Inspection on 26/09/06 for 34 Ceely Road

This inspection was carried out on 26th September 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

34 Ceely Road 15/12/08

34 Ceely Road 18/03/08

34 Ceely Road 06/12/05

34 Ceely Road 27/06/05

34 Ceely Road 04/05/04

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

CARE HOME ADULTS 18-65 Ceely Road (34) Aylesbury Bucks HP21 8JA Lead Inspector Sue Smith Unannounced Inspection 5th September 2006 09:30 DS0000023048.V303877.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 DS0000023048.V303877.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. DS0000023048.V303877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ceely Road (34) Address Aylesbury Bucks HP21 8JA 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) 01296 485756 www.macintyrecharity.org MacIntyre Care Mrs Penny Cummings Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000023048.V303877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: 34 Ceely Road is a large, two storey, detached modern house located within a residential area of the market town of Aylesbury and is close to Stoke Mandeville Hospital. It is home to six younger adults with learning disabilities. The home has six single bedrooms on the upper floor and has a secure maintained garden which is accessible to all service users. The home is situated close to Aylesbury and local amenities that include shops, cinema, pubs and restaurants. Public transport is available and accessible to service users living in the home. The fees charged are presently £4,304 and £4,363 per month. Information pertaining to the current fees was received from the Home on the 28th July 2006. Additional costs exist for such things as personal activities including holidays, hairdressing, clothes and personal toiletries. Information to support potential Service Users and their families to make a decision for admission to the home is provided in the homes Statement of Purpose and the Service Users Guide, which are provided to potential Service Users, with additional copies held in the home. DS0000023048.V303877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 26TH September 2006 over 8 hours. The Acting Manager was available throughout the inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information such as the previous report and the pre-inspection questionnaire was used in the planning process to ensure hypotheses were formulated to support the inspector to explore issues of concern and verify practice and service provision. In addition feedback surveys received, which included the views of Service Users, Families and Staff, were used in the planning process. During the inspection a variety of documentation was assessed, which included Careplans, Risk Assessments, Pre-Admission Assessments, Menus, Rota’s, Training records and Recruitment records. A full environmental tour took place, with no issues of concern raised. The Inspector identified three Service Users for Case tracking, observing these Service Users and their interactions with others including staff at the home, and assessing the available information held in the home relating to the care provision, checking this against observed practice and feedback from families and relevant professionals. In addition the Inspector spent the morning and early evening with the Service Users and Staff joining them for their lunchtime meal and evening supper. Feedback received prior to the inspection provided evidence that Service Users and family members are happy with the care and support offered by the staff, they were complimentary of the friendly, sensitive and respectful approach of the team. The Inspectors observed positive practice throughout the day, finding Ceelys Road to be a relaxed and pleasant home with an emphasis placed on providing a person centred approach to implementing care and support. The inspector would like to thank the Service Users and Staff for their hospitality and their support in completing this inspection. DS0000023048.V303877.R01.S.doc Version 5.2 Page 6 What the service does well: The home ensures a thorough pre-admission procedure is in place, which is reflective of consultation with the Service Users and significant others before an admission is approved. The home has individual plans of care that are reflective of the preferences of Service Users. All Service Users are supported to maintain their levels of independence making decisions that affect their lives with Staff support. Individual Risk Assessments are in place, which support Service Users to maintain their levels of independence safely. Service Users are supported to maintain their independence and access a variety of social facilities within the Community. Service Users are supported to maintain links with families and friends. Daily activities promote independence and choice, with support offered to Service Users to maintain their home. Menus are formulated in consultation wit the Service Users, with additional dietary support available. Staff ensure Service Users health care support needs are met thorough a referral system using the G.P. service, additional support from other professional therapists is available. Knowledgeable and skilled key workers maintain this system. The Privacy and dignity of Service Users is maintained when delivering personal healthcare, ensuring the individual preferences of the Service Users are reflected. Staff ensure all care is implemented in a sensitive and professional manner. Robust Medication systems are in place, which support staff to deliver a safe administration system, which protects Service Users. The home has a complaints procedure in place which supports Service Users and significant others to make complaints appropriately. The home has systems in place with