within the Home and in the local community. They were able to maintain appropriate relationships with family and friends and were provided with a healthy personalised diet. Daily routines reflected their individual choice and promoted independence. EVIDENCE: No service user was involved in any occupational or educational activities but they did participate in age-appropriate and valued activities. Discussion with one case tracked service user highlighted a good level of enthusiasm and pride in these activities. There were items of pottery, on this service users’ bedroom window sill, that had been made at a Mencap day centre. Service users’ involvement in organising the annual garden party, Christmas party and Halloween party, and their obvious enjoyment in this participation, was further evidence of these activities being valued. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 12 Support staff stated that service users were well known in the local community. They accessed restaurants, pubs, shops, the Post Office, hairdressers and the surgery. Support staff provided service users with oneto-one support on one designated day each week and visits to the local community figured highly during this day. When travelling further afield a taxi or the local community transport service was used. The Manager confirmed that an extra member of support staff is on duty every Tuesday afternoon to enable service users to go out, as a whole group, to the cinema or other leisure pursuit. The Home had a good relationship with its immediate neighbours. The case tracked service user, who was spoken to, said, “I like being taken out and going out”. This service user was attending a local C of E Church each Sunday and a Spiritualist Healing group one evening a week. The service users had differing degrees of contact with relatives but it was clear that these contacts were being encouraged by the Home. The two support workers said that two service users had friends that visited them at the Home. One case tracked service user stated that, “They’re all my friends here”. Opportunity to spend time with other adults with learning disabilities in the area arose from the parties organised by Spire Voice, as mentioned earlier in Standard 7. The two support workers stated that all routines, in which service users were involved, promote their independence. Service users’ one-to-one days had flexible agendas, staff said, and were based on preferences personally expressed by the service users – with staff encouraging and prompting where necessary. They were all involved in food shopping and meal preparation/clearing up and, staff added, some had definite culinary skills. One case tracked service user said, “I like helping people in the house” and “I make buns and tarts”. Another service user was seen ‘hovering’ around the kitchen anxious to help clear away lunch items from the dining table. A further case tracked service user had a Daily Planner that had been personalised with pictures for each day’s activities. Staff confirmed that each service user held their own bedroom door key and two had chosen to regularly use their key. Support staff spoke of the expectation that they knock on bedroom doors and wait to be invited in. Privacy locks were fitted to bathroom and toilet doors. The Manager said that service users have expressed a preference to eat at the same time each day although actual mealtimes will reflect activities at the time. Three service users were observed, at this inspection, eating lunch with staff at the dining table. One service user was out, on a one-to-one day with staff, and another was at day services. The Home’s written four-week rolling menu was displayed in the kitchen along with a pictorial menu. These indicated that service users were being provided with a nutritious and balanced diet. One case tracked service user said the food was “lovely”. The larder cupboards and refrigerator/freezer were very well stocked and photographs of these contents were affixed to the front of these storage spaces. Fresh fruit and vegetables were seen. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were receiving very individualised personal support, in the way they preferred. Their health needs were being met and they were being protected by the Home’s procedures for dealing with medicines. EVIDENCE: Support plans detailed individual preferences as to how service users wished to receive support and assistance with their personal care. There were no set times for getting up or going to bed and it was evident from talking with staff and service users that daily routines were as flexible as possible. Support staff stated that the ‘timetable’ on each service user’s one-to-one day was flexible and took account of their expressed preferences. Records indicated that service users were consulted concerning which member of staff would be their key worker, including the gender of the worker. The Manager said the Home had one voluntary befriender/advocate who had worked with a previous service user and who, she hoped, would agree to work with one of the current service users who had little family contact. A number of service users had been assessed for technical aids in view of their deteriorating mobility; three used a walking frame and two used wheel chairs at various times. Other ‘moving and handling’ equipment was also available. Handrails had been fitted to one wall on the first floor corridor and in the ground floor toilet. Both Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 14 shower enclosures were of a ‘walk-in’ design. All staff had had training in Makaton sign language although only one service user was using Makaton. Pictorial boards were in use in the Home to address some service users’ limited communication skills. The degree of individualised personal support being offered to service users is commendable. Service users health needs were well documented and the Medical Profile included appointments with health professionals, diet and mobility. A weight monitoring chart was seen on one case tracked service user’s file that addressed the individual’s diabetes. Each care file had a completed ‘Medical/Health Information Form’ that, the Manager said, is taken to appointments with GPs, dentists, chiropodists