Inspection on 30/08/07 for 48 Cedar Road

This inspection was carried out on 30th August 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

48 Cedar Road 21/11/06

48 Cedar Road 20/10/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 48 Cedar Road Dudley West Midlands DY1 4HW Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 30 & 31st August 2007 10:30 th 48 Cedar Road DS0000063797.V340789.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 48 Cedar Road DS0000063797.V340789.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. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 48 Cedar Road Address Dudley West Midlands DY1 4HW 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) 01384 241877 01384 241746 Mr L Swarbrick Vacant Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Physical disability (9), Sensory of places impairment (9) 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: 48 Cedar Road is registered to provide care and accommodation for a maximum of nine adults, between the ages of 18 and 65, with acquired brain injury. Service users are offered 24-hour personal care and support, including one waking/one sleeping in night staff. The aim of the home is to provide medium to long-term support to service users to assist them to develop an independent lifestyle, according to their individual abilities. The home is a two-storey detached purpose built property situated in a residential area of Dudley, close to local shops, amenities and public transport. It has its own transport and off-road parking is available to visitors. It provides good access for people with limited mobility. The first floor can be accessed by a passenger lift. Communal facilities include lounge, kitchen with large dining area, activity room and private rear garden. Nine single-occupancy bedrooms are provided all are spacious, furnished to a high standard and have en-suite facilities. Service users have the option to use the bathroom, if they prefer, and additional toilets are situated close to communal areas. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 30th & 31st August 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults and report on the progress made to address previous requirements. The inspector’s findings are based on the information received by the Commission for Social Care Inspection since the last inspection, surveys completed by service users, relatives and other stakeholders, examination of relevant records and documents kept at the home and discussions with the manager, staff on duty and service users present during this visit. The atmosphere within the home was relaxed and friendly. A tour of the premises found it to be clean, tidy and furnished to a high standard. Service users expressed satisfaction with the environment, the plans for the redecoration of their bedrooms and the care provided. Two requirements remain outstanding from the previous inspection and a further two were identified during this visit. What the service does well: What has improved since the last inspection? The home’s Statement of Purpose, Service User Guide and other documentation is provided to service users in alternative formats. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 6 Service users continue to be consulted about their individual care needs and participate in the day-to-day running of the home. The key worker role is being developed further to ensure it meets the expectations of the service users. The home continues to work well with healthcare specialists and employs the service of a neuro psychologist on a contractual basis. Training for staff identified at the previous inspection has been provided and a review has been undertaken of the management of medication to ensure practice continues to safeguard the well being of service users. 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. 48 Cedar Road DS0000063797.V340789.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 48 Cedar Road DS0000063797.V340789.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): 1, 2, 3, 4 & 5 Quality in this outcome area is good. Information is available in user-friendly formats to enable prospective service users to make an informed choice about where to live. The home is advised to keep records to demonstrate that this information has been provided to all prospective service users. A detailed assessment process is followed to ensure the home is able to meet prospective service users care needs and aspirations. This includes the opportunity for service users to visit the home and stay overnight. A copy of the contract/terms of statement and conditions, signed by the service user (or their representative) and the home is provided with her/his Service User Guide. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home is provided in the form of a Statement of Purpose and Service User Guide. Both documents have recently been reviewed and are being provided in written formats. The manager stated work is also being carried out to provide information about the service on DVD. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 9 A copy of the individual contract agreement is provided to each service user with their Service User Guide. A mixed response was received from service users about whether information about the home was given to them prior to their admission. The manager is advised to record details of the information given to prospective users in order to demonstrate this has been provided. Information about prospective service users is obtained from the placing authorities at time a referral is made. Once this has been received the senior care planner for Milbury Voyage carries out a detailed assessment on the prospective service user’s care needs. The manager stated she is consulted about the outcome of the assessment and involved in the decision-making process to identify whether the home is able to meet the needs of the prospective service user. Copies of the needs assessments are available on the service users files, together with written confirmation from the senior care planner, on behalf of the manager, stating the home is able to meet her/his needs. A transitional planner is produced that includes arrangements for staff to visit the prospective service user, visits to the home and an agreed plan of how the move to the home is to be managed. The home has improved its access to specialist services by recently retaining the service of a neuro psychologist. Training in caring for people with acquired brain injury (ABI) has been provided to staff to ensure the care needs identified through the assessment process can be fully met. 48 Cedar Road DS0000063797.V340789.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, 8 & 9 Quality in this outcome area is good. The home produces care plans with the individual service users. They are encouraged to make their own decisions and are supported to take risks as part of an independent lifestyle. Consultation takes place with service users about all aspects of life in the home on an individual and group basis. However, service users would benefit from group meetings that are facilitated by confident and skilled staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are developed from the information provided from the needs assessment. The home is in the process of developing more user-friendly formats. The records show service users are regularly consulted about their individual plans. The plan is signed by the service user (or their representative), the home and health/social care professionals. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 11 Physiotherapists, speech and language therapists and behavioural therapists provide supplementary guidance, where applicable. The allocated key worker for each service user regularly monitors and carries out in-house reviews of the plan with the service user. This includes supporting service users to make their own decisions. Monthly summaries of the outcome of the discussions are available on the service user’s file. The manager stated work is currently being undertaken to explore, with the service user, how the key worker role can be developed to ensure it meets her/his expectations. Minutes of formal care reviews show these are held at least once every six months. Service users confirmed they were able to make their own decisions and valued the support provided by staff. Individual risk assessments are carried out and risk management strategies are put in place to enable service users to safely participate in their preferred activities. The risk assessments looked at included a range of areas that affect the life of individual’s, such as management of seizures, reducing the risk of injury through falls and managing challenging behaviour. Regular reviews are carried out on each risk assessment and, where applicable, relevant professionals are consulted on any changes. For example the home increased its staffing levels for a newly accommodated service user with a history of falls at night. More recently the home has been working closely with professionals in an effort to identify strategies to reduce the incidents of challenging behaviour displayed by a service user towards other service users and staff. Weekly meetings are arranged to provide service users with opportunities to express their views and contribute to the running of the home. The minutes of the meetings show a wide range of topics are discussed, however, on occasions, the way in which some service users chose to express their views has resulted in the meetings being drawn to an early close. The manager stated the diversity within the group is an area that is being looked at. The manager is advised to consider providing staff with opportunities that will assist them in developing their confidence and skills in facilitating meetings. 48 Cedar Road DS0000063797.V340789.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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. Service users are provided with opportunities for personal development and are supported to participate in activities. However, they would benefit from being supported to access a wider range of more community-based activities on a more regular basis. Service users rights are respected and they are supported to maintain and develop their relationships with family and friends. The home provides service users with a healthy diet and pleasant surroundings in which to enjoy their meals. This judgement has been made using available evidence including a visit to this service. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 13 EVIDENCE: Individual goals are detailed in the service users plans and various in-house and external tasks are identified to support service users to achieve these goals. Tasks identified for more independent service users include opportunities to improve social and practical skills by regular visits to the pub and preparing meals. The more dependent service users are encouraged and supported by staff to carry out exercises identified by healthcare professionals to improve their communication and mobility skills. The manager stated service users often express an interest in attending courses to learn new skills. Staff provide support by ensuring suitable arrangements are made to facilitate this. However, current service users often chose not to attend once the arrangements are made. Key workers discuss any concerns the service user may have. The home is now looking at alternatives, such as distance learning, to enable service users to gain new skills. One service user enjoys working as volunteer in a local charity shop, a position s/he has held for some time. A member of staff supports her/him during each shift. The service user commented that s/he is not always aware of which member of staff will support her/him until the day they day of her/his shift. This was brought to the attention of the manager. The home is situated close to local shops and amenities and has its own transport, but service users are also encouraged to use public transport wherever appropriate. During the visit one service user was accompanied to a multi-sensory centre and other service users spent time at the shops. However, there is little evidence that regular day trips or holidays have been provided since the last inspection. The manager has identified this as area for improvement in the home’s self assessment. The home has a designated activity room that is furnished with a pool table and exercise machine. A selection of art materials and various board games are also available. Previous arrangements for keyboard lessons have been replaced, at the service users request, with guitar lessons. The home also employs a part-time activity technician who encourages service users to develop their creative. An activity folder is provided for each service user and a record is kept of their current interests and participation in activities and made available at the service user’s review. The inspector spoke to a service user who had chosen to spend the morning drawing. The majority of pictures originally purchased by the home have been replaced by artwork completed by this and other service users. The home operates an ‘open door’ visiting policy, but asks that visitors give due consideration to other service users. All visitors are asked to sign the visitor’s book on arrival and departure. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 14 Service users are supported to maintain contact with family and friends, where applicable. Positive comments were received from relatives about their visits and the care being provided. One relative expressed concern over care and staffing issues. The manager stated she was aware of this and the matter was currently being dealt with through home’s complaints procedure. On a more positive note relationships between the home, service users and relatives are promoted through barbeque parties in the summer and other social activities during the rest of the year. Service users are encouraged and supported to keep a ‘communication book’. This assists with effective communication with others and service users choose what information they wish to include and who may they wish to see it. The records kept by the home show service users daily routines are observed. They are provided with keys to bedroom doors and the lockable facility. Staff respect service users right to privacy and do not enter bedrooms without being invited. Service users are supported to arrangement to be included on the electoral role if they wish. One service user is being supported to access an independent advocate. The provision of meals is the responsibility of the care staff and all have received training in basic food hygiene. Service users are consulted about menus and records are kept of individual preferences and dietary requirements. Arrangements are being made for staff to be more informed about the needs of service users who are diabetic. Service users participate in shopping trips to purchase food and other tasks associated with providing meals. There are few occasions when service users choose to eat meals in their own rooms, preferring to take their meals with others in the dining are of the kitchen. Positive comments were received from service users about the meals. One service user said, “The meals are really good and I also enjoy cooking”. Staff stated one service user regular makes use of the small domestic kitchen on the ground floor to prepare a meal for her/himself. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. Service users are provided with personal support in the way they require and that meets their individual preferences. Suitable arrangements are made to ensure their physical and emotional health needs are met. The home’s policy and practice for managing medication protect the health and well being of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans include details of how service users prefer their personal care needs are to be provided. The home is equipped with suitable aids and adaptations to promote independence and enable staff to provide care in a safe manner. Training in manual handling has been provided to all staff. Information provided by the home prior to the inspection identified two service users who “occasionally” require personal attention during the night. This was not identified in their care plans and the home does not have written guidance for promoting continence. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 16 The manager and staff stated such occurrences are infrequent and appropriate care is provided. The manager is advised to provide information on promoting continence for staff to refer to. Service users have access to all relevant health care professionals and are supported by staff to attend appointments. As previously report the home has recently contracted the services of a neuro psychologist. Detailed records are kept of all service users physical and emotional health needs demonstrating these are being appropriately met. Training in caring for people with epilepsy has been attended by the majority of staff. Suitable arrangements are in place for the storing and safe handling of medication. Responsibility for managing medication is given to staff that are suitable trained and been assessed as competent by the manager. A random sample of Medication Administration Records Sheets (MARS) was examined and found to be satisfactory. The home has reviewed its practice since the last inspection to ensure accurate entries are made on the MAR sheets for medication prescribed in between the pharmacist’s normal cycle of delivery. 48 Cedar Road DS0000063797.V340789.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 & 23 Quality in this outcome area is good. Service users feel the home provides them with good opportunities to express their views. They feel these views are listened to and appropriately addressed. The home has good systems in place and provide suitable training for staff to ensure service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission for Social Care Inspection (CSCI) has received no complaints about the service. Information about the home’s complaint procedure is included in the Statement of Purpose and a copy is provided to service users in a user-friendly format. Service users stated they are encouraged to express any concerns they may have on a day-to-day basis, during key worker sessions and at weekly house meetings. They reported that staff appropriately deals with any concerns they have and are aware of the home’s complaint procedure but have not felt it necessary to make use of this. The records show a complaint received from a relative was appropriately dealt with and a written response of the findings was forwarded to the complainant. As previously reported the manager said she was already aware of the comments provided to the inspector by a relative. A record of relative’s complaint has not been entered in the home’s records. The manager stated the investigation into the relative’s complaint had not yet been concluded. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 18 The manager is advised to record the nature of any complaint on the date it is received. The staff team has received training in the protection of vulnerable adults. Appropriate policies and procedures for safeguarding adults are available in the home and copy is provided to service users in an alternative format. Three referrals have been made by the home under the safeguarding vulnerable adults procedures, satisfactory investigations have been carried out and appropriate action taken. One service user continues to display inappropriate sexual and aggressive behaviour towards service users and staff. Training has been provided for all staff in managing challenging behaviour. Risk assessments are reviewed regularly and strategies identified to protect service users and staff. Previous discussions have been held with the relevant agencies about the service user’s behaviour. Due to the increase in the frequency and seriousness of these incidents discussions are now taking place to identify a more suitable placement. 48 Cedar Road DS0000063797.V340789.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 & 30 Quality in this outcome area is excellent. Service users live in an excellent environment that is fully equipped to meet their physical needs and enable them to develop their independent living skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Off-road parking is available at the front of the house and a small, secluded, pleasant garden and patio area is situated at the rear. The atmosphere in the home is welcoming. One service user offered the inspector and staff drinks through out the visit. Furniture and fittings in the home are of good quality and domestic in style. Service users who have poor mobility can be accommodated on either the ground or first floor, as hallways and landings are wide and spacious a passage lift provides access to the first floor. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 20 All bedrooms are single occupancy, spacious and have en-suite facilities comprising of walk-in shower, wash hand basin and toilet. There is an assisted bathroom on the ground floor. As previously stated suitable aids and adaptations are fitted throughout the building. Service users are encouraged to personalise their rooms and are being consulted over the plans for redecoration. Each service user has made a personalised name plate for their bedroom doors. Communal rooms are located on the ground floor and include a comfortable lounge, kitchen with spacious dining area, an activity room and a small domestic kitchen. An appropriately equipped laundry is situated on the first floor. Support is provided for service users to carry out laundry tasks that have been identified in their individual plans. 