supporting policies, which protect Service Users from abuse. The environment is well maintained providing a homely and relaxed environment for Service Users to enjoy. DS0000023048.V303877.R01.S.doc Version 5.2 Page 7 The home is staffed by suitable numbers of skilled and experienced staff who undertake regular training to support their professional development and meet the needs of Service Users. Recruitment systems in place protect Service Users, ensuring all security checks are completed before start dates are given. The home is managed by a suitably skilled and experienced management team who ensures the home is run in the best interest of the Service Users. Health and Safety systems are in place, which ensure the protection of Service Users and Staff at the home. What has improved since the last inspection? With the recent changes in the Senior Management structure within the Organisation the Management team at the home have more responsibility for the day-to-day operation of the home. This has been a positive step for the home with the Management team providing the Organisation with monitoring reports on a monthly basis on the progress of the home. In addition more responsibility for the maintenance of Service Users records has been given to the homes management team, ensuring records were available for inspection. Improvements in the systems in place for maintaining Service Users finances have been implemented in the past 12 months, providing a clear audit trail for all transactions. The home continues to be maintained to a high standard of decoration and décor, providing a homely and pleasant environment for Service Users to enjoy. Behaviour management plans have been put in place for those Service Users who have behaviours that challenge them in the environment; this provides a consistent and positive approach to supporting Service Users experiencing difficulties. DS0000023048.V303877.R01.S.doc Version 5.2 Page 8 The home have begun to plan for the development of person centred plans for Service Users, they are currently exploring the most beneficial way to develop these plans in a medium understood by the Service Users. 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. DS0000023048.V303877.R01.S.doc Version 5.2 Page 9 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 DS0000023048.V303877.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The Organisation operates a thorough admissions procedure, which ensures the home is able to meet the holistic needs of a new Service User. EVIDENCE: The Organisation has an admissions policy in place; this is reflective of consultation with the Service User, Families and all relevant Professionals. The home ensures all admissions are based on a thorough assessment process, which includes trial visits and consultation with the present Service User group to ensure compatibility. There are no restrictions placed on admissions based on cultural, religious or the Organisations personal preferences, with the home ensuring the equality and diversity of any individual is addressed through the assessment process. There have been no admissions to the home in the past three years. DS0000023048.V303877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. All Service Users have an individual plan of care in place, which supports them in a manner that addresses their holistic needs whilst living at the home. Service Users are supported to maintain control over their lives with risk assessments in place, which support them to maintain their levels of independence safely. EVIDENCE: All Service Users have an individual plan of Care, which highlights their needs based on assessment. Within these plans are individual support plans, which are in line with the needs and personal preferences of Service Users. The home are currently redeveloping these plans to a more Person Centred Plan, with the Service User copy prepared in a medium which they prefer, currently the home are exploring the use of a touch pad computer programme for one Service User. The home believes it will be able to complete planning and development of this system within 12 months. It is recommended emphasis be placed on the proposed development of person centred plans to further support Service Users. DS0000023048.V303877.R01.S.doc Version 5.2 Page 12 Individual risk assessments are in place to support Service Users to maintain their levels of independence in the home safely. These were all found to be up-to-date. Staff have worked hard to develop Behaviour Support Plans for those Service Users who have behaviours that challenge them in the environment, these have been well written with clear information provided to assist staff to support the Service User in a positive manner. Minor areas for improvement were discussed which will be left in the capable hands of the staff to implement. In addition to the Careplans each Service User has a Health Passport, which contains relevant information that can be taken with them to hospital or appointments, these are an excellent information tool that provides other professionals clear guidance on the needs of the Service User as well as necessary medical information. Throughout the inspection practice and interactions with Service Users was observed, staff have a clear understanding of the needs of the Service Users, how to communicate effectively and are knowledgeable of the challenges some of the Service Users have. Staff are respectful of the Service Users individuality and support them in a manner preferred by the individual. Interactions throughout the day were inclusive ensuring Service Users were able to make choices in their daily activities and the day-to-day running of the home. DS0000023048.V303877.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 at least once during a 12 month period. 