Inspection on 31/10/07 for 41 Newport Road

This inspection was carried out on 31st October 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

41 Newport Road 14/03/07

41 Newport Road 11/01/06

41 Newport Road 24/08/05

41 Newport Road 18/11/04

41 Newport Road 22/07/04

41 Newport Road 17/02/04

Similar services:

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

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

CARE HOME ADULTS 18-65 41 Newport Road Cowes Isle Of Wight PO31 7PW Lead Inspector Mark Sims Key Unannounced Inspection 31st October 2007 14:00 41 Newport Road DS0000012514.V353227.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 41 Newport Road DS0000012514.V353227.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. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 41 Newport Road Address Cowes Isle Of Wight PO31 7PW 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) 01983 294134 01983 294134 Islecare `97 Ltd Mark Thomas Kenyon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Authorisation to accommodate a service user over 65 years of age The home has been authorised to accommodate a named individual with a learning disability over 65 years of age. The condition will no longer apply when the individual ceases to be resident in the home. 14th March 2007 Date of last inspection Brief Description of the Service: 41 Newport Road provides personal care and accommodation for up to six adults with a learning disability. It is a detached two-storey property situated on the main Newport to Cowes road about half a mile from Cowes town centre with its shops and amenities. While parking is mainly limited to side streets, bus stops are only a few yards from the home. There is a reasonably sized terraced rear garden available for residents use and a small lawned front garden with flowerbeds. Accommodation is on both levels. There are ten steps from the pavement to the front door and no lift from the ground to the second floor, making the home generally unsuitable for people with mobility difficulties. The current scale of charges is £320 - £490 per week with additional charges for chiropody, hairdressing, toiletries, transport and day care services. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures the service against core National Minimum Standards. The information used to write this report was gained from the homes Annual Quality Assurance Assessment; a visit to the service and a review of comment cards received from service users, relatives and social care professionals. Other information was gathered from the services history of events, previous inspection reports, direct conversations with staff, an analysis of the information supplied to and recorded by the link inspector and the fieldwork visit, which was conducted over three and half hours. What the service does well: The service involves both existing and prospective service users in the planning an assessing of a persons suitability to move into the home, the individual most recently admitted to the home describing how they came to visit the home and stayed for lunch and tea prior to deciding that the placement would their needs. The home’s person centred support plans are being well maintained and contain evidence of both the service users and their keyworkers involvement in the developing and updating of information. The service users social lives appears to be both active and rewarding, with the client group excited by the prospect of a Halloween Party, which they were preparing for during the fieldwork visit, people making costume and adorning masks, etc, as part of the build-up to the party, which had been organised at the services sister home in Venner Avenue. The environment is generally bright, modern and inviting with the communal areas of the home providing the focal point of the home for socialisation and activity. People’s bedrooms were individually laid out and decorated. The occupants had stamped their own character and identity on their rooms through the use of ornaments, pictures, posters, knick-knacks and entertainment centres and each person could lock their room if they desired. The staff team of Newport Road generally consider themselves to be a stable group with a low staff turnover. Training is made available both on a routine/mandatory basis and in accordance with staff requests and the specific needs of the client group. 41 Newport Road DS0000012514.V353227.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. 41 Newport Road DS0000012514.V353227.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 41 Newport Road DS0000012514.V353227.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service and their representatives had the information they needed when choosing the home. They had their needs assessed, an opportunity to visit the home and a contract, which clearly told them about the service made available. EVIDENCE: Several service users were met during the fieldwork visit, one of whom had been the last person to move into the home and who was able to discuss how his move had come about, the process involved, including visits to the home to meet other residents and members of the staff team and how since he had moved he had been happy and settled. Four service users completed surveys prior to the fieldwork visit taking place, all four indicate that the person was asked if they wanted to move into the home before taking up the offer of accommodation and one person recalled visiting prior to her move to 41 Newport Road. The surveys also suggest people were provided with contracts, although two people could not recall this, as it had been sometime since their arrival at the home. However, a review of the service users files, established that each person had been issued with a contract and that this was now a mix of pictorial 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 9 prompts and written phrases, which will be of benefit to anyone educated in the use of pictorial or written forms of communication. The service user plans contain information provided by professional sources during the persons admission to the home, as well as historical information about the person and their settling in period and progress since arriving at the home. 41 Newport Road DS0000012514.V353227.