Inspection on 06/06/06 for 36 Martin Close

This inspection was carried out on 6th June 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

36 Martin Close 16/08/07

36 Martin Close 12/12/05

36 Martin Close 11/07/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 36 Martin Close Oakridge Basingstoke Hampshire RG21 5JZ Lead Inspector Isolina Reilly Unannounced Inspection 6th June 2006 09:30 36 Martin Close DS0000064998.V297234.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 36 Martin Close DS0000064998.V297234.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. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 36 Martin Close Address Oakridge Basingstoke Hampshire RG21 5JZ 01256 327894 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.c-i-c.co.uk. Community Integrated Care Mrs Tracey Janet Caulkett-Shelley Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: 36, Martin Close is a semi-detached house set in a housing estate within Basingstoke. It is in easy reach of the local shops and a bus ride away from the local college and main town centre. Community Integrated Care (CIC) is the registered provider and Mrs Tracey Caulkett-Shelley is the registered manager. However, Hamsphire County Council owns the building and landlords for this service. The home is registered to provide care and accommodation for five service users with learning disabilities. The home comprises of five single bedrooms, a sitting room, dining room, kitchen and laundry facilities. The garden provides additional recreational space. Staff at 36, Martin Close encourage service users to retain their own privacy and endeavour to support them in reaching their own personal goals. The manager states in the pre-inspection questionnaire she completed on the 24th April 2006, fees vary between individuals average £636.44 a week and there are no additional charges. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over one day. The inspector looked around the home, viewed records and procedures, spoke with all the service users, a visiting relative and friend, two staff and observed the interaction between them. The manager helped the inspector during the visit and one resident took the inspector round the tour of the home. Information has also been taken from the pre-visit questionnaire filled in by the manager, correspondence with the home and monthly reports on how the service is doing, sent in by the area manager. What the service does well: The service users all stated that they liked their home and felt the staff were friends and are there to help them when they need it. The home is good at assessing if it can meet the needs of service users before they come to the home and makes good records. This includes medical and personal care needs. Everyone spoken with confirmed that staff are caring, respectful. They encourage independence and are mindful of peoples need for privacy and dignity. The staff support individuals to make decisions about their lives and service users are fully involved in planning their lives and care. There is an excellent attitude towards service users personal development expressing their own opinions and participating in activities as well as accessing the local community. The service users take the lead with support from staff in menu planning, reparation and cooking of meals. The home has an open and good process in place for dealing with complaints, concerns and compliments. The staff team at the home is skilled and receive regular training to be able to care for the residents. The home has a logical and detailed process for recruiting new staff. There are good systems in place for making sure that the service is run in a safe manor for residents. The residents stated they all feel safe and comfortable at the home and their opinions are sought by the home. The organisation has a good system in place for monitoring the quality of the service being delivered at the home. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 36 Martin Close DS0000064998.V297234.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 36 Martin Close DS0000064998.V297234.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 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 this service. The home has a good admission process that is well managed and prospective service users’ individual aspirations and needs are assessed. EVIDENCE: The service users spoken with said that they had been made welcome when they first came to live at the home and they were able to look around an visit various times including stopping for a meal. One service user said they were anxious about moving into the home but soon made friends and is now very happy. The relative spoken with also confirmed this and felt they are fully involved in the support their loved one is receiving. The inspector tracked four out of the five service users’ records and each file contained a detailed assessment. The records showed individual aspirations, educational, training and work needs, potential restrictions, choice, freedom, information on family and friends, their cultural and faith needs, physical and mental health care, treatments and methods of communication. Written assessments and relevant risk assessments on files were relevant and reflected care needs assessments completed by Adult Service’s care managers. 36 Martin Close DS0000064998.V297234.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place that fully involves service users in decision-making, taking reasonable risks, assessing changing needs and meeting personal goals. EVIDENCE: The service users had a good knowledge of their goals and care plans held within the home. Three out of the five service users talked to the inspector about their personal centre plans, aspiration and goals for the future. This was reflected in the records seen. Person centred plans were presented in a way that was easy for the individuals to understanding using visual representations, pictures and colour. The relative spoken with confirmed that they were fully involved in planning support for their loved one and felt the home was doing an excellent job in helping the service user to have a fulfilling life. They also stated that the social and recreational time with their loved one was incorporated and part of the whole plan. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 10 Three personal plans were seen in the individuals’ bedrooms. The plans seen give information on assessed and changing needs and personal goals. There were separate personal and health care plans completed on the organisation’s forms that could be in an easier format for the service users to read. However, the service users were very clear about the agreements and support they would receive. Records seen are regularly reviewed and updated as necessary with the service users who sign their plans. Service users formal reviews were seen on the files that involve the service user; Adult Services care manager, health professionals, family or advocate. The individual care plans and centred planning records see reflect outcomes, activities and instruction specified on the care management reviews. The staff spoken with stated they assist service users to update their care plans are have a good knowledge of the individuals’ needs and aspirations. One staff member said that the home was very flexible and providing an appropriate risk assessment and actions had been undertaken, recorded and followed the service users are able to follow their wishes. Risk assessment seen were informative and contained clear instruction to staff. They covered all aspects of support and personal care provided both in and outside the home. 36 Martin Close DS0000064998.V297234.