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 the service. The Service Users take part in meaningful and enjoyable activities, which support their independence and personal lifestyles. Family and friends are welcomed at the home, which supports Service Users to maintain their personal relationships. Service Users are supported to express their opinions and their rights are protected through effective communication systems. Meals are effectively planned by consulting with Service Users, ensuring all menus are nutritiously balanced taking into consideration the likes and dislikes of the Service Users. EVIDENCE: The Service Users at Ceeleys Road have a full and enjoyable lifestyle, which is supported by a knowledgeable and professional staff team. The day-to-day DS0000023048.V303877.R01.S.doc Version 5.2 Page 14 routines for Service Users are planned with Service Users attending Day Centre most days with a home day to support them to clean their bedrooms and undertake such things as personal shopping, attend appointments and support staff in maintaining the home. In addition a range of activities are planned for Service Users to enjoy based on their personal and group hobbies or interests, ensuring the diverse needs of Service Users is catered for, these include such things as swimming, trips to the cinema, the park, picnics, bowling, Gateway Club, Scouts, Slimming Club, Reflexology and Massage. There is room in the programme for flexibility, ensuring Service Users are able to access the local community. Service Users are supported to access new activities with leaflets and information sheets in the home on coming events and places of interest for Service Users to look at, any interest shown in an activity or event is then planned for the individual or group to attend. On the day of inspection Service Users were engaged in a variety of activities such as supporting staff to do the weekly shopping, cleaning the home and receiving personal support, other Service Users were out of the home attending their day centres, returning to the home in the afternoon happy and relaxed. Positive interacts were observed throughout the inspection between Staff and Service Users. Links with family and friends is encouraged with all visitors welcomed at the home. Service Users are supported to make choices as to whom they see and are able to receive visitors in privacy with staff support where necessary. Service User (resident) meetings regularly take place, this is done in a manner that promotes Service Users to express their views in their own method of communication, staff take the opportunity to up-date Service Users on coming events and changes that may have an affect on Service Users. These meetings are all documented and are held in a relaxed and inclusive manner. The home have a staff member with previous experience in the catering industry who supports Service Users to plan menus which take into consideration their likes and dislikes as well as ensuring a nutritious and varied menu is provided. Meals are planned weekly and are of a high standard. All meals are taken together in a pleasantly decorated and relaxing dining area, this is a time for the Service Users and Staff to meet as a group and enjoy each other’s company. Meal times are well organised with the individual needs of Service Users acknowledged, with softer options provided for those with difficulty swallowing. Service Users who find this time of day stressful are supported to leave the table if they desire with their meal provided at a time that more suits their needs. DS0000023048.V303877.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 at least once during a 12 month period. 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 the service. All care is implemented in a supportive and sensitive manner ensuring flexibility in times to suit the personal preferences of Service Users. A range of healthcare professionals are in place to support the ongoing and changing needs of Service Users which is supported by the homes key worker system to identify any issues of concern thus protecting Service Users. Robust medication procedures are in place, which ensure the protection of Service Users. EVIDENCE: All Support is offered to Service Users in a manner that is in line with their personal preferences. Each Service User has a key worker who ensures staff are made aware of the ongoing and changing needs of the Service User. This includes support to attend medical and healthcare appointments. As previously mentioned in this report the staff team are knowledgeable of the needs of the Service Users which supports them to observe and assess for any changes in their wellbeing, ensuring any changed needs are reported to the management of the home so additional support can be arranged. DS0000023048.V303877.R01.S.doc Version 5.2 Page 16 Throughout the inspection there was evidence of positive practice when observing staff supporting Service Users, flexibility in routines was evident, with one Service User signing her desire for a bath after the evening meal, staff were quick to support her in meeting this request whilst ensuring the needs of other Service Users continued to be met. Interactions between Service Users and Staff were respectful with Staff ensuring the privacy and dignity of Service Users was maintained at all times. This included giving additional support to Service Users who have behaviours that may challenge them in the environment, all actions taken to minimise the effect of these challenges was implemented in a caring and sensitive manner with staff consistent in their approach to providing a supportive environment for Service Users. All Service Users are registered with a local G.P. service who ensures regular reviews