Inspection on 01/12/06 for 4 West Street

This inspection was carried out on 1st December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

4 West Street 01/06/07

4 West Street 22/12/05

4 West Street 18/05/05

4 West Street 29/09/04

4 West Street 03/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 4 West Street, Biddulph Staffordshire ST8 6HL Lead Inspector Key Unannounced Inspection 1 December 2006 11:30 4 West Street, DS0000029679.V317214.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 4 West Street, DS0000029679.V317214.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. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4 West Street, Address Biddulph Staffordshire ST8 6HL 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) 01782 514141 Choices Housing Association Limited Mrs Diane Deakin Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 4 West Street was registered in March 2002 to accommodate four younger adults with learning disabilities. It is a large detached bungalow, which has been extended to provide suitable accommodation, including 4 single bedrooms, a spacious bathroom and a walk in shower room. Communal space includes a large lounge and a kitchen/dining room. The service also provides a separate laundry and large storeroom housing the food freezer and other household items. Externally there are good-sized gardens and a patio area, all are accessible to service users. A large garage is used for storage purposes, the drive way provides parking space. The home is located in the village of Biddulph, within a short walk from the main shopping area, local pubs, church and other facilities. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection for 2006/2007 was conducted during the late morning and early an afternoon of Friday the first of December 2006. At the time of the inspection, the manager of another choices home in the vicinity was supervising the management of the home on two days of the week, as the person currently registered as care manager had resigned her position. The commission have been kept up-to-date with proceedings to investigate issues surrounding her resignation and allegations of grievance, and had received a letter from the chief executive of Choices detailing the steps being taken to ensure the management of the home until this issue can be resolved. At times during the inspection all four of the residents were in the home, but all continued to follow the program that had been arranged for the day, one going to a local college for a pottery class, others going down to the bank to draw out some money, and in the afternoon, to going to visit relatives in another Staffordshire town about 30 miles away. Sufficient staff was on duty to enable residents to be supported to undertake these activities, and to leave the home with a safe cover of carers to meet the needs of those at any time remaining within the home. Discussion took place with the supervising manager over the need for early resolve to the issue of leadership of the home, and a couple of environmental issues that were noticed during the inspection. These will be reflected in the requirements and recommendations at the end of this report, but them aside, the home appeared in good order with residents enthusiastically engaged in activities of daily living supported by knowledgeable and empathetic care staff. The current scale of charges is between £914 and £950 per week. What the service does well: This home continues to provide the most domestic style of accommodation possible for four persons with a learning disability. It does it within a neighbourhood community, with out in any way being stigmatised as a care institution. It supports residents to be as independent as is consistent with reality and safety, and documents show there to have been commitment towards enabling an individual with learning disability, rather than to disable them. 4 West Street, DS0000029679.V317214.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. The summary of this inspection report can be made available in other formats on request. 4 West Street, DS0000029679.V317214.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 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. The outcome from this group of residents in this area was good. This judgment was made using all available evidence including a visit to the service. The home’s Statement of Purpose and Service User Guide was good, providing service users and prospective service users with details of the services the home provides, thus enabling an informed decision about admission to be made. EVIDENCE: The acting care manager and deputy care manager of the home stated that the photographs and picture aids had not yet been inserted into the homes Statement of Purpose, but were able to display copies of the Service Users Guide that had been amended, and had been very thoughtfully tailored to the known needs of each individual resident. These had been introduced at a recent clients meeting, and had been very well received by the residents of the home. Examination of a sample care plan during the afternoon revealed that one of the residents who had been most recently and admitted had received a full assessment under the care management procedure, and that this had formed the basis for the care plans designed for her accommodation in the home. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 9 These plans and their attendant risk assessments had been reviewed on a regular basis, or when needed, and included contributions from the resident, significant others in the life of the resident, and health and social care professionals charged with the care of the resident. 