Inspection on 20/06/06 for 36 Station Road

This inspection was carried out on 20th 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 Station Road 27/02/06

36 Station Road 09/08/05

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 Station Road Petersfield Hampshire GU32 3ES Lead Inspector Isolina Reilly Unannounced Inspection 20th June 2006 08:30 36 Station Road DS0000064989.V297265.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 Station Road DS0000064989.V297265.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 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 36 Station Road Address Petersfield Hampshire GU32 3ES 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) 0151 420 3637 www.c-i-c.co.uk. Community Integrated Care Joseph Snowden To Be Confirmed Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3) of places 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: 36 Station Road is a small residential service providing care and support to three adults with a learning disability. Community Integrated Care (CIC) who took over the service on the 1st July 2005 from the previous provider. The building is owned by a housing association that is responsible for the maintenance of the property. Staff provide twenty four hours a day support for the service users. The home is located on a busy road and is indistinguishable from the other houses in the street. The home is close to the shops and public transport in the town of Petersfield. The manager states in the pre-inspection questionnaire he completed on the 10th May 2006, fees vary between individuals from £62.35 to £94.45 a week and there are additional charges for activities such as social outings, holidays hairdressing, chiropody, toiletries, magazines and confectionery. 36 Station Road DS0000064989.V297265.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, two staff, the area manager and observed the interaction between them. The manager helped the inspector during the visit. 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 to the commission by the area manager. What the service does well: The service users all stated that they liked their home, 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 and 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 a supportive attitude towards service users personal development, expressing their own opinions and participating in activities as well as accessing the local community. The service users with support from staff help to plan menus, and are involved in the preparation 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 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 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home is in the process of putting together person centred plans for each resident but needs to make them easier for the service users to understand. The manager has identified that staff would benefit from training in care planning. Despite this the service users benefit from a staff team that understand and provide good individualised support. The home is going to seek the advice from the local continence promotion nurse regarding specific needs of two service users. The managers confirmed that disposable hand towels would be made available at the communal hand-washing sink on the first floor. There was an error in administration of medication for one service user that the home dealt with promptly and correctly. But the manager had forgotten to send the commission information on this incident under the Care Homes Regulations 2001, regulation 37. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 7 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 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected 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 having meals and overnight stays. The staff spoken with confirmed this. The inspector tracked the three 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 seen and reflected care needs assessments completed by Adult Service’s care managers. Since the last inspection, service users’ contracts of residency and service user care plans have been put on audio tape and one service user has made use of them. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 10 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 improved its systems for involves service users in decisionmaking, taking reasonable risks, assessing changing needs and meeting personal goals. Records have also improved and are being further developed. EVIDENCE: The service users had knowledge of their goals and that care plans are held within the home. Two out of the three service users talked with the inspector about their support plans, aspiration and goals for the future. This was reflected in the records seen. Person centred plans are still in the process of being developed. One service user’s person centred plan was available on this visit. The plan has fully involved the service user and their key worker. However, the manager and key worker are looking at ways to make the record more service user friendly by using colour symbols, pictures and photographs. The other two person centred plans have yet to be started but the manager confirmed they were schedules to be completed by the end of July 2006. The 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 11 staff and manager confirmed that they involved family within the care planning and there was evidence within the multi-agency reviews that family were present for one service user. Three personal plans were seen and found to have improved since the last inspection to include clearer instructions to staff, appropriate risk assessments and agreed restriction for personal safety. The plans also had information on assessed and changing needs and personal goals. There were separate personal and health care plans completed on the organisation’s forms and the service users were aware of the agreements and support they would receive. Records seen are regularly reviewed and updated as necessary with the service users who sign their plans. It was noted that not all aspects of the care planning records were dated and signed. This was discussed with the manager who stated he would ensure this was done in the future. 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 record 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 and had a good knowledge of the individuals’ needs and aspirations. However, one staff member stated that it was difficult to gage how much information and how to record this in the home’s record systems. This was discussed with the manager who confirmed that the agency run care planning and person centred plan training and that staff would benefit from this. Risk assessment seen were present and contained clear instruction to staff. They covered all aspects of support and personal care provided both in and outside the home. An issue regarding one service user’s behaviour towards another has yet to be included in the risk assessments and care plans but information was available in the daily records. The staff and manager spoken with were all aware of the issue and one strategy is being followed although this was not recorded. This was discussed with the manager and area manager who agreed that a multi-agency assessment and agreed strategies would be in the service users involved best interest and written plans will be made. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. The service is good 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 the service users were out an about two attended day care and the third was being supported by the staff at the home and went out for a long walk. Two of the service users stated they enjoyed going shopping especially when buying their own new clothes. This service user’s key worker explained that the service user enjoys painting and colouring and there many examples of their work in the bedroom and in work books. The service user and their key worker also stated that the 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 13 individual enjoys walking and will go out for long walks supported by a staff member. The other service users stated that they enjoy going ten-pin bowling, to the cinema and theatre and to museums. They explained that they had had an enjoyable day out at Paulton’s Park and Elizabeth Country Park. The staff spoken with explained that individuals are encouraged to try new things. The daily records and care plans showed that all service users are involved in suitable activities and were part of the local community. However, some records do not completely reflect the level of activities the service users participate in. Throughout the day the inspector observed staff and service users interacting respectfully with each other and staff encouraging in an appropriate way. The staff spoken with explained that there was a little tension between two service users. The staff were aware of this and have tried to manage the situation but often the situation is resolved by one of the service users withdrawing into their room. This was discussed with the manager who agreed that it may appropriate to speak to social service to see if a multi-agency review of the situation and an agreed planned strategy be developed. 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. The service user present at lunchtime assisted the staff member with making the lunch. The two other service users stated that they also help around the home and with the cooking. They all said they enjoyed the occasional eating out and takeaway meals. On the tour of the home one service user showed the inspector around their room were there was evidence of personal effects. It was observed that the service user was relaxed when preparing and eating meals. Service users were seen helping themselves to snacks including fresh fruit, hot and cold drinks. Copies of menus were sent with the pre-inspection information and found to be variable balanced. The service users stated that they chose the meals and the staff help them put them together. 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, gloves, temperature recording including probing of food, fridges and freezers. 36 Station Road DS0000064989.V297265.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 helpful and will tell them when they need help in a way that is supportive and respectful. The inspector observed staff being respectful and prompting in a sensitive and dignified way. 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 routine. However, records do not necessarily reflect the good practices explained by the manager and the staff. The inspector observed this. Two service users stated they attend the local church and enjoy going to special services. This information was available in the records seen. Staff spoken with are aware of individuals’ preferences. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 15 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. 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 two service users have an increasing health care need regarding promoting continence. The manager stated he was trying to secure the services of the local continence promotion nurse and would discuss with the service users and their doctors. Records seen in individuals’ files held risk assessments and instruction for staff on personal and health care support needed. However, these records could be set out in a in more user friendly format. The staff were observed administering medication appropriately and there is a satisfactory medication policy and procedures. The home uses a blister pack system from 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 and disposal were seen and found to be satisfactory. However, there was one gap seen in the administration records for one service user. The manager explained that this had been an oversight and he would ensure that this did not reoccur. 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 he regularly assessed the staff when administering medication. Staff training records seen that confirmed this. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 16 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 and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a fair understanding of Adult Protection issues that protects residents from potential abuse. EVIDENCE: The service users spoken with stated that they would go 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 inspector observed staff dealing with one service user’s concern in a sensitive way. 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. The home has received no complaint since the last inspection. All the service users and staff spoken with stated that they felt safe at the home. Most of the staff spoken with confirmed that they have received instruction and are aware of the protection of vulnerable adults from abuse. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 17 The manager confirmed that the home copy of the Hampshire County Council (HCC) ‘Protection of Vulnerable Adults’ policy and procedure is at his home because he was working on it. This meant that the service did not have a copy available for reference. At the last inspection a requirement was issued for the home to have an up to date copy of HCC policy and procedure. The manager and staff were aware of their responsibilities regarding reporting allegations and keeping appropriate records. The manager downloaded a copy of the policy from the Internet so that a copy was available in the home. The home’s policy and procedures on protecting vulnerable adult and abuse reflect the Hampshire County council’s policy guidelines. 