of medication is undertaken as well as overseeing the general healthcare needs of the Service Users, this includes visiting the Service Users at the home if necessary. Access to the Learning Disability Special Medical Services at Manor House is provided which includes the Dentist, Psychologist and the Learning Disability Consultant. The home also accesses the service of a visiting Optician and are able to ask the health visitor to come to the home. The home operates robust medication systems with necessary information provided to Staff to maintain the systems in place. Guidance for safe administration of medications is in place; a list of persons trained to administer medication was in the medication file. A procedure is provided to support staff in the event of errors. All MAR (medication administration records) sheets were maintained to a high standard with no gaps in signatures evident. All liquid, creams and tubes are stored appropriately with the opening dates recorded. There is an ordering and disposal-tracking system in place, which is audited monthly to ensure the stock amount, is accurate against the records. Training for staff in the safe administration of medication was undertaken in June 2006 and a managing medication risk assessment is in place. All medication was found to be appropriately stored with no out of date or excessive stock held in the home. In addition to the Organisations policies and procedures the Pharmacy provider (on a regular basis) also audits the medication procedures at the home. DS0000023048.V303877.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 at least once during a 12 month period. 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 the service. The home has a comprehensive complaints procedure which supports Service Users and significant others to make a complaint appropriately. The home ensures the protection of its Service Users through regularly updated Protection of Vulnerable Adult training, which supports the safety of Service Users against abuse. EVIDENCE: The home has a copy of the Organisations complaints procedure which is accessible to staff and Service Users. Formal complaints are documented and reported to the Area Manager, any information of a sensitive manner is filed in a lockable facility. A complaints book is provided at the home, which can also be used to document any concerns, however this is in a loose-leaf book, which the pages can be torn from. The inspector recommends a complaints file is set up so all information can be stored with the original complaint, any complaints in relation to staff will need to continue to be maintained securely in the personal files. One complaint was received in the past twelve months, which was fully investigated by the Organisation. All staff have attended Vulnerable Adult training with ongoing abuse training provided by the Organisation. Staff understand the need to report any alleged abuse to the management and know who to go to should an allegation be made in relation to a Manager. The homes systems are in line with the Buckinghamshire Inter Agency Policy on the Protection of Vulnerable Adults and its reporting systems. DS0000023048.V303877.R01.S.doc Version 5.2 Page 18 In response to historical issues, the home has implemented a new system to protect the personal finances of Service Users from abuse; this is discussed in the management standards of this report. A recommendation is made for this to be further developed to include double signatures on all balance sheets to further protect Service Users and staff. DS0000023048.V303877.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 at least once during a 12 month period. 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 the service. Ceeleys House provides a safe, pleasant and homely environment for Service Users to enjoy. EVIDENCE: Ceeleys House is a two-storey house situated in a residential street, the home is decorated to a high standard providing a homely and relaxed environment for Service Users. Adequate communal space is provided with comfy furnishings, fittings. The Organisation has ensured the home is maintained to a high standard with a rolling programme of decoration in place. Staff work with Service Users when planning the colour schemes for the home ensuring they are consulted in any changes to the environment. All Service Users have single bedrooms, which contain their personal possessions. The quality of furnishings and decoration is of a high standard providing Service Users with pleasant and private facilities. DS0000023048.V303877.R01.S.doc Version 5.2 Page 20 The Care team with the support of Service Users undertakes all cleaning at the home, the home was found to be cleaned to a high standard on the day of inspection with no offensive odours. The home were awaiting repair to the oven on the day of inspection which had been booked, changes to menus had taken place to ensure this did not have an impact on Service Users. There were no outstanding maintenance issues for the home. DS0000023048.V303877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home has a thorough recruitment procedure, which is reflective of good practice, thus protecting Service Users. All staff receive ongoing training, which supports their professional development and ensures the needs of Service Users are met by a knowledgeable and professional staff team. EVIDENCE: The home has recently recruited two relief staff that are presently awaiting security clearance before they will commence duties. There are no other actual vacancies at the home, however as the Manager is presently on Maternity Leave her thirty-nine hours are covered by permanent and relief staff, the home only uses one agency worker who is familiar with the needs of the Service Users and has