4 West Street, DS0000029679.V317214.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. The quality outcome for this group of residents was good. This judgment was made using all the available evidence, including a visit to the service. This was based upon comprehensive personal care plans, and finding that residents had been assisted to make what decisions they were able to, and to take any risks that were appropriate. EVIDENCE: The care plans of one resident were examined in detail. This was taken as a sample, chosen at random, and verified by discussion with both senior members of staff, and the identified resident. There was an extensive range of risk assessments and subsequent detailed plans about how to meet this persons assessed needs and expressed choices, both in the fields of their health, and of their social care. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 11 There was a 22 point Person Centred Plan based on the British Institute for Learning Disability life experiences checklist and key values, together with a 24-hour personal support plan and an individual disability distress tool, that set a baseline for observations of when the subject presented observations or behaviours that would indicate that they were unwell or unhappy in some way. The plan was founded upon a multidisciplinary care management assessment made prior to the admission of the resident, and had been reviewed and amended both as and when necessary, and at appropriate minimum intervals. More detailed reference will be made in the personal and health care sections to the wide variety of co-working with health professionals to ensure the well being of this individual. A pleasing feature of this plan was the inclusion of what had been called Pamper Sessions, reflecting the recognition of the need of everybody to receive positive regard for the person they are. The plan stated who the key worker was for this resident, and included a behavioural risk assessment and details of contact with family and friends, and a record of this years Holiday in Rhyll. The capacity of residents to have a say in the managing of their finances was demonstrated when a support worker walked two of them down to the village so that they could draw out some money from their bank accounts. A discussion had previously taken place with the acting care manager as to this care worker not being a recognised signatory at the bank, but this difficulty was quickly overcome when a member of permanent staff pointing out that they were able to sign for themselves. During the morning one resident expressed an interest in pursuing an interest that they had previously enjoyed in a former health service institution, and the deputy manager was able to talk to them about opportunities available locally, and undertook to obtain more precise details to assist this resident in making a decision about whether or not to join these classes. 4 West Street, DS0000029679.V317214.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. The quality outcome for this group of residents was good. This judgement was made taking into account all evidence available including a visit to the service, and because they are enabled to have a community presence, to be occupied or stimulated, to maintain affiliate links, and to be able to eat well. EVIDENCE: During the visit to the service a resident was able to point to certificates that he had received in recognition of achievement in courses undertaken at a local college. For part of the time he was away from the home attending a pottery class at Leek College. Two other residents spoke of how they undertook therapeutic work at the main office of the providers, one of them stating: I was helping sort out the paper this week . Care plans and daily schedules a room in expanded on the east to examples quoted above, show that residents were helped to undertake appropriate work, and training/education, within their range of ability. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 13 As stated previously, during the morning one resident expressed a desire to pursue an interest that they had previously enjoyed in a former Health Service institution, and the deputy manager was able to talk to them about locally available opportunities, and undertook to obtain more precise details to assist this resident in widening their option of activities. Residents were being helped with their benefits/finance by the companies cluster worker who assisted them to go down to the bank and draw out money for their personal needs. Staff talked about the integrated status of the home within the community, which was helped by Biddulph not being too large, independent of its larger neighbours, and the place where many of them also lived. They felt that this had helped with the community taking ownership of the home within their midst and relating to the residents who had come to live there. Reference to care plans and discussion with residents demonstrated they used all the local facilities, as well is continuing to relate to former fellow patients of learning disability hospitals in the area, some of whom reside in other homes run by the same provider. Visits were made between individuals, as well as residents going in a group to parties and coffee mornings at other homes. During the afternoon of the inspection two residents were transported some 30 miles to Cannock, to visit relatives. One resident was very enthusiastic about a holiday that had been shared with a resident from another home, with whom he had been friendly for many years, and which had been themed around their joint love of steam