Inspection on 06/02/08 for 44 Wilton Road

This inspection was carried out on 6th February 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

44 Wilton Road 10/05/06

44 Wilton Road 05/12/05

44 Wilton Road 17/05/05

44 Wilton Road 21/12/04

44 Wilton Road 25/08/04

44 Wilton Road 26/02/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Wilton Road (44) 44 Wilton Road Salisbury Wiltshire SP2 7EG Lead Inspector Alison Duffy Unannounced Inspection 6 February 2008 10:00 th Wilton Road (44) DS0000028684.V335887.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 Wilton Road (44) DS0000028684.V335887.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. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilton Road (44) Address 44 Wilton Road Salisbury Wiltshire SP2 7EG 01722 410724 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) judith.grant@rethink.org www.rethink.org Rethink Mrs Judith Grant Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2006 Brief Description of the Service: 44 Wilton Road is an 8 bedded home for adults who have long-term mental health problems. The registered provider is Rethink, and the building is owned and managed by Shaftsbury Housing Association. The registered manager is Mrs Judith Grant. 44 Wilton Road is located in the city of Salisbury and is within walking distance of the city centre. The home offers easy access to local amenities and is situated in a quiet cul-de-sac. There is ample parking to the front of the home, and ramped access is available. There is a large secluded garden to the rear of the house, with a patio area and a conservatory. Staffing levels are maintained at two or more staff on duty during the waking day. At night, a member of staff provides sleeping in provision. An on call management system is available at all times. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place on the 6th February 2008 between the hours of 10am and 5.30pm. Mrs Judith Grant the registered manager was not on duty yet came into the home for the morning, to enable access to staffing records. We spoke with three residents and four staff members. We looked at the medication systems and at care-planning information, training records and recruitment documentation. As part of the inspection process, we sent surveys to the home for residents to complete, if they wanted to. We also sent surveys, to be distributed by the home to residents’ relatives, their GPs and other health care professionals. The feedback received, is reported upon within this report. We sent Mrs Grant an Annual Quality Assurance Assessment (AQAA) to complete. This was returned on time and completed in detail. Some information from the AQAA is detailed within this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. What the service does well: Residents are encouraged to take responsibility for their lives and direct the support they need. Key factors such as enablement, empowering and independence are promoted. Care planning is person centred and reflects the individual’s overall goals, as well as day-to-day support. The manager has a sound value base, which is transferred to the staff team and service provision. Staff are motivated, have a clear awareness of residents’ needs and interact positively with residents. Meal provision is based on healthy eating and fresh produce, with residents’ choice and involvement key factors. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 6 Residents are clear about how to raise any concern and feel they would be listened to. Advocacy systems are in place, for residents to use as they wish. A robust recruitment process is in place, which gives residents additional protection. 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. Wilton Road (44) DS0000028684.V335887.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 Wilton Road (44) DS0000028684.V335887.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed, well-organised admission procedure, which fully involves the prospective resident. EVIDENCE: Within the AQAA a detailed admission process was evidenced. The placing authority would complete an initial application form. This would include a copy of the prospective resident’s current multidisciplinary care plan (CPA) and any current risk assessments. The manager would meet with the prospective resident and complete the home’s own assessment form. If it were felt the home could meet the resident’s needs, various visits would be encouraged. A key worker would be allocated and a trail period offered. There has been one new placement to the home, since the last inspection. The above process was evidenced within written documentation. Two residents told us that they had been fully involved in selecting 44 Wilton Road as their new home. They said they had visited and met residents and staff. Both were happy with the information given to them before their admission. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 9 Within surveys, four residents said they were asked if they wanted to move into the home. One resident could not remember. One resident said ‘It was either this or the Old Manor.’ Wilton Road (44) DS0000028684.V335887.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a good standard of recovery planning and are fully involved in the process. Residents are actively encouraged to make decisions regarding their daily lives, with support where necessary. Risk taking is used as a means to enable, rather than restrict activity. EVIDENCE: Each resident has a detailed, up to date recovery plan. The plan highlights various personal goals. The support needed to meet the goals and potential barriers were also clearly stated. Each plan contained a monthly review of information. Monitoring sheets were used to evidence particular issues, which could then trigger a change in the recovery plan. Documentation demonstrated that residents are involved in both the development and review of their plan. At the last inspection, a recommendation was made to ensure greater separation between mental health needs and physical health needs, when planning how to support residents. This had been addressed. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 11 One resident told us about their support plan. They said they talk to their key worker about what they want. Residents told us they were happy with the support they received. We heard a member of staff and one resident talk about a forthcoming review. The staff member was encouraging the resident to be honest and express how they felt. They emphasised the view by saying, ‘it is your time and your review, so you can use it, as you wish.’ Within surveys, five relatives told us that the care home meets their relative’s needs. One relative commented ‘very caring, thoughtful and professional.’ Residents are supported to follow their preferred routines and make decisions within their daily lives. Within surveys, residents said that they could choose what they wanted to do. Residents told us that they could get up and go to bed when they liked. They could make drinks and snacks and go into town if they wanted to. One resident told us that staff were helping them with losing weight. Another resident told us that they now help around the house more. Staff told us that they felt it was important to enable residents to voice their opinions and enable them to be in control of the support they needed. They said that there were various opportunities to discuss such aspects. These included residents meetings, one-to-one time, discussion over meal times and the local advocacy service. Mrs Grant confirmed a person centred approach and spoke of setting achievable targets with residents. Within the AQAA, Mrs Grant told us ‘staff support residents in decision making about their lives by respecting them as individuals, and respecting their views.’ We noted that while residents have free access to the kitchen during the day, the facility is locked at night. Residents told us that they could take a drink to their room in the evening, in case they wanted one during the night. Mrs Grant told us that locking the kitchen at night was historical. We advised a review of the restriction. Mrs Grant agreed with this and said she would discuss free access with residents and staff at the next residents meeting. Risk taking is incorporated into recovery planning and is used to enable, rather than restrict activity. There are a number of risk assessments within each recovery plan. Issues addressed included, self-administration of medication, buying over the counter medication, road safety and not disclosing information from a GP appointment. Specific guidelines for staff were available, in the event of managing any potential hazard. Wilton Road (44) DS0000028684.V335887.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and leisure activities are based on individual wishes and therefore tailored to individual need. Residents are supported to maintain important relationships and take control over their lives. Meal provision ensures variety, healthy eating and individual preference. EVIDENCE: Residents told us that they regularly go out to places of their choice. One resident said they often go into town for a coffee or shopping. Another said they liked the library. They said they often used public transport, as there was a bus stop just outside the home. One resident was having a quiet day. They had been to the ballet the previous evening and were therefore up late and tired. Some residents regularly go out to collect their medication, have their hair done, buy their cigarettes or cash their allowances. One resident undertakes dog walking on a voluntary basis. Mrs Grant explained that at Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 13 present, paid employment is not focused upon. However, if a resident expressed a wish to investigate these options, support would be given. Recovery plans identified self-fulfilment and the support needed to reach any identified goals. The notice board contained details of a range of local activities, which residents could become involved with, if they wanted to. Staff told us, that activity provision is regularly discussed during residents meetings and informally over a meal. Within a survey, one relative told us ‘staffing and resource constraints sometimes limits choice in activity but service appears to do its best.’ Further comments included ‘XX is very happy living where s/he is’ and ‘it [the service] helps XX to manage his/her independence.’ Also ‘helps XX to maintain quality of life and provide care and support. They’ve also helped him/her settle into a regular and balanced daily routine. Special praise to XX, XX’s key worker.’ As a means to improve the service, one relative said ‘more one-to-one time to enable activities away from the home for individuals.’ Another said ‘more days out for the residents, to organise trips and events.’ Residents have access to a local advocacy group. Contact details are highlighted on the notice board in the hallway. Residents told us that they could have visitors, as they wished as long, as they did not disrupt other residents. They told us they could have visitors in their own room or in the lounges. Residents had a key to their room. They said their privacy was respected. Within surveys, three relatives said that staff helped their relative keep in touch with them. One relative said they relied on their relative’s letters and phone calls from the staff. Another relative said ‘we visit XX regularly but I’m not aware of any help given to XX to maintain contact.’ All relatives said they were kept up to date with important issues. Mrs Grant told us that the home emphasises residents having ownership over their lives. All residents now have their own supply of items such as milk. If supplies run out before the planned shopping trip, it is the resident’s responsibility to go out and purchase more. Since introducing this, staff said that residents are now taking more responsibility and are being empowered. Residents told us that they all have specific jobs to do around the house. One resident showed us the housekeeping roster, which was displayed on the notice board. Another resident told us that staff had helped them change their bed and launder their bedding. Staff told us that the weekly menu is devised with residents on a Sunday. All residents are therefore able to contribute and have their preferences catered for. Staff told us that healthy eating is promoted. Fresh produce is used as far as possible. The majority of meals are ‘cooked from scratch.’ We saw a good range of fresh fruit and vegetables in the kitchen. Residents are supported to make their own breakfast and lunch. Staff told us they generally take Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 14 responsibility for the evening meal yet residents may assist if they want to. Staff and residents eat together, so the time is used to talk about the day’s events. Wilton Road (44) DS0000028684.V335887.