Inspection on 02/12/08 for 43 Station Road

This inspection was carried out on 2nd December 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

43 Station Road 04/12/06

43 Station Road 12/01/06

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Dalewood Respite Care

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Treloar College

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Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 43 Station Road 43 Station Road Wraysbury Middlesex TW19 5ND     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Helen Dickens     Date: 0 2 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: 43 Station Road 43 Station Road Wraysbury Middlesex TW19 5ND 01784488581 01784482592 43stationroad@voyagecare.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): Milbury Care Services Ltd The registered provider is responsible for running the service Name of registered manager (if applicable) Type of registration: Number of places registered: care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) Date of last inspection Brief description of the care home Station Road is a purpose built residential home that provides a service to people with learning and associated physical disabilities. The service users are between the ages of 17 and 65 and of both sexes. Each service user has a large individual bedroom and shares the communal space. The building is two storeyed and there is no internal lift for access to the first floor. The home has its own vehicle to easily access Langley and Care Homes for Adults (18-65 years) Page 4 of 30 6 Over 65 0 Brief description of the care home Slough town centre. The home is within walking distance of local shops and facilities in Wraysbury. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was unannounced and took place over 6 hours. The inspection was carried out by Mrs. Helen Dickens, Regulation Inspector. The previous manager Julie Skelly has now left the home, and the new manager and care staff represented the service. A partial tour of the premises took place and a number of documents and files, including three residents assessments and care plans, two staff recruitments files, quality assurance information, and the annual quality assurance assessment (AQAA) were examined as part of the inspection process. A number of questionnaires returned to CSCI about this service were also considered in writing this report. Care Homes for Adults (18-65 years) Page 6 of 30 The current fees are in the region of 1400.00 per person per week. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Adults (18-65 years) Page 8 of 30 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs and aspirations are assessed prior to them moving into this home. Evidence: The AQAA states that the home identify the needs of the individual from an assessment of need, and continually review this assessment. They include the family, with service users agreement, in this process, and service users are involved in their individual plan. No new residents have been admitted to the home since the last inspection. At the last inspection it was noted that there was one new resident, and their assessment had been conducted professionally and sensitively, with the prospective new resident being given the opportunity to spend time in the home. Other files sampled during this inspection showed that a full assessment is carried out by the home. The local authoritys care management assessments are kept on file and some residents had additional specialists assessments as necessary. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents assessed and changing needs are reflected in their care plans, and these are set out in a user friendly format so as to include residents as much as possible in the care planning process. Residents are encouraged to make decisions for themselves and to be as independent as possible. Evidence: Residents care plans are in accessible formats with large print, easier words and with photos and pictures included to enhance particular areas. Two care plans were sampled in some detail, and two others looked at in brief. A new format is being introduced so one care plan from each format was sampled. Both reflected the assessed and changing needs of service users, and were very detailed in regard to how support should be delivered. Specific areas covered included personal and health care support, healthy eating, relationships, activities, mobility, and there was also a separate and more detailed section on health. The user friendly formats are continually being improved upon and the manager adapts the Voyage format to suit each Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: particular resident. There are good guidelines about how to communicate with residents in the form of a Communication Passport. Families are involved in care planning and the manager said all their current residents had families who were very involved in their care and activities. Staff and resident interactions were observed throughout the day and it was noted that residents moved freely around the home and were able to decide for themselves how to spend their time. During the morning, one resident came and sat with the inspector in the office, others were in the lounge, and two others were in bed. Each resident has a communication passport and staff were seen to follow the guidelines when working with residents. Individuals choices and preferences are recorded in their support plans, and the staff on duty were heard to give residents choices and encourage them to make decisions for themselves. A previous Requirement to ensure decisions made on behalf of residents are properly recorded is now met. Residents are encouraged to be involved in their day to day expenses though their overall finances are managed by their parents. Each resident has a wallet, kept securely by the home,with small amounts of cash. Records are kept and receipts were sampled for one resident. The records showed that money had been spend on following faith based activities, and for meals and drinks when they were out. The manager conformed that residents only pay their own expenses whilst they are out, and staff expenses are paid from petty cash. Residents make a contribution towards transport costs, either directly, or through their local authoritys funding package. Residents are supported to take risks and risk assessments are drawn up on admission to the home. Risk assessments are in place for a variety of activities and those seen had been reviewed at least every three months, and some more often. Those sampled covered moving and handling, epilepsy, and choking, and also social activities including horse riding and swimming. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to take part in interesting and fulfilling activities, and to be part of the local community. Family and friendship links are encouraged, and residents are treated respectfully by staff. Residents are offered a healthy diet in pleasant surroundings. Evidence: There is an activities plan in place for each resident with photographic evidence of their participation around the home and in individual support plans. Each residents plan sets out the planned and regular activities undertaken. For example all residents go to day services at some point each week for educational activities. Two plans were sampled. The first showed that the resident attended day services on four days per week and went to football on the fifth day. This resident also attended Church and went to their parents home at the weekend. In addition to these regular activities this Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: person also goes out in the car, and has some ad hoc activities, for example going to the pub. Staff try to arrange alternatives if a resident cannot attend their planned activity and this was evident on the day of the inspection when the horse riding activity had to be cancelled due to poor weather, and another resident was unwell and did not go to day care. Staff were seen to be occupying residents in the dining room with drawing and colouring, and was seen to add each residents name and the date on all drawings completed. Some of the drawings were on display in the dining room. Staff were observed to be very attentive and encouraging to residents as they were drawing. Another persons file showed regular activities included feeding their fish, helping with housework, posting letters for the home, horse riding, personal shopping, day services, attending the temple, and looking at their own collection of old movies. This resident also goes home to their parents, and goes on holiday. The board in the dining room advertises various activities, for example the day care programme, and the Voyage Christmas disco to which all residents are invited. The board also has photographs of the staff on duty each day to assist residents. The home maintains a neighbourly relationship with the local community and it was noticeable that the front of the house is kept neat and tidy, and there is now a regular gardener during the summer months to keep the large back garden pleasant for residents. People who live at this home are encouraged to be part of the local community and use day care, health and leisure facilities. This includes activities such as going horse riding, using local pubs and restaurants, and being part of local faith communities, with some residents attending a local Church, and others going to the Hindu Temple. Residents family and friendship links are encouraged and the manager said all current residents have caring families who spend time with them and are involved in overseeing their care. Support plans note the involvement of families and there is a section on relationships which covers the support each resident needs in this regard. Family and other important birthdays and dates are noted on each file so that staff can assist residents to send birthday cards etc. Staff are very respectful to residents at this home and throughout the day were seen to always knock on residents doors before entering, and whenever a resident entered one of the communal areas, staff acknowledged their arrival and encouraged them to be involved in what was happening. The manager was absent for the first hour of the inspection and the two staff on duty were noted to be very attentive to residents needs. They put residents needs first, and were observed to interact well with them. There were no instances during the day of staff speaking exclusively with eachother or excluding residents. People who live at this home are encouraged to make their own Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: choices about what they did and where they wanted to spend their time, and staff were observed to communicate well with residents, despite each person having very individual and complex communication needs. Communication passports are on each residents file, and staff were seen to follow this guidance. Residents are included in housekeeping tasks and the manager described how some helped with fetching their laundry, kept their own rooms tidy, or helped staff with the meals. One resident looks after and feeds their own fish. Residents at this home are offered a healthy diet and the dining room is pleasant and well furnished. Staff said the menu is on a four weekly cycle though this about to change to more seasonal choices as the weather becomes colder. One staff member was asked which items on the menu for the coming week were homemade and on closer inspection, she said that most of the supper dishes are homemade including vegetable soup, curry, and pasta bakes. There were no nutritional risk assessments in place but the manager said residents have all been seen by the dietitian for advice in the past, and currently two residents are consulting the dietitian on specific issues. Residents occasionally have takeaways including Chinese meals, and fish and chips. Staff said residents have input into the menus on a weekly basis and individual support plans were seen to note each residents likes and dislikes in relation to food. Some residents help staff to prepare food such as putting ingredients into pans, and stirring, and this is always done under supervision. The kitchen was clean and tidy. However there was no evidence of an Environmental Health Officers visit to the home, so the manager was asked to follow this up. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal support in the way they prefer and require, and their health needs are met. Medication administration needs more work to ensure the safety of residents. Evidence: Two Support plans were sampled and both were very detailed about how residents would like their support to be given. Communication passports enable staff to improve their interactions with residents, and to be as clear as possible about residents needs and wishes. Times for getting up and going to bed are flexible and there were several examples on the day of inspection. Residents were dressed very individually and their appearances reflected their personalities. Staff were seen to spend time assisting residents with their personal grooming. The home has a designated key worker system offering consistency of support to each resident. The home has separate care plans on health and health related issues for each resident and these are in picture and word formats to ensure residents can be more involved. For example there was a section on healthy eating, with residents likes and Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: dislikes being recorded. The care plans also cover sight, hearing, chiropody and dentistry, and highlights any issues with skin. Risk assessments are in place relating to health conditions such as epilepsy. There were no nutritional risk assessments in place but the manager said residents have all been seen by the dietitian for advice in the past, and currently two residents are consulting the dietitian on specific issues; records sampled confirmed this was the case. Good records are kept of visits by health related professionals. One visiting health professional was interviewed during the inspection. They told the inspector that the the home is Very good and the staff Very helpful. They had been visiting the home on and off for three years and said staff always carried out any instructions they were given in relation to health care. When asked about the home overall, they said Station Road was One of the better homes. There is a medication policy in place at this home and the shift leader checks medication records to make sure they are satisfactory. Each resident has a laminated sheet with their photo and support guidelines in relation to medication. Two staff files were sampled and these showed they had had medication training. The manager outlined arrangements for medication training which she carries out with staff. Staff were observed giving medication and they were seen to be sensitive to the particular needs of each resident. Staff followed the District Nurses instructions to give one medication to a resident an hour before she arrived to do a dressing. Some good practices were observed including washing hands before dealing with medicines, keeping medicines securely, and allowing residents to be as independent as possible whilst taking their medication. The community pharmacist visit is overdue and the manager has approached the pharmacy, but this needs following up again. There were some concerns in relation to medication on the day of the inspection. One medication record was unclear due to the form being photocopied and dates had been written over. Also, a medicine given prior to the inspection had not yet been signed for. A new medication recommended by the hospital over the weekend following an emergency visit was not written up properly, this was an over the counter medicine. Other prescribed medication had not been recorded as given during the previous month. The manager said these medicines would have been given otherwise they would be in the blister packs at the end of the week, but she agreed that the current standard was unacceptable and she outlined several methods she had used to improve staff recording. During the week following the inspection the manager said she had introduced a new system to ensure medication was properly recorded and that there had been no further unexplained gaps. The issue with the over the counter medicine being badly recorded was dealt with immediately. It was also discussed with the manager that she should consider renewing her own training on medication administration, as she is currently doing the in-house medication training for staff; the previous external course she completed was Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: three years ago. Care Homes for Adults (18-65 years) Page 19 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident their complaints will be taken seriously, and any suspicions of abuse will be dealt with satisfactorily. Evidence: There is a complaints policy in place and a complaints book to record any complaints received, and this was looked at during the inspection. Staff are knowledgeable on how to communicate with residents and any concerns would be picked up by them. Staff were also observed to be very attentive to residents throughout the day and whenever they needed support or attention this was given immediately. All current residents also have relatives who would be able to make a complaint on their behalf. Two recent complaints from relatives had now been satisfactorily dealt with by the manager. The home has a copy of the local safeguarding adults procedures and a copy of the safeguarding adults flowchart from the local authority which shows staff what action to take in the event that they become aware of a protection of vulnerable adults issue. This was displayed in the office and on the dining room notice board. The subject is covered in staff induction and subsequently in the homes El box training. This is a lap top based training package purchased by the company and covers a variety of training subjects. The pova training session was demonstrated to the inspector and it was noted that the marked assessment at the end needed to be passed before candidates were issued with a pass certificate. It was very clear about reporting any suspected Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: instances of abuse to the person in charge immediately. The local safeguarding adults co-ordinators number is readily available on the telephone contacts list in the office. Two safeguarding issues have been raised since the last inspection and these have now been satisfactorily concluded. Residents money is managed by their families, though each resident has the option of keeping a wallet for day to day expenses, and where this option is taken up, the wallet is kept securely within the home. These arrangements are outlined on Page 13 of this report. Care Homes for Adults (18-65 years) Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Station Road offers a very homely and pleasant environment, which is clean and hygienic throughout. Evidence: Station Road offers a very pleasant and homely environment with a high standard of decor and furnishings. The lounge area had over 20 ceiling spotlights, with coordinated carpets, curtains and furniture being carefully selected. There were matching pictures on the walls which staff said the residents had helped to choose. The kitchen is domestic in appearance with a large range style cooker. This area was clean and tidy and kept locked unless staff and residents are in there. There is a dining room which was popular with residents as it also doubles as an activities room. The sensory room is currently being refurbished and had an excellent range of sensory objects, sounds and lights, for the enjoyment of residents. Two residents rooms were visited and one in particular was like a sensory room in itself, with restful lights and colours, and was