trains. A member of staff had travelled with them to make this possible, and to provide transport so that they could enjoy the beauties of the North Yorkshire Moors, and the Vale of Pickering. Other residents spoke about the individual friendships that they maintained, keeping contact in between personal visits by using the telephone, or sending letters. Details of another person’s supported holiday were taken from a care plan. Menus demonstrated a wide variety including seasonal and local choices, and the likes of different residents when it came to the venue for places to eat out. There is a domestic kitchen/diner, and the cupboards were well stocked with named brand goods, and surfaces were tidy and clean. There was a domestic dishwasher in the kitchen, (there is a separate laundry where the washing machine is situated) with the deep freeze situated in the brick built storeroom adjacent to the laundry. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 14 When examined, this also was stocked with good quality food items, and the thermometer showed it to be set at an appropriate temperature. Residents told the inspector that they enjoyed their meals. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, and 21. The quality outcome for residents in this area was Good. This judgment was arrived at using all the evidence available including a visit to the service, and was formed because residents were seen to receive comprehensive social and Healthcare support in line with their assessed needs and choices, and their programs had been reviewed regularly as demonstrated by the record in their personal care profiles. EVIDENCE: In a formal interview with a member of staff the subject of assisting a resident to bathe was discussed at length. The answer received demonstrated the expectation of staff working within the home that privacy and dignity would be maintained at all time, together with a commitment to ensuring that the resident was enabled to maintain what ever independence they had, rather than disabling them by doing things for them that they could do themselves. Throughout her description of this task she showed herself to be conscious of the need to respect choice, and to keep the resident in control of the process. Observation of these staff/resident dynamic clearly brought out the sensitivity between accepting all the demands made by individuals, and ensuring that nobody stigmatised themselves by being unacceptably inappropriate. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 16 Discussion with the acting manager determined that there were individuals within the home who like to keep to the set routine of going to bed early so they could rise early, and others who either stayed up late on a routine basis, or when there were things they wanted to do such as watching a television programme. The care plan of one resident was examined in detail, and others were sampled less extensively. These contained a whole raft of entries relating to maintaining general and psychiatric health of residents in the home, and to regular checks that had been initiated by the providing organisation on the basis of the good practice recommended by the British Institute for Learning Disability. There were lists of key values, 24-hour support plans, behavioural risk assessments, appropriate and regular reviews of the status of the individual’s health, tissue viability measurements, blood pressure monitoring, nutritional screening, and regular individual reviews of medication. Appointments had been made with individual health care clinicians including hospital consultants, GPs, and district and specialist nurses, and at clinics and health centres with appropriate support and transport being provided to enable residents to attend these. The tertiary health care practitioners were also seen to be visited at appropriate and/or regular intervals, including opticians, chiropodist, dentists, and audio-clinicians. The local GPs surgery had been involved in Well Woman and Well Man annual health checks. In one of the files examined some sensitive work had been undertaken with the resident in obtaining their views about how they would like to be treated at the time of and after, their death. This was just one of many documents that had been amended with picture symbols to make it more accessible to the individual resident. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The quality outcome for this group of residents was good. This judgment was made using all the available evidence including a visit to the service. It was made because staff was been seen to be well trained, and because policies and procedures had been in place to protect these vulnerable adults. EVIDENCE: The Commission for Social Care Inspection has not received any complaints during the period under review in respect of this home. The inspector was told on arrival that the relatives of one resident had made a number of complaints directly to the home prior to the last inspection, thought that regular meetings are now been held with these relatives, and a better system of communication have been devised to enable them to share more fully in the problems and care of the resident. In a residents survey on file at the home, another relative indicated that they were unaware of the complaints procedure, and the new acting manager undertook to contact that relative and explain the procedure, ensuring that this was followed up with a written copy of the providers policy. In a formal interview with the deputy care manager, reassuring answers were received in relation to the subject of abuse. She correctly identified that anybody could abuse the vulnerable residents in her care, and what steps that she should take should she suspect that this would have she was equally aware of the wide range of acts both of omission, and of commission, that would constitute an abuse on a vulnerable adults. 