and therapists. The Form includes information for the health professional and is used, also, to bring information back to the Home from the health professional. Four of the service users were attending a weekly session at the local community centre that involved reminiscence and reality orientation – which addressed the increasing degree of dementia being experienced by these service users. The continence of two of the service users was being managed appropriately and advice had been sought from a local district nurse on this matter. However, the Home had no written policy concerning continence promotion. The medicine records of one case tracked service user were examined and found to be satisfactory. The records included details of medicines administered by staff and of medicines received and returned to the pharmacist. The latter were handwritten and good practice was being followed by two staff signing them. Medicines were securely stored in individuals’ bedrooms. The Manager said that United Response provides training in the use of medicines to new staff following appointment. She was also providing in-house training on this subject, which took the form of questionnaires and other assessments of staff skills and knowledge. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the Home’s complaints policy and procedures and were being protected from abuse. EVIDENCE: The Home had a clear complaints procedure in place. A pictorial version was displayed in the kitchen for use by the service users. This was good practice although a written one should be available to visitors. Two complaints were on record as having been received within the previous 12 months. Both were from service users regarding other service users and shows how these concerns were being taken seriously. The Home had a comprehensive written policy on ‘Safeguarding Adults’ and support staff showed they were aware of this policy and the associated ‘Whistle Blowing’ policy. These policies were in the Home’s Policies and Procedures folder and it was noted that staff had signed individual sheets confirming they had read and understood the contents of each policy. The Manager stated that staff had received training on the subject of adult abuse. She said she had attended a Derbyshire County Council (DCC) awareness training course on ‘Safeguarding Adults’ and showed awareness of proper procedures on this matter. Completed ‘body maps’ were seen on the care file of one case tracked service user. The Manager explained that these are completed whenever a bruise is noted on a service user – possibly following a fall. She stated that no ‘Safeguarding Adults’ referrals had been made to Social Services within the previous 12 months. Good practice was being followed regarding the security and handling of service users’ personal money. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. The service users were living in a comfortable, homely and safe environment that was clean and hygienic. EVIDENCE: The Home was attractively furnished and homely in appearance. Two bedrooms and both lounges had been redecorated since the last inspection. Two service users’ bedrooms were viewed and these were found to be personalised and comfortable. The Manager said that service users had all chosen their bedroom décor and colour scheme. At the time of this inspection there was a leak in both the shower and the specialist bath within the bathroom. There had been a continuous problem with the leaking shower, the Manager said, and both were due to be repaired. In this bathroom the floor covering around the WC was significantly discoloured. There was an additional bathroom with walk-in shower. There were two lounge areas that were both comfortable and homely and both had a television. There was a toilet on the ground floor near to the lounge area. The passenger lift, between the two floors, was used by several service users that would have difficulty with the stairs. One service user was seen to use the lift independently. The Manager Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 17 pointed out that the front staircase was lit all the time due to service users physical vulnerability. There was a large garden to the rear of the Home containing a pond that had been made safe by railings. The grounds were fully accessible with the use of ramped areas. A large marquee was also in the rear garden. This was used for garden parties and was awaiting dismantling and storage in the shed. The Home was clean with no unpleasant odours. Items brought to the laundry room did not have to pass through lounge, food storage or preparation areas. There was a sluicing facility on the washing machine. Staff described good facilities and hygienic practices regarding the transportation and disposal of infected material. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 18 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): 32,33,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were being supported by a very well-trained and effective staff group. They were also protected by the Home’s recruitment procedures. EVIDENCE: The Manager confirmed that 38 of the care staff group had achieved a National Vocational Qualification (NVQ) in care at level 2. This was short of the requirement to maintain a staff group with at least 50 qualified staff. The Manager stated that there were normally three members of staff on duty on the early shift and two on the late shift with one waking staff at night. At weekends this pattern was reduced by one staff per shift during the day although additional staff hours were provided on Sunday morning and Tuesday afternoon to cover church attendance and leisure pursuits. The staffing rota, sent to the Commission with the pre-inspection questionnaire, supported this. The Manager explained that a group of five relief staff worked at the Home but they were well established here. She was planning to reduce these relief hours as permanent staff were recruited. The personal file of a support worker, appointed in July 2006, was examined. It was found to meet all the Regulation requirements. The Manager stated Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 19 that the Home’s full recruitment practices were followed, including