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service is excellent at providing support for individuals to take part in age appropriate, peer and cultural activities with the local community. They encourage appropriate personal, family and other relationships whilst respecting and empowering individuals rights and dignity. The service users enjoy varied balanced meals in a relaxed atmosphere. EVIDENCE: On the day of the visit, the inspector observed that four of the service users were eagerly waiting their ‘horseology’ session. Three of the service users explained that horseology meant they were able to help with the horse and also ride them. They were debating the various characters of the different horses that they regularly ride. This is an activity that they greatly enjoy. The fifth service user express an interest in going to watch and this quickly arranged. The staff spoken with explained that individuals are encouraged to try new things. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 12 The daily records and care plans showed that all service users were involved in many suitable activities and were part of the local community. Three service users discussed their holiday plans with the inspector with one looking forward to going on a Butlins Holiday place and another going to the Isle of Wight. The one service user explained that in the past some of the children on the estate had been unkind and rude. The manager and staff confirmed this. The home had taken appropriate action and is an active member of the neighbourhood watch scheme. The service user spoken with was proud of their role within this scheme. The home also has very good relationships with the local police. The manager, staff and service users confirmed that the local police have been in for informal chats about what is acceptable behaviour and personal safety. Information on these relationships and community activities were seen in the home. There was a number of local community leaflet covering local events, outings and interests. One service user’s friend visited the home and spoke with the inspector. This person was very complimentary of the home and the service provided. He felt that this was a good service and often participated in the activities. The inspector observed one service user going out to get some money from their account to pay for the horse ride session that day and another go to the local shop for a bottle of water to take with them. Throughout the day the inspector observed staff and service users interacting respectfully with each other and staff encouraging in an appropriate way. Staff and the manager were seen encouraging one service user to voice their opinion and choice on clothes they were warring and how they felt. The service users confirmed that they helped with the cleaning and they all had tasks to do on certain days. These tasks were recording in their files. All the service users had a turn at cooking for the others and three of them described what they were cooking on their night. They all enjoyed the occasional eating out at the pub and takeaway meals. It was observed that service users are relaxed when preparing and eating meals. Service users were seen helping themselves to snacks including fresh fruit, hot and cold drinks. One of the service users is a vegetarian and meat is stored in a separate fridge to the vegetables and other food. Another service user is a practicing Muslim and all their meat is Halo and stored separately from all other meats, there is also a separate cupboard for other food to be stored in. A third service user is trying to loose a little weight and has agreed with the staff to reduce their calorie intake. The service users and staff explained that they have special meals when they try other culture’s foods. Everyone said this has been successful. Copies of a months menu’s for April 2006 were sent with the pre-inspection information and found to be variable balanced and many examples of individuals’ choices. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 13 Similar menus were seen at the home. There were various health and safety procedures in place within the kitchen including colour co-ordinated chopping boards, cleaning rota, pro-biotic wipes for surfaces, gloves, temperature recording including probing of food, fridges and freezers. The manager confirmed Environmental Health Officer had visited in September 2005 and the report seen stated that the service was assessed as being good. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ health and personal care needs are being met ensuring are support is given in the way they prefer. The home medication practices, policies and procedures supports and protects service users. EVIDENCE: The service users spoken with confirmed that the staff are supportive prompting them with their personal care in respectful and dignified way. The relative spoken with confirmed this. One service user stated they were able to look after themselves but staff reminded them when it was bath time in a discreet way. One service user is very private and staff were observed asking permission to enter their room. The inspector observed staff prompting a service user regarding their choice of clothing for going out. Following the discreet discussion the service user listened to and their wishes respected by the staff. All the service users spoken with stated that their lives and daily routines were flexible and they were fully involved in planning their activities and daily 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 15 routine. The inspector observe that the lunch time meal had been delayed due to the planned visit to the horse riding school. On the tour of the home the service users showed the inspector around their rooms were there was evidence of personal effects including make up and other toiletries, which they had chosen for themselves. Three of the service users stated they enjoyed going shopping especially when buying their own new clothes. Staff and family support one service user to following their cultural and religious believes. They attend the local religious temple and social functions. Another service user stated that they enjoyed the occasional visit to their local church. The other service users stated they had chosen not to attend church. This