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The review of the service users plans or client centred plans took place with the resident present and it was the resident who went and collected their plan for discussion during the visit. Each person clearly had an appreciation for what was contained within the plan, although as the majority of the entries are made in writing the residents’ are reliant upon the staff and their keyworkers to explain some of the more complex and detailed entries. The plans are now based upon the person and reflect the care they desire, require and need, although as with many such plans the writer or author of the 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 11 plan is still preferring to write in a third party sense or style and not truly documenting comments as they would naturally be expressed by the person. However, the plans are a great improvement on the previous documentation employed by the service provider and contain reference to people’s access points for health and social care support, leisure pursuits, families, friends and relationships, personal histories and risk assessments. In discussion with the residents it was established that two of them had secured employment on a part-time voluntary basis, which is documented with the person centred plan and that these jobs form part of their weekly routine alongside visits to day services and days at home. Each of the client has an agreed activities schedule, a copy of which is maintained within the person centred plan, which they are completely familiar and comfortable with, clients are encouraged to prepare their own sandwiches or lunches before departing for their various centres and risk assessment documents are in place to any potential dangers are kept to a minimum. During home days, weekends or evenings the residents are encouraged to do what they wish, which is reflect through the surveys that people completed and observations made during the fieldwork visit when people were noted to be engaged in a number of various activities, although preparations for the Halloween Party did appear to be taking precedence. In discussions with staff it was made clear that people are encouraged to do what they wish during their leisure or free time and that each person has a unique character, which they express through their choice’s, an example of this being a client who loves to collect knick-knacks and has a room full of ornament, soft toys, etc, which she has collected and catalogued with the help and support of her keyworker(s). Choice of holiday destination and who is going to holiday with who are also good examples of the efforts made by the staff when supporting the client’s decision-making. People spoken with during the visit discussed where they went this year, with who (staff and fellow service user) and where they are going next year and again with who as each person likes something different. Service users meetings also provide people with the opportunity to discuss issues of concern or ideas for the home and the resident group, minutes of the meetings are maintained and again indicate that people are encouraged to influence and direct their own lives, where possible and practical. 41 Newport Road DS0000012514.V353227.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the services are able to make choices about their life style and are supported to develop their social, educational, cultural and recreational activities to meet their individual expectations and wishes. EVIDENCE: As mentioned previously the service users were preparing for a Halloween Party during the fieldwork visit and were being assisted by staff to produce Halloween costumes and prepare food items for the evening. The party, according to the staff is an annual event, which is hosted by the service users and staff of Venner Avenue, the sister home to 41 Newport Road, with the service users and staff of Newport Road reciprocating by organising the Christmas Party. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 13 In discussions with the service users it was evident that they enjoyed the opportunity to socialise and were excited at the prospect of attending the fancy dress party. The people residing at the home are generally very active people, with two clients, as mentioned, working on a voluntary basis, whilst other people attend day centres and organised activities, copies of their schedules or weekly activities programmes are contained within their person centred plans. The person centred plans also contain information about people’s preferred activities and hobbies when not attending day services or work, which included horse riding, shopping, visits to local attractions and general outings; including the weekly household shopping trip. People’s bedrooms, visited at the invitation of the service user, contained various entertainment equipment and leisure pursuits, including a model train collection, DVD and Video collections, collections of ornaments and soft toys, music systems & CD’s and digital television systems. Residents also discussed their hobbies and interests with the person who collects railway memorabilia describing visits to working railways like Havenstreet Steam Railway on the Isle of Wight and the person with the soft toy and ornaments recounting how she had won her last soft toy on holiday in Blackpool. No visitors were seen during the fieldwork visit but the indication from the service users is that they are involved with their families and friends, won person discussing visits to his mothers, whilst two other residents discussed the recent visit, by one of pairs brother, to the home. People are also supported with continuation and development of their personal relationships, a client discussing her fiancé during the visit and describing how and when they meet up privately and the role the staff play in helping her cope or manage any interpersonal hiccups. The staff stated that the resident’s care manager and a member of the learning disabilities nursing team had also worked with the client on understanding sexuality and sexualised behaviours and emotions and that this was monitored and reflected through her person centred plan. Generally the person centred plans focus on family relationships, as apposed to friendships and identify immediate next-of-kin, visiting arrangements, birthdays and anniversaries (dates of significance) and a brief personal history, which includes details of a persons family life and interactions. Service users are supported to keep in touch with their families, as not all of the service users families are Island based, some living on the mainland and 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 14 others abroad, by means of a telephone that is situated within the hallway and correspondence read, according to the residents, to them by staff or other family members. People’s right to privacy, is a little hampered by the location of the communal phone, which is affixed in the hallway, however, it is understood, from the staff, that calls can be taken on the office phone if required. Service users were, until recently, also able to make use of the home’s computer, which was connected to the Internet and so provided emailing opportunities, as well as other applications. However, this stopped when changes were made to the computers operating systems, which provides access to different databases according to the operator’s password permission. In discussion with the staff and deputy manager it was explained that they had alerted the company to the problems associated to making the changes to the database, however, this made little difference and the service users can no longer use the computer to access the internet. Within the home the staff team do attempt to recognise and support people’s rights to respect and dignity, with the service users noted to have keys to their bedrooms, which