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are consulted about the way in which they would like to be supported. Residents have access to a range of health care services, as required. Medication systems are sound yet staff must follow the home’s procedures to minimise the risk of error. EVIDENCE: Residents are able to discuss their personal support needs with their key worker and within review meetings. These are fully recorded within recovery plans. Identified interventions highlighted the importance of maintaining privacy and dignity at all times. Aspects of healthy living such as taking exercise and healthy eating are promoted. Staff spoke of encouraging exercise through normal daily activity, such as walking to the local shop to get a newspaper. Residents have access to a range of health care services as required. Residents are able to make their own appointments, if they wish. A record of all health care appointments and intervention is maintained. Such appointments include the dentist, consultant psychologist, podiatry and the community mental Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 16 health team. Residents are supported to keep a record of their weight. One resident told us that if they are feeling unwell, they tell a member of staff. They said ‘they [the staff] know what to do.’ Mrs Grant told us that consideration has been given to enabling residents to self-administer their own medication. At present, systems have been developed for two residents to do this. All medication was orderly stored and satisfactorily receipted. The medication administration records were generally well maintained. However, one instruction stated a medication should be given four times a day. There were no signatures to demonstrate administration. Staff said this medication had been discontinued but not changed on the record. Staff said they would address this immediately. Another resident was prescribed two different types of pain relief. Staff told us when each medication was to be given. However, we advised that such detail must be documented both in the medication administration record and care plan to avoid error. As good practice, a member of staff had countersigned all handwritten medication instructions. Guidelines were in place for the administration of ‘as required’ medication. At the last inspection, a requirement was made to cease transferring medication into small pots, before being given to residents. Mrs Grant and staff confirmed this practice had stopped. The medication is now dispensed from the monitored dosage system. Within 2007, there were four drugs errors whereby individual residents were not given their medication. Mrs Grant told us that to minimise further error, the systems had been reviewed and additional staff training and competency checks had been arranged. Mrs Grant said she felt this action had addressed the risk of further error. Wilton Road (44) DS0000028684.V335887.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are clear about the ways in which they can raise a concern and feel that issues would be acted upon. Residents are assured greater protection from abuse through well-managed adult protection systems. EVIDENCE: All residents have a copy of the complaints procedure. There is also a copy of the procedure on the notice board. Various contact numbers of people within the organisation and the community mental health team are available for residents to use, if required. Residents told us they would speak to a member of staff, Judith [the manager] or their key worker if they had a problem. They felt that their concerns would be sorted out. Staff told us they would try to address any issue as it arose. They said any serious issues would be passed to the manager or senior managers within the organisation. Mrs Grant expressed an open approach to complaints. She told us that she views complaints, as a means to improve the service. There have been no formal complaints reported to the home or to us, since the last inspection. Within surveys, four relatives were aware of the home’s complaint procedure. One relative was not aware. One relative told us ‘service is proactive in enabling service users to voice views. Always welcoming of advocacy.’ Another survey stated ‘service always responds appropriately.’ Staff told us they would immediately respond to any allegation or suspicion of abuse. They said they would intervene to stop any incident but would then Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 18 notify management of the situation. Management would then make the decision to alert the Safeguarding Vulnerable Adults Unit. Staff said they had a copy of the local adult protection reporting procedures ‘No Secrets.’ Mrs Grant told us that such procedures are discussed in staff meetings and supervision. Staff have received training in the protection of vulnerable people. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a clean, homely and safe environment that they are able to maintain and take responsibility for. EVIDENCE: All residents have a single room to which they have a key. There is a large lounge/dining room and separate conservatory. The kitchen is domestic in style and of a good standard. The bathroom contains a bath and a walk in shower. One resident gave us a tour of the accommodation. They told us they liked their room. They showed us important possessions and their small fridge, in which they kept snacks. They told us the shower had made their life easier. The environment was comfortable, homely and furnished to a good standard. Mrs Grant told us that a programme to install radiator covers is in place. Staff told us they would like to see the opportunity for more refurbishment. The corridor has carpeting, which continues up the wall. This was in place to minimise the damage from wheelchairs. This is no longer needed yet staff felt Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 20 the cost to remove the carpet, would be high and therefore not a priority at present. We agreed that replacing the carpet would enhance the area. Staff told us that since residents have been involved in housekeeping tasks, they take more pride in their environment. All areas we saw were cleaned to a good standard. One resident told us that staff helped them with their laundry. Staff told us that this support is given, as required. Within surveys, three residents said the home is always fresh and clean. Two said the home is usually fresh and clean. One said it sometimes was. In answer to the question, what does the home do well? One relative wrote ‘provides a homely environment.’ Wilton Road (44) DS0000028684.V335887.