4 West Street, DS0000029679.V317214.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, and 30. The outcome for this group of residents was good. This judgment was reached using all the evidence available including a visit to the service and was made as the residents were seen to be living in a homely, comfortable, and safe environment, with personal and communal space that met their needs and lifestyle, and helped to promote their independence, in an environment that was well maintained, clean, and hygienic. Minor concerns about the material stored in the garage and the uncapped drainage vents in the front garden will be covered in Recommendations. EVIDENCE: As indicated in the judgment above during the tour of the home uncapped drainage vents were noted in the front garden, and the acting manager agreed to contact the estates division of the providers to have these investigated and dealt with appropriately. There will be a recommendation at the end of this report reflecting that agreed line of action. Similarly, her undertaking to obtain a skip and empty the garage of extraneous discarded items, and to speak to estates about means of enclosing the heating appliances housed there, will be a recommendation of this report. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 19 A cursory visual examination was made of the exterior of the home and office adjacent outbuilding where the laundry and storage room are situated did not bring to light anything obvious that needed attention. Where fixtures and fittings were not of a UPVC manufacture, paintwork was in good order, and nothing was identified as needing to be renewed. The extensive grounds were well maintained, as were the perimeters and the tarmac drive and parking areas. There was a long gentle ramp to the front door, with substantial handrails on either side, and in the porch way outside the front door there was a wellconstructed garden bench that was evidently used by those people who wished to smoke. Internally, there was a roomy hallway that was suitable for wheelchair users, and this led to the kitchen diner, where the table was substantial enough to also be used for activities. The room was tidy and well maintained, and as well as the substantially provisioned cupboards mentioned earlier, attention to infection control was observed in the provision of colour-coded utensils, especially chopping boards. There was also a good-sized lounge with two doubles settees, two single chairs (one of which was an assisted recliner), large TV and video systems, and the usual coffee table & sideboard. The radiator in this room as elsewhere was suitably covered so that should anybody fall against it there would be no risk of them becoming burnt. One Resident was pleased to invite the inspector to look at his room. He had appropriate storage systems in place to show off the pottery items that he had made at college, and stated: I want another set of shelves putting up so that I can get a model steam engine to put on them . (This was discussed with the acting care manager who said he was looking forward to obtaining this for Christmas, and that she would see that he had appropriate shelving on which to display). There was also a small fridge for the storage of topical creams, and it was suggested to the resident and the care manager that this would work more efficiently if switched on. He had the rest of the room arranged to suit his own needs, and there was adequate floor space for him to undertake the activities of his choice, and there were many items that indicated his interests in life, and recorded achievements that he had reached at college, and personal mementos of things that he wanted to be reminded of. The room was warm, clean, and tidy, and he had a key to his door, and emergency button to raise an alarm if he was unwell, and demonstrated that he was able to open the window if he wanted more fresh air. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 20 The shower room was equipped with a walk-in shower of the falls and gully type, a WC, and a washbasin, and appropriately placed grab rails to help residents maintain their balance. There was a separate bathroom that also had WC and basin, and was equipped with a Hi/Lo style of bath that would be helpful to staff when they were assisting anybody to bathe, by doing away with the need for them to bend to be at the same level as the resident. Although not the subject of either a requirement or a recommendation, it was discussed with the acting care manager that whilst this room was appropriately clean and clinical, there was much that could be done to make it more homely, and attractive for residents to enjoy time to have a soak after performing the purely functional hygiene activities. With the exception of the garage storage area referred to earlier, the home was clean, warm, and tidy throughout, and there were no issues of odour within the home, though there will be a recommendation that the matter of the drain vents be investigated and appropriate action taken. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. The quality outcome for this group of residents was Good. This judgment was made using all evidence available including a visit to the service. It reflects an adequate staff-to-resident ratio, and there being sufficient and appropriate training of, and employment of, experienced and qualified staff. EVIDENCE: The deputy manager who is a level 1 nurse, has now completed her registered managers award, and has received her certificate for this. She was on duty for the duration of the inspection visit, and was able to provide much valuable assistance. The registered care manager had recently tendered her resignation, and the providers had advertised the position in the local press two days prior to this inspection. As has been detailed earlier in this report, the home is receiving managerial support from the registered care manager of another home in the group, and she too was on duty at the inspection. In addition to these members of management, the cluster worker linked to the home was working at this home on the day of inspection, together with two other members of care staff. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 22 A member of staff was engaged in a formal interview, and she confirmed the wide-ranging and regular training opportunities that were available, and that a record was kept of when mandatory certification was due for renewal, so that staff were always kept up-to-date with their knowledge on such things as; Moving and Handling, Fire Safety, First Aid, Food Hygiene, and Infection Control. She had also received appropriate training in the specialisms associated with Learning Disability. This person was also able to confirm that at recruitment, she had had to provide the names of two referees, and undertake a criminal records bureau check, and that the nature of her being employed conformed with equal opportunity and employment legislation. The position had been advertised in local paper, and after making telephone contact she had been sent an information pack including application form, and then had been short-listed for interview. Her induction training had been appropriate, and had started with a week at the Head Quarters of the providers, were all mandatory subjects had been addressed, and where she had undertaken a five-day course on the management of actual and potential aggression. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. The quality outcome in this area was Good. This judgment was made using all the available evidence including a visit to the service. Although the current care manager had recently resigned, CSCI are being kept informed of the progress of the procedure to replace her, and appropriate steps have been taken by the company to ensure the continued management of the home during this period. EVIDENCE: Following an internal investigation where she had been exonerated by the providers of any malpractice, the registered care manager had recently resigned. The providers have kept the CSCI informed of the progress of their procedure to find a replacement manager, and of the arrangement is that they have made to ensure the appropriate running of the home until a new manager is in place. 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 24 The Commission For Social Care Inspection receive regular reports from the provider in respect of their Reg. 26 visits to the home to monitor the quality within the service. During the inspection a relatives satisfaction survey card was examined, and this stated that they were: Very Happy with the standard of care, and stated that their relative Had never looked so happy before . When the form asks them if they had any complaints, they had responded: None whatsoever . The fire prevention records were checked and it was found that alarms were tested on a weekly basis, and correct intervals were recorded for the testing of the emergency lighting, and for the training of staff in what to do should a fire be discovered. There were sufficient people qualified in First Aid to ensure that there was always a qualified member of staff on duty, and the records for the servicing of equipment used in the home, including portable electrical appliances and gas appliances showed that these had been done at the recommended intervals. There was evidence of regular input of all relevant training, and of good liaison between the providers and the Commission for Social Care Inspection over incidents occurring within the home and other matters relating to the management of the home, and no hazards were observed during the tour of the environment, other than the need for a good tidy out in the garage, and the two drain vents in the front garden, both of which will be mentioned in a recommendation. 4 West Street, DS0000029679.V317214.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 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 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 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 4 3 X 3 X X 3 X 4 West Street, DS0000029679.V317214.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. 1 2 Refer to Standard YA37 YA24 Good Practice Recommendations Arrangements must be made to appoint a new registered manager as soon as possible. Steps must be taken to remove all unwonted discarded items from the garage, and to ensure that where this is used as storage in future, that items are stored safely and tidily. The providers are also recommended to consider action to divide the space so that the ignition source represented by the heating systems in the room is isolated from the rest of the area. The providers are recommended to obtain further advice concerning the two drain vents so thats necessary action can be taken to ensure that they do not pose a danger of contamination, and of being a source of unpleasant odour. 3 YA30 4 West Street, DS0000029679.V317214.R01.S.doc Version 5.2 Page 27 A Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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