information was available in the records seen. Staff spoken with were aware of individuals’ preferences. Three service users stated that they could visit their doctor when they needed to and that they can go in on their own without staff, although one service user stated they preferred to have a member of staff come with them. This was documented in the care plans seen. Three of the service users confirmed that they visit the dentist, opticians and chiropodist regularly. Medical correspondence, records of outpatient appointments and health care checks were seen in the files. The manager and staff confirmed that one older service users has had increasing health care needs and the doctors had been supportive. The individual has had modification to their room and additional handrails fitted around the home following an occupational therapist assessment. However, the manager stated that they are still waiting for the landlords Hampshire County Council to fit a fully accessible shower. This has been outstanding since the last inspection. The manager shared with the inspector correspondence regarding this delay that showed the home has been proactive in trying to have the shower fitted but the delay is out of their hands. Records seen in individuals’ files held risk assessments and instruction for staff on personal and health care support needed. The staff were observed administering medication appropriately and there is a satisfactory medication policy and procedures. The home uses a blister pack system form the local pharmacist. The medicines were correctly stored in an appropriate cupboard that was clean and reasonably orderly with medication stored correctly in date and in sufficient quantities. There were no control medicines at the home on this visit. All residents need assistance with their medication. The records for receipt, disposal and administration were seen and found to be satisfactory. However, the manager stated there were times when the pharmacist sometimes holds 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 16 onto the medication disposal record book and it can take several days to get it back. The home uses the ‘Medicine Administration Record Sheets (MARS) system for recording the administration of medication and medication received in the home. The carers spoken with stated they had received training in the safe handling of medicines and they regularly up date by completing a workbook and test. The manager confirmed that she regularly assessed the staff when administering medication. Staff training records seen that confirmed this. 36 Martin Close DS0000064998.V297234.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users, relatives and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues that protects residents from potential abuse. EVIDENCE: The service users, visiting friend and relative spoken with stated that they would go straight to the manager or a staff member if they had a concern or complaint. They confirmed that the staff are good and listen to their concerns and the inspectors observed this during the day. The service users and staff spoken with were aware of the home’s complaint procedure. The home’s complaint procedure includes the various stages; the address for the Commission and complaints will be dealt within 28 days. An easy to read complaint procedure was available on the service users’ notice board. The home has received one complaint since the last inspection that has been investigated by the home but remains unresolved as the complainants were not satisfied with the outcome but have not attended various meeting with CIC to find a resolution. All the service users and visiting friend spoken with stated that they felt safe at the home and the relative also confirmed this. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 18 Most of the staff spoken with confirmed that they have received instruction and are aware of the protection of vulnerable adults from abuse. The home has an up to date copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure and it’s own policy and procedures reflecting the guidelines from Hampshire County council’s own policy. There is a clear whistle blowing procedure and the manager has encouraged an open and fair ethos within the home. The staff spoken with confirmed this. 36 Martin Close DS0000064998.V297234.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a clean, homely, comfortable and suitable environment for the service users. The standard of the décor within the home is good with evidence of on-going maintenance. EVIDENCE: One service user showed the inspector around the home, explaining that they had been involved in choosing the colour schemes in their own bedroom and in the communal areas. Each service user showed the inspector around their individual rooms. Since the last inspection, the home has had ordered new blinds for the window, new carpets throughout and on the day of the visit a new hand made wooden dining table and chairs were delivered. The home has recently had new fridge, freezer, cooker, television and DVD player. The manager explained that as part of the agreement between the providers and landlords Hampshire County Council were replacing worn and outdated furniture and fittings. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 20 All the service users liked their bedrooms and the inspector observed that they had been personalised. One service user explained the at their father had helped them to set up their new bedroom furniture. Another service user explained that they were waiting for the new bedroom furniture that they had chosen. The garden surrounds the house but is in need of landscaping, there are various areas that are concreted. The service users and staff stated that they are waiting for the to be redesigned and landscaped. There are some high hedging around one side of the perimeter that is too high for staff to maintain and needs special professional equipment to trim. The manager confirmed that there is an expectation that part of the garden could be used to safely house the house car. All service users and staff spoken with felt there were enough toilets and bathrooms. However, the home has been waiting for one of the two bathrooms to be converted into a fully accessible shower. The manager explained that there has been a unexplained delay in this being fitted by the landlords. The inspector was shown correspondence from the home requesting the refurbishment and repeated reminder of the delay in the fitting. On the tour it was noted that the communal toilets had disposable hand towels and liquid soap. The home was found to be clean and tidy with no clutter or obstacles in corridors. The service users and staff confirmed that they all have cleaning tasks and rotas. The home has a supply of gloves and aprons that staff use when necessary. The staff confirmed that they have received training on infection control. The laundry room is accessed of the ground floor corridor and within easy access to the garden. There is a washing machine and tumble dryer. The service users spoken with stated that they do their own laundry with support from the staff. 