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a motivated staff team with positive relationships evident. While staff are clearly aware of residents needs, more training in recovery, may support residents further. Residents are protected through a clear, well-managed recruitment procedure. EVIDENCE: Staffing rosters demonstrated that there are two or more staff on duty during the working day. Since the last inspection, night staff arrangements have changed. There is now a sleeping in arrangement rather than waking night staff. Mrs Grant told us that this had initially caused concern. However, since being in place, the arrangements have worked well. Mrs Grant told us that she felt residents are now more empowered and take more individual responsibility. Staff confirmed this. They said residents now think of their own safety and that of others. For example, residents are aware of what to do if they come across a fire, they find staff unwell or they go out alone at night. One resident told us that at first, they did not like the staff not being around at night. They said ‘its ok now, as I know I can wake them up.’ Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 22 Staff told us that they have access to ongoing training. They said they could also ask if they needed more information about a subject. Mrs Grant told us, that by the end of the year, all staff would have a NVQ qualification. Training records showed that staff had undertaken various training courses. These included first aid, medication, adult protection, equality and diversity and basic mental health awareness. We noted that many of the subjects were mandatory and not particularly linked to the individual needs of residents. Mrs Grant agreed with this and felt that staff would benefit from subjects such as recovery. Mrs Grant confirmed this within her AQAA and commented that she would investigate the options available. We spoke to staff on duty about service provision. They spoke of residents in a respectful manner and appeared clear about individual needs. Staff said they felt well supported by management and believed they had a good team. Residents spoke favourably about the staff. One said ‘XX is my key worker. She’s good. We talk a lot and she helps me.’ Another resident said ‘they are all very good. We couldn’t ask for more.’ We saw staff talking positively with residents. We saw one staff listening attentively to a resident. Time was given to the interaction and the member of staff waited appropriately before responding. During one interaction, staff signed with a resident. Since the last inspection, there has been one new member of staff. We looked at the documentation demonstrating the recruitment process of this individual. The information was clear, ordered and all required information was in place. There were two written references. A Criminal Records Disclosure had been received before the member of staff had commenced employment. Wilton Road (44) DS0000028684.V335887.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a manager who is motivated and resident focused. Systems are in place to regularly audit and improve the service given to residents. Residents’ well being is promoted through clear health and safety systems. EVIDENCE: Mrs Grant has worked for the organisation since 1994. She initially started as a project worker then was promoted to team leader and acting manager. We have now registered Mrs Grant as the registered manager. Mrs Grant is undertaking the Registered Manager’s Award and then plans to undertake NVQ level 4. Mrs Grant demonstrated a sound value base and a commitment to developing service provision. She was clearly aware of residents’ needs and spoke in detail Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 24 about the wish to empower individuals. Mrs Grant spoke highly of the staff team and valued their work. We observed Mrs Grant talking to residents. Conversations were attentive, respectful and sensitively undertaken. One resident said ‘she’s lovely, she gets stuck in.’ Another resident said ‘she works hard and you can talk to her at any time. She listens to you.’ Mrs Grant told us that developing the service and improving residents’ quality of life were important factors. This included primarily, listening to residents to ensure a resident led service. Residents have access to an advocacy service. Mrs Grant and staff told us that residents’ meet with their advocate alone. This enables residents to have total control. There are regular residents meetings and a key worker system is in place. At the last and previous inspection, we made a requirement that the organisation’s quality assurance questionnaire be sent to residents and their families. Mrs Grant has done this. We advised that the feedback received should be coordinated and made available to residents. Mrs Grant told us she would do this and would discuss the findings at the next residents meeting. The organisation has a range of health and safety policies. Health and safety audits regularly take place. One member of staff told us they were responsible for fire safety. They showed us the fire log book. This demonstrated regular testing of the fire alarm systems. All staff had received fire instruction. We advised that the dates of the instruction be documented. Staff told us residents have fire training. One resident told us what they needed to do in the event of a fire. They showed us emergency contact numbers on the notice board. Environmental and individual risk assessments were in place. All staff have received up to date first aid and food hygiene training. As good food safety, maintaining refrigerator and cooked food temperatures are in place. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement The registered person must ensure that guidelines are in place within the resident’s care plan for taking two different pain relief medications at the same time. Timescale for action 28/02/08 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 3 Refer to Standard YA35 YA39 YA42 Good Practice Recommendations The registered person should ensure that there is an on going programme of recovery training. The registered person should ensure that feedback received from the quality assurance questionnaires is evaluated and available to residents and their advocates. The registered person should ensure that the dates fire instruction is given to staff are recorded. Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Wilton Road (44) DS0000028684.V335887.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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