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 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 18 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. Since the last inspection, the kitchen and bathroom has recently been repainted. The first floor bathroom is due to be refurbished and the worn bath panel and flooring on the maintenance programme to be replaced. The kitchen cupboards are also due to be refurbished. All the service users liked their bedrooms and the inspector observed that they had been personalised. One service user room had been painted with a very bright yellow that the key worker stated the individual would like to change. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 19 The garden is small with a patio area and small lawn. The premises are situated in the middle of town with a tiny frontcourt yard and car parking at the back accessed by the side of the house. At the bottom of the garden there is an old stable block that service users and staff are looking to turn into a separate activities area. All service users and staff spoken with felt there were enough toilets and bathrooms. 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 part of the large kitchen diner and within easy access to the back door without going through the food preparation areas. There is a washing machine and tumble dryer. The service users spoken with stated that they do their own laundry with a lot of support from the staff. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 20 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: Since the last inspection, the home has met all seven requirements issued. 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 interested in what the service users were doing and saying. It was noted from the June staff rotas that there are normally one staff member on duty at any one time not including the manager who shares his time between two home. The staff normally work afternoon, do a sleeping night duty and the work the next morning. The risk assessments on nighttime support needs for each service user indicates that a sleeping member of staff is able to meet needs. There are extra staff hours on a Friday evening and 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 21 Saturday for additional one to one activities. Social Services contract with the home has cut the budget from 171.75 hours to 132.75 hours. The outcome for service users has been negligible as the home is routinely providing over the minimum hours. This is being funded by the organisation. The staff spoken with stated that they received regular training and had a good knowledge of each service user. 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. Some of the staff have completed the Learning Disability Awareness Framework (LDAF) induction and LDAF foundation course. Two out of the five staff hold a National Vocational Qualification (NVQ) level 3 in care. A further staff member is due to enrol on their NVQ level 3 in Care. This is means that the home has achieved over 50 of staff with a qualification in care. Staff files seen on this visit confirmed this. Two staff files of the newest staff recruited 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 food hygiene, first aid, moving and handling, assisting with mobility, principles of care, induction and foundation, health and safety, in house fire safety refresher instruction, crisis prevention intervention (CPI), Autism, bereavement, medication and abuse. Certificates and the home’s staff training matrix were seen confirming this. The written information in the home’s pre-inspection questionnaire also confirmed this. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 22 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, although record keeping could be improved. The home has a satisfactory quality monitoring system for reviewing and developing the home’s performance. EVIDENCE: The manager has the necessary experience and skills to manage the home and provide good outcomes for service users. Record keeping has improved since the last inspection but still needs further work. The service users and staff, all stated that the manager was approachable, fair and listened to their views and concerns. He has achieved a National Vocational Qualification (NVQ) in Care level 3 and is in the process of completing his NVQ registered manager’s award. The manager confirmed that he regularly undertakes training to 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 23 maintain and develop his own skills these courses include person centred planning, health and safety, infection control, food hygiene, leadership training, budget setting, first aid and abuse. The home informally seeks the views of the service users on a regular basis and these are recorded in the individuals’ files. Since the last inspection, service user, relatives or representative and health and social care professionals quality surveys have been completed and sent out by the organisation to assess quality of the service being provided. These are collated by the organisation and the manager shared the completed questionnaires with the inspector. These were found to be generally satisfactory and there was a sense of contentment with the service. A summary of the outcomes from the surveys was discussed with the manager that includes outcomes and actions taken by the home. The manager completes a monthly performance monitoring report for the organisation and he 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 manager and staff confirmed that staff meetings are held quarterly and minutes. These were available in the office. The home is currently not holding residents’ meeting but the manager feel this is something that he will reinstate. The inspector was able to see various up dated risk assessments for the environment, fire safety and activities. The service users and staff 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 service users and staff 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. However, one incident record held within the home included a medication error to which the home responded to and took appropriate action. However, it was noted that a Care Homes Regulation, regulation 37 reports was sent to the commission for this incident. This was discussed with the manager who stated that this had been an omission on his part and would ensure this did not happen again. The area manager stated this would be monitored by the organisation. 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 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 3 X X 3 X 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 25 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 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI 36 Station Road DS0000064989.V297265.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!