36 Martin Close DS0000064998.V297234.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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported by competent and qualified staff that undertake regular training. There are satisfactory recruitment procedures that ensure service users are not put at risk. EVIDENCE: The service users confirmed that the staff treated them with respect and they felt comfortable with them. The inspector observed staff interacting with the service users making themselves available, listening and appeared interested in what the service users were doing and saying. It was noted from the June staff rotas that there are normally two staff in the morning, one during the evening and one sleeping staff at night. Risk assessments seen on service user files identify staffing level necessary to meet service users individual and collectively needs. The staff spoken with stated that they received regular training and had a good knowledge of each individual. There was a good understanding of one service user’s cultural and religious needs. The manager explained that the staff had undertaken research and expanded their knowledge on the different cultural. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 22 The manager explained that all new staff complete an organisation induction on starting work at the home that meets the Skills for Care Council minimum standards for induction. This induction last for up to six weeks and is recorded in a workbook that is signed by the manager and staff member. All the staff have completed the Learning Disability Awareness Framework (LDAF) induction and all but one had completed the LDAF foundation course. The staff currently employed at the home either hold or are in the process of obtaining a National Vocational; Qualification in care level 2. Staff files seen on this visit confirmed this. Two staff files were seen and these held the necessary documentation including two satisfactory written references, identification, criminal record bureau and protection of vulnerable adult list checks prior to starting work. The staff and manager confirmed that each staff member had their own copy of the General Social Care Council’s Code of Practice. Signed contracts of employment including terms and conditions were seen on the file. The staff explained to the inspector the various training and learning they had recently undertaken these included person centred planning, health and safety, infection control, food hygiene, equal opportunities and diversity, first aid enhanced communication skills, equal opportunities and diversity, moving and handling, induction and foundation, fire safety, principles of care and abuse. Certificates and the home’s staff training matrix were seen and confirmed this. The written information in the home’s pre-inspection questionnaire also confirmed this. It also details future training as NVQ3, dementia and on-going health and safety courses. 36 Martin Close DS0000064998.V297234.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): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from a well run home where their view are listened to and their health, safety and welfare are promoted and protected. The home has a satisfactory quality monitoring system for reviewing and developing the home’s performance. EVIDENCE: The manager has been post for over three years and has the necessary experience and skills to manage the home well. The service users, staff, relative and visiting friend all stated that the manager was approachable, fair and listened to their views and concerns. She has achieved a National Vocational Qualification (NVQ) registered manager’s award in December 2005. The manager confirmed that she regularly undertakes training to maintain and develop her own skills these courses include person centred planning, health and safety, infection control, food hygiene, leadership training, budget setting, 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 24 first aid enhanced communication skills, moving and handling facilitators course, principles of care and abuse. The home seeks the views of the service users on a regular basis and these are recorded in the individuals’ files. The inspector observed the manager seeking the opinion of the service users regarding the preferred colour for the new house car. Service user quality surveys are sent out by the organisation to assess quality of the service being provided. These are collated by the organisation and the manager confirmed that she is waiting for feedback from this year’s survey. The home also has a suggestion box by the front door that one service user pointed out to the inspector and the manager confirmed is used occasionally. The manager completes a monthly performance monitoring report for the organisation and she confirmed that policies and procedures are reviewed annually and amended as necessary. The area manager undertakes monthly monitoring meeting and generates a written report that meets the Care Homes regulations 2001, regulation 26 reports. The home has a Best Value file that includes all quality monitoring outcome and actions to be taken. The service users stated that hold ‘house meetings’ and notes are taken at these meetings. The minutes of the last residents’ meeting were in an easy to read format pinned to the service users’ notice board. Staff also confirmed that they attend regular meetings and they each take it in turn to take the minutes. These minutes were available in the office. One service user explained to the inspector that they produce a regular residents’ newsletter with the support of staff. Copies of the latest, colourful newsletter were seen in service users’ bedroom and on the notice board. The inspector was able to seen various up dated risk assessments for the environment, fire safety and activities. The service users, relative and visiting friend spoken with stated that they felt safe at the home and confirmed that the fire alarms are regularly tested. They participate in regular drills and evacuations. The inspector viewed the records for fires safety maintenance, evacuation and visual checks and found them to be satisfactory. The manager organises and undertakes ‘in house’ training on fire safety and records were seen showed that staff had received the necessary training and participated in drills. The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) with information leaflets for each chemical being utilised within the home and chemicals were securely stored. The home’s records for reporting injuries and incidents were appropriate. The incident records matched the Care Homes Regulation, regulation 37 reports. 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 36 Martin Close DS0000064998.V297234.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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