observed to be very much enjoyed by that resident. The home was clean and tidy throughout, with no unpleasant odours in any part of the building. There are sufficient laundry facilities though the washing machine had recently been out of action and staff had been taking washing to the launderette. The Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: manager said it had now been repaired. All staff do infection control training either as part of health and safety training, or as the new separate infection control course. Care Homes for Adults (18-65 years) Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by competent and qualified staff. Recruitment and training arrangements are well developed and protect service users. Evidence: The AQAA states that staff at the home have clearly defined job descriptions and understand their roles. It stated that they are very supportive of residents and of each other, and this was observed during the inspection, where staff were seen to work together for the benefit of residents. The staff know and understand the residents very well, and were observed to be very approachable and accessible to residents during the inspection. Residents were seen to go to staff when they needed support. The staff at this home do LDAF training so they are knowledgeable on the needs of those with learning disabilities. Care plans and communication passports include the cultural and religious needs of residents and how staff should support residents in this regard. Half of the care staff hold an NVQ 2 or 3 qualification in care. Recruitment files for this service are kept at the head office by prior agreement with CSCI, and a copy of this agreement is kept at the home for reference. A proforma is kept at the service containing the details needed during the inspection. Two staff files were sampled and both had an application, a full employment history with any gaps Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: followed up, and two references. Interview notes are kept, as are copies of staff identification. Where staff start with a POVAfirst only, whilst waiting for the full CRB, a risk assessment is carried out. The new staffs files showed they had had regular supervision sessions. The copies of staff terms and conditions were also on file. The AQAA states that staff training and support meets the Sector Skills Council training targets. Staff records sampled showed that training considered to be mandatory by the home was given to staff on a rolling programme and those courses sampled during the inspection including fire, first aid, health and safety, infection control and protection of vulnerable adults, showed staff were up to date with training. There is structured induction training and the two most recently employed staff had both done an induction to care, the Voyage Induction, and the manager said they would be moving on to a learning disability qualification following completion of their main induction. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well managed home where the quality assurance processes are well developed. The health, safety and welfare of service users is promoted at this home. Evidence: A new manager has been appointed at Station Road since the last inspection, and she said she is currently completing the application forms to register with CSCI. She has worked in care for 10 years, and managed a previous service for 4 years before joining Station Road. The manager said her RMA now completed and she will be starting the NVQ4 in care in the New Year. She keeps up her own knowledge and training and attended an 8 month management development programme with Voyage which included courses on recruitment, supervision, and disciplinary and grievance procedures. The manager is responsible in her job description for the overall management of the home including ensuring that the home complies with the Care Standards Act and Regulations. Throughout the day she demonstrated a positive attitude to the inspection process and the few shortfalls highlighted during the day Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: were either dealt with immediately, or she set out how she would be dealing with them. Quality assurance processes are well developed and the system is monitored by the quality assurance officer from Voyage who has recently visited the service. The home also has Regulation 26 visits on behalf of the provider to look at the quality of care and service provided by the home. The home carries out an annual service review, and they send surveys to residents and families. Regular reviews of residents care plans are another way in which the home looks at the quality of the service they are providing. A recent Quality Assurance officers visit in November 2008 made a number of recommendations, but also described the home as clean, tidy and inviting, with a warm and friendly atmosphere. The manager demonstrated that she had already completed a number of the recommendations either in full or in part, and was still working on some others. Health and safety policies are in place at this home and the manager outlined the arrangements including weekly health and safety checks in bedrooms and communal areas using a checklist, monthly health and safety audits, weekly checks on wheelchairs and swings, and weekly fire checks covering alarms, lights and doors. A full legionella risk assessment was carried out in September 2008 and this identified the regular monitoring required to prevent legionella, for example running taps that were not used very often. The Environmental Health Officer has not visited the home for some time and the previous report from them could not be found. The manager was asked to chase up whether a visit was overdue, or to ask for a copy of the previous report. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 The arrangements for the 02/01/2009 administration of medication must be reviewed to ensure record keeping is improved, and meets safe administration standards. For the safety and welfare of residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 17 It is recommended that the manager follow up with the Environmental Health Department of the local authority to see if a visit to the home is overdue, or to obtain a copy of the report from their previous visit. The manager should follow up on the overdue community pharmacists visit to ensure the staff and residents benefit by an inspection of their medication arrangements. The manager should consider renewing her own training on medication administration. 2 20 3 20 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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