received an induction for the home. The use of Agency staff is minimal with the home preferring to cover shifts with their own relief or permanent staff. Copies of all recruitment files are held in the home on completion of all relevant checks, there were no files to check during this inspection as the Organisation are awaiting the return of CRB’s and references for the new recruits before they are transferred to the home. DS0000023048.V303877.R01.S.doc Version 5.2 Page 22 All staff receive mandatory training and up-dates where needed, there has been a push on training at the home in the past twelve months which has supported the professional development of staff. Two staff are currently working towards their NVQ 3 with five others already completing this qualification. In addition to the mandatory training staff have also received training courses for Observation and Recording, Medication Awareness Health and Safety, Personal Relationships and Sexuality and Epilepsy. Mandatory training is programmed for up-dates. DS0000023048.V303877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home is managed by a suitably skilled management team who ensure the needs of the Service Users are met at all times by a knowledgeable and supportive staff team. Improvement in the residents monies system has been implemented, which protect the personal finances of Service Users whilst residing at the home. The home ensures the health, safety and welfare of Service Users is protected through robust systems, which are maintained to a high standard. EVIDENCE: The Registered Manager is currently on Maternity Leave with the Deputy Manager in charge of the home at this time. There are no issues of concern with the management of the home with both the Manager and the Deputy working well as a team. Emphasis is placed on the management and staff working together to provide the best possible outcomes for Service Users. The DS0000023048.V303877.R01.S.doc Version 5.2 Page 24 management style at the home provides the necessary support to staff to ensure they are able to raise any concerns in a professional manner with additional support offered where needed. Service Users benefit from the philosophy and management style at the home with an inclusive and progressive culture evident. Due to necessary restructuring at a senior level of management, the management and staff of the home have required additional support to get them over this somewhat difficult period, the Acting Manager reports a supportive Senior Manager who has been helping them to develop the home and provide additional support to the management team. Changes in the systems now maintained by management and staff at the home have taken place (due to the restructuring) ensuring a more open and transparent practice is in place. Not all of these systems were assessed during this inspection due to the absence at this time of the Manager. The Acting Manager is presently supported by a Senior Manager to maintain quality audit records. Regular Regulation 37 notifications are received for all reportable instances affecting Service Users and monthly Regulation 27 monitoring visits have been taking place. This area of the standards will be assessed once the Registered Manager has returned to duties. An improvement has been made to how Service Users monies are maintained with a more comprehensive system implemented which is open to audit. Only senior members of staff are able to access monies held on behalf of Service Users with the balance sheets routinely checked twice a week. Receipts are held for all transactions, with end of month returns then sent to Head Office for monitoring. Monies held were checked for all Service Users during this inspection against the balance sheets. It is recommended the home adopt a double signature system on the balance sheets to further protect both Service Users and Staff. The home has a designated staff member who oversees all of the health and safety monitoring systems, excellent records are maintained which support staff to ensure all necessary checks are undertaken. Information to support staff to adhere to health and safety legislation and guidance is available at the home. Health and Safety monitoring undertaken is signed off by the Manager and then sent to the Organisation for monitoring. The last Fire Authority inspection took place in August 2006 with no outstanding requirements. The last fire drill took place in February 2006. The home ensures weekly checks of alarms and fire points takes place with records maintained. Up-to-date fire certificates for equipment are in place. There were no outstanding health and safety issues at the home with all records maintained to a high standard. All items of C.O.S.H.H. were found to DS0000023048.V303877.R01.S.doc Version 5.2 Page 25 be locked away securely when not in use and generic risk assessments are in place to further protect Service Users and Staff. DS0000023048.V303877.R01.S.doc Version 5.2 Page 26 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 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X 3 X DS0000023048.V303877.R01.S.doc Version 5.2 Page 27 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. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended emphasis be placed on completing the proposed development of person centred plans to further support Service Users. A recommendation is made for the Service Users personal fiancé system to be further developed to include double signatures on all balance sheets to further protect Service Users and staff. 2 YA23 DS0000023048.V303877.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000023048.V303877.R01.S.doc Version 5.2 Page 29 - 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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