checks with the Criminal Records Bureau (CRB), before a volunteer is appointed. One member of staff confirmed that she had undertaken induction training to Learning Disability Award Framework (LDAF) standards, as required by Standard 35, when she started work at the Home. The Manager spoke of new staff, during their first two weeks of induction, shadowing other staff and having access to the ‘Information File’. This document includes a section called ‘Key Points to Wellbeing’ which gives a profile on each service user’s needs and risks and shows the staff member where to find more information, for example, in the service user’s support file. At the end of the new staff member’s six month probationary period a training session is provided called ‘The Way We Work’ which is a recap and validation of the induction and involves the service users. This induction system is commendable. The preinspection questionnaire showed that all staff having been provided with all mandatory training and discussion with staff supported this. Additional specialist training provided and planned included SCIP (working safely with people with challenging behaviour), dementia awareness, loss and bereavement, autism and ‘Understanding Learning Disabilities’. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 20 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 excellent. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a very well run home and an effective quality assurance system. Their health and safety was being fully promoted and protected. EVIDENCE: It was evident that the Manager was very competent and experienced to run the Home. She had worked for 14 years with adults with learning disabilities and a further 18 years with older people. She had the required qualifications and was clearly committed to developing her skills and knowledge. Additional training that she had undertaken included effective team management, managing for effective performance, strategic thinking, conflict resolution and managing resources. There was clear evidence of an “excellent management approach” at the previous inspection and this conclusion was supported at this inspection. The Manager stated that, “The core of my job is to make their (service users’) lives Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 21 more enjoyable and easier”. Standard 38 was not fully assessed at this inspection. Service users were encouraged to give feedback at any time and offer ideas as to the way that the Home could be improved. Service users, staff and visitors were encouraged to complete written feedback sheets as to their findings during their visit. These feedback sheets were examined and there were many positive comments. There were good self-monitoring systems in place including audits undertaken by the Manager and the Area Manager. Audits were undertaken around finances, medication, repairs, staffing and accidents. However, there were no records of monthly visits to the Home, on behalf of the Registered Provider, between March and August 2006 - although these visits had been made, the Manager said. Records that were seen provided no evidence that service users or staff were being interviewed, as required by The Care Homes Regulations 2001. A helpful Shift Planner was completed each day to remind staff of the duties they were to undertake including checks, supporting service users, reminders concerning records and domestic tasks to be undertaken when service users were in bed. The Manager has set up a group called Spire Voice. This group had members from this Home as well as other services run by United Response. The aim of the group was to encourage service users to offer ideas as to how the services should be run and think of ways to raise money in order to help the service. Two service users from the Home attended this group and one was the chairperson. The Manager explained that although staff support service users within this group there are encouraged to run the group on their own as much as they are able and to make their own decisions. This work is commendable. The Manager confirmed, in the pre-inspection questionnaire, that equipment was being maintained, and Health and Safety checks made, at required intervals. Well documented environmental risk assessments were in place. Cleaning materials were being stored securely in a kitchen cupboard along with safety information required by the Control Of Substances Hazardous to Health (COSHH) Regulations. Good food hygiene practices were being followed in the kitchen. Flashing lights, linked to the fire alarm system, had been provided in three bedrooms where service users with a hearing impairment were accommodated, and in all communal areas. Monthly fire drills were being held, with full evacuation. Two of these, each year, were being held during hours of darkness – the time when service users were most vulnerable. A First Aid box was in a kitchen cupboard with a sign on the cupboard front indicating its position, for easy staff access. During this inspection it was clear that the Manager was taking a very pro-active approach to service users’ health and safety. This is most commendable. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 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 4 3 3 X 3 X 3 X X 4 X Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 23 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 requirements were made at this inspection. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA19 YA22 YA24 YA32 YA39 Good Practice Recommendations A policy concerning continence promotion should be written. A written complaints procedure should be displayed for visitors to the Home. The floor covering should be replaced in the ‘blue’ bathroom. 50 of staff should achieve a National Vocational Qualification (NVQ) to level 2. Records of monthly visits to the Home, on behalf of the Registered Provider, should be maintained at the Home at all times. These records should indicate that service users and staff are being interviewed. Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Station Road (33) DS0000020099.V315820.R01.S.doc Version 5.2 Page 25 - 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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