are locked when not occupied and knocked before entering. People are also supported in the development of skills, such as the preparation of their packed lunches and snacks, one client quick to offer and make coffee during the visit, as well as being involving in decision-making about meals and menus, holidays and activities and the people they live with, some of these issues discussed and minuted during residents meetings. Access to food items is not restricted within the home, although people are encouraged to consume healthy snacks were possible, with bowls of fruit noted in the lounge and kitchen, as well as crisps and biscuits. One client is being supported to manage their weight and documentation around how this is to be achieved is available to staff within the home, although during conversations the staff appeared fully aware of how to encourage or support the client choose healthier snack option and meals. A menu is produced however, it is not followed rigidly, the staff advising that mealtime’s and the food provided changes depending on the client’s wishes or requests. No meals were seen being prepared or consumed during the visit, as the client’s were off to their party and the food being taken was snack or finger foods. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 15 However, in discussion with the service users it was established that the meals are considered to be good. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The person centred plans contain detailed information around the needs, wishes and areas of support the service users have in respect of their personal hygiene. The clients were observed to be very independent during the visits and the staff indicated that generally their role is to prompt people with the basic aspects of their personal care and to monitor them with the more complex or hazardous activities, bathing or showering, when accidents could occur. It is evident from both the service user surveys and the comments obtained during the fieldwork visit that the residents consider or feel the staff provide adequate levels of support and listen to what they need and require. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 17 Information taken from the Annual Quality Assurance Assessment (AQAA), indicates that the service users are also well supported when managing their health and social care needs, with the resources of the local medical centred utilised in the promotion of well men and women’s health, attendance at wellness clinic documented. The person centred plans, also contain detailed Health Action Plans (HAP’s) and Hospital Inpatient Learning Disability Assessments (HILDA’s), which provide a unique picture of the persons involvement with and experience of various health professionals and agencies. In discussion with some of the service users it was apparent that they are familiar with both their main health and social care contacts (Learning Disabilities Nurses and Social Workers) and confirmed that they see these professionals at reviews, which occur at their day service. Copies of the reports produced, following a review, are maintained within the home and accessible to staff and authorised personnel, in conversation with staff it was established that reviews often take place at the client’s day service, as the home is not large enough to accommodate the meeting. During a recent visit to Plean Dene, another home within the same company group, an improved health management plan or file was seen and scrutinised. This particular document was found to provide much quicker and easier access to important health and social information and it is suggest that the company role this format out across all of its services. The staff’s approach to supporting people with their medications was observed during the fieldwork visit and noted to be appropriate and satisfactory, with the client present throughout the dispensing of their medicines and therefore able to take the medication immediately and without the need to transport the tables around the home. The Medication Administration Records (MAR) were accurately and comprehensively maintained and the storage facility for the medicine secure. The Annual Quality Assurance Assessment and Dataset materials returned to the Commission in the build up to a visit, establish that staff have access to up to date policies and procedures on the safe management and handling of medicines and all the staff involved in administering medicines have completed the companies ‘appointed persons’ training, the latter information provided by the staff. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: The Annual Quality Assurance Assessment states that clients have access to a complaints policy that has been improved and made more accessible. A copy of the company’s new complaints policy was seen and is a mix of pictorial representations and written instructions, the pro’s and con’s of this style of presentation discussed earlier within the report. The service users, via the surveys indicate that they are generally familiar with the process for raising concerns, three of the four people returning their survey indicating that they would approach the manager or their keyworker if they had a problem. In conversation with staff it was established that complaints are often addressed, on a non-personal level via the residents meetings, where people are encouraged to talk about issues or events that have upset them. The service users comment cards also indicate that staff listen to the clients, which is a key component of supporting a person address or minimise the impact of a concern, although general observations suggest the client group interact well. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 19 The Commission’s database evidence’s that one adult protection referral has been made since the last inspection and that this has been successfully resolved. The Annual Quality Assurance Assessment and Dataset indicate that the company has a safeguarding policy and procedure in place and that this was last updated in January 2007, whilst training records, seen during the fieldwork visit establish that safeguarding adults training is being provided. The service users raised no concerns, either during their conversations with the us, or through their behaviour, which was relaxed, happy and confident throughout the visit. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The communal lounge and dining areas of the home are in a good decorative condition and well furnished and equipped, although as stated the computer in the lounge is no longer accessible to the service users. People’s bedrooms, were all uniquely decorated and personalised, with a range of pictures, ornaments, poster and equipment used to create an individual feel by the occupant. In discussion with service users it was established that they were involved in choosing the colour and design of their room and that items used to personalise the environment were either purchased by them or gifts. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 21 In discussion with staff it was stated that maintenance is undertaken by the estate team, who can be contacted via central office and work on a priority basis or as part of a planned or scheduled programme of redecoration. The Annual Quality Assurance Assessment and staff indicates that the main lounge and the bathroom were the areas of the property to undergo any remedial or redecorative work, however, the bathroom is likely to prove a constant problem, as it has no natural ventilation and the extractor fitted is in adequate and not fit for purpose, leaving the bathroom damp, musty and spotted with mildew. Generally the cleanliness of the home is good, with the tour of the premise raising no concerns with the hygiene of the home. A view shared by the service users who indicated via the surveys that they feel the home is clean, tidy and fresh. During the visit to the home several service users invited us to visit their bedrooms and discussed how they are involved in keeping their bedrooms clean and tidy. People also discussed how they use either their home days or the weekends to undertake basic cleaning and tidying of their rooms and that they all assist in the kitchen with the dishes. A programme or schedule was noted to be displayed in the kitchen, which indicated who should be involved in which task on a daily basis, although the staff stated that this was not rigidly followed and that people generally mucked in together to keep the home tidy. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and support the people who use the service and the management with the smooth running of the service and their day-to-day lives. EVIDENCE: The deputy manager produced a copy of the company’s training planning, which indicated that the staff have access to both mandatory courses, provided by the company and specialised training events, such as Autism Updates and Downs Syndrome Awareness. In discussion with staff it was confirmed that annually they are required to complete the company’s mandatory training courses and that this includes the appointed persons training, which enables people to be left in charge of the home. Staff also discussed only being allowed or deemed competent to undertake medication rounds once they have completed the required training course, records of the training completed and there updated or revision dates are 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 23 retained by the company’s administration team centrally, copies of these records have been seen on visits to other Islecare services, including 41 Newport Roads sister home Venner Avenue. Information taken from the dataset and confirmed with the deputy manager, indicates` that currently the home employs seven care staff. Five of the seven care staff have completed a National Vocational Qualification (NVQ) at level 2 or above and this gives the home a percentage of 71 of its staff possessing an NVQ at level 2 or above. The dataset establishes that a recruitment and selection strategy/procedure exists to support the management staff when employing new staff and that an induction based on the ‘Skills for Care’ induction standards is in place. It also indicates that all of the people who worked in the home over the last twelve months had undergone satisfactory pre-employment checks. On reviewing the files of two newly recruited staff all of the required checks were in place, Criminal Records Bureau (CRB) checks, Protection Of Vulnerable Adults (POVA) checks and two references. The files also contained completed application forms, health declarations, photographs of the employee, interview summaries, personal information and information used to support the CRB application process. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and effective quality assurance systems ensure the service users are supported in comment upon the service provided. EVIDENCE: The deputy manager is currently managing the home, although during the fieldwork visit it was stated that a new permanent manager had been appointed. The staff and the service users seemed happy with the way the home had been operating recently and both groups seem confident in the abilities of the deputy manager, the service users turning to the deputy manager for assistance with their fancy dress costumes and the staff for assistance organising transport arrangements, etc. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 25 The deputy manager, whilst only taking charge of the home on an interim basis, has continued with the management systems introduced by the previous manager, which appear generally well organised, as all essential information was accessible during the visit. The Annual Quality Assurance Assessment indicates that the deputy manager has completed The Registered Managers Award and holds an NVQ level 3 in care. Whilst in conversation it was established that the deputy manager is an experienced manager who has worked for the company for a number of years. The service users are provided with their opportunity to influence the day-today operation of the home via the residents meetings, where they can discuss concerns, consider ideas like activities or menus and decide upon holiday arrangements. The service users are also more involved in the development of their support plans, which in association with their keyworker they keep reviewed and updated to ensure it reflects their immediate support needs. The Annual Quality Assurance Assessment indicates that the company have yet to introduce a formalised quality auditing system and surveys, despite this being a previous requirement of the service. A tour of the premise raised no immediate health and safety concerns and basic environmental risk assessments were noted to be in place. The Annual Quality Assurance Assessment and Dataset establishes that full health and safety policies/guidance documents are made available to the staff and that equipment is regularly maintained and serviced, gas, electrical installations, portable electrical appliances, hoists, baths, etc. Health and safety training is made available to staff, with the training plan providing evidencing of the health and safety training being completed by the staff including moving and handling, appointed persons (first aid) and health and safety and health and hygiene. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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. 1. Standard YA39 Regulation Requirement Timescale for action 16/11/07 Regulation The company must introduce a 12 formalised quality assessment programme into its younger persons services. This requirement remains outstanding from the last inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA16 Good Practice Recommendations The company should consult with the service users on any changes that will affect the quality of their life and the service or facilities provided, i.e. the withdrawal of their access to the internet. 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 41 Newport Road DS0000012514.V353227.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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