50 of the staff team have attended training in infection control. The manager stated arrangements have been made for the remaining staff to attend this training. The home was found to be clean and tidy. 48 Cedar Road DS0000063797.V340789.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, 35 & 36 Quality in this outcome area is adequate. The home provides sufficient competent and qualified staff to meet the needs of the service users. Recruitment procedures and systems for supervising and supporting staff need to be fully implemented to ensure service users are well protected and cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided by the home shows 50 of the permanent staff team hold a Level 2 National Vocational Qualification or above. The staff team have all attended the ABI (acquired brain injury) training course and the most have attended a session on the key worker’s role. As previously stated staff are working with service users to identify areas in which the key worker role can be improved. Staff stated they would benefit from more client-centred training. One member of staff said they were particularly interested in developing skills in art therapy. An individual training and development programme needs to be produced for all staff. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 22 The recruitment records for three staff appointed since the last inspection were examined. This showed there continued to be some shortfalls in the home’s recruitment process. For example there was no evidence that the gap in the employment history for one applicant had been explored and a reference from another applicant’s most recent health care employer had not been requested by the home. However, improvements have been made to ensure POVA (Protection of Vulnerable Adults) First and CRB (Criminal Record Bureau) checks are appropriately carried out. A copy of the contract of employment for two employees, who commenced duties in February and May this year, were not available on the files. The manager must ensure all recruitment procedures are completed in a timelier manner. There are good procedures for the induction of new staff that includes a workbook to be completed by the worker and a seven-day programme for working supernumerary under the direct supervision of a senior member of staff. However, these have not been completed. Suitable induction and foundation training programmes must be implemented for staff and completed within the required timescales. Arrangements must be made to discuss progress with the worker on a regular basis. Plans are made for staff to attend mandatory training and regular update training. The home’s Statement of Purpose states supervision is mandatory for each member of staff and staff meetings are held approximately once a month. Records of individual supervision and training were not available on the files examined. The minutes of two staff meetings were available for the last nine months. The need to provide suitable support to staff through regular structured supervision and staff meetings was discussed with the manager. She confirmed a staff meeting had been arranged for 3rd September to discuss the home’s Statement of Purpose, service user meetings and activities. 48 Cedar Road DS0000063797.V340789.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 & 42 Quality in this outcome area is good. Service users benefit from living in a home run by new manager who is known to them. Their best interests are safeguarded by the home’s policies, procedures and record keeping. Implementation of a comprehensive quality assurance system and a process for providing feedback would further promote service users confidence that their views underpin the self-monitoring, review and development by the home. This judgement has been made using available evidence including a visit to this service. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager was previously employed at the home as the deputy. She holds nationally recognised qualifications and is working towards attaining the Registered Manager’s Award. The Commission for Social Care Inspection (CSCI) is processing her application to be the registered manager for 48 Cedar Road. The home has relevant health and safety policies and procedures. The majority of these have been reviewed during the last six months. Regular checks are carried out on the premises, appliances and equipment and appropriate records are kept. Training is provided for staff in health and safety issues such as fire safety and first aid. Accident records are appropriately maintained and, where applicable, the relevant agencies are notified. A comprehensive quality assurance system has yet to be implemented for the home to measure its own success in achieving its aims, objectives and statement of purpose. The manager stated this was in the process of being addressed. Monthly visits continue to be made by a representative of the company and a written report is produced on the conduct of the home. 48 Cedar Road DS0000063797.V340789.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 3 2 3 3 3 4 3 5 3 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 Requirement Recruitment procedures for staff must be fully completed to ensure the safety and best interests of the service users are protected. Newly appointed staff must be provided with a suitable work programme. (Original timescale, 10/02/06, has not been fully met) Staff must be supported in their duties through a regular programme of supervision. The home must implement a monitoring system to selfaudit its performance against its aims, objectives. statement of purpose and the National Minimum Standards for Adults. The registered persons must produce an annual development plan. (Previous timescale, 07/02/07, has not been met) 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 27 Timescale for action 23/11/07 2. YA35 18 23/11/07 3. YA36 18 23/11/07 4. YA39 24 04/01/08 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. 4. 5. 6. Refer to Standard YA1 YA8 YA14 YA18 YA22 YA35 Good Practice Recommendations The home is advised to demonstrate through its recordings that suitable information about its service has been provided to all prospective service users. The manager is advised to provide suitable training opportunities for staff to develop their confidence and skills in facilitating service user meetings. Service users should be provided with more opportunities to participate in community-based activities and to enjoy regular day trips and/or take a short holiday. The manager is advised to provide staff with information on promoting continence. The complaint details should be appropriately recorded at the time it is received by the home. All staff should be provided with an individual training and development programme. 48 Cedar Road DS0000063797.V340789.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Office Ground Floor West Point Mucklow Hill Halesowen B62 8BR 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 48 Cedar Road DS0000063797.V340789.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!