Inspection on 27/09/06 for 49 Regents Park

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

49 Regents Park 26/06/08

49 Regents Park 31/07/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 49 Regents Park 49 Regents Park Heavitree Exeter Devon EX1 2NZ Lead Inspector Louise Delacroix Unannounced and announced Inspection 27 September and 2nd November 2006 11:00 th 49 Regents Park DS0000067537.V296976.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 49 Regents Park DS0000067537.V296976.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. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 49 Regents Park Address 49 Regents Park Heavitree Exeter Devon EX1 2NZ 01392 423847 01392 201324 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) Regents Park Limited Michael Andrew Cox Care Home 3 Category(ies) of Learning disability (3), Physical disability (3), registration, with number Sensory impairment (3) of places 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Service users with learning disability aged 16 to 25 years Date of last inspection 2nd March 2006 Brief Description of the Service: 49 Regents Park is a small registered care home for young adults. It provides individual care for up to three young people with learning or physical disabilities aged between 16 and 25 years. The home provides bright, cheerful and nicely decorated family style accommodation with three single bedrooms. There is also a noisy room with a CD player. Gardens at the rear are to be combined to provide a large garden providing more space social activities. Currently the garden is being landscaped and only the patio area is in use by residents. The owner of 49 Regents Park, also owns 47 and 51, and the three gardens are being joined together. The inspection report is on display. The cost of the service according to the home’s pre-inspection questionnaire is £1,000. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. The first visit took place during the day and was announced, lasting approximately five hours. The home’s paperwork was inspected, which included fire records, staff training and recruitment files, and a tour of the building took place. Time was spent discussing the service with the home’s registered manager. The second visit was unannounced and took place in the evening, starting at 5.30pm and lasting over two hours. On this occasion, time was spent observing the interaction between staff and the young people living at the home, and talking to two of the staff on duty. Care records were also looked at to check that they reflected the current experience of the service users living at the home. At the time of the second inspection, one service user was unwell and needed a high level of support to keep them and others safe. It was therefore inappropriate to speak with this service user. The two other people living in the home have profound communication needs, and therefore where possible observation was used to assess their well-being. As part of the inspection, surveys were sent to staff, service users’ representatives and people visiting the service, including health care professionals. Six staff members responded from the staff team. The responses from these surveys have been included in this report. Prior to the inspection, the home completed a pre-inspection questionnaire, which provides the commission (CSCI) with current information about the service, staff and people living at the home. What the service does well: Service users’ plans of care are generally well written and in a respectful style. The plans recognise the service users’ individuality, and their individual communication needs. Generally clear guidance is given for most aspects of service users’ lives and routines. The home has good links with the local community, and service users make use of a wide range of facilities. There is a well thought out menu, which is provided in a supportive atmosphere. The health care needs and medication needs of service users are well met, with regular reviews. Staff demonstrate a skilled approach to ensure service users’ individual personal care needs are met, and to recognise their changing needs. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 6 Staff are knowledgeable and confident in the area of safe guarding younger adults. There have been no complaints about the service since the last inspection, and the home’s complaints procedure is clearly displayed. The building is homely, clean and well maintained with service users benefiting from individually decorated rooms that are personalised. Staff demonstrate a strong sense of commitment to the service users and their well-being, and recognise the importance of good communication to provide continuity of care for service users. The levels of staffing appear to meet the needs of service users. The manager is currently auditing the training needs of staff and evidence to show that he is addressing shortfalls in knowledge. Staff feel well supported by the home’s management. What has improved since the last inspection? What they could do better: Poor staff recruitment practice continues. There have been previous requirements made in this area, with the imposed timescales unmet. The Commission for Social Care Inspection has not been kept informed of adverse events that have happened at the home and have therefore been unable to monitor how risk is managed. Requirements have been made in these areas to improve practice and timescales specified. The home will be asked to supplement an improvement plan to show how these concerns will be addressed. The following recommendations have been made to improve practice in the home. Care plans need to be reviewed and up dated to ensure that they reflect the service users’ current circumstances. Restrictions upon service users rights or freedoms need to be discussed in a multi-disciplinary setting, and the outcome recorded. The complaints policy needs to be made more useable for service users. The home promotes training but more staff should hold qualifications in NVQ in care, and the manager would benefit from further training to broaden their understanding of the complex needs of the service users. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 7 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. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 8 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 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home ensures that they can meet the needs of prospective service users through a joint assessment. EVIDENCE: No new service users have moved to the home for several years but in the past the home has worked closely with Social Services to ensure that they can meet the needs of prospective service users. 49 Regents Park DS0000067537.V296976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with information to help them to meet service users’ needs safely but improvements are needed to ensure they are up to date and appropriate. Decisions made on behalf of service users are not always done in consultation with others therefore not ensuring the decisions are in service users’ best interests. EVIDENCE: 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 11 Each service user has a plan of care and these were looked at during the inspection. These are generally well written, in a respectful and informative manner. The care plans are written to include most aspects of social and health care needs but they need updating to reflect changes to either service users’ current life experience or current care practice. For example, one plan of care did not reflect that one service user had left school. One plan of care did not evidence the specialist clothing that a service user wore at night to assist with personal hygiene. Regular reviews of the plans of care would help ensure that all the service users needs are being met, and help identify changing needs. However, the home does hold clear records to illustrate the changing moods and needs of a service user who is currently unwell. Staff spoken to were clear about the use of beanbags for two people living at the home as a ‘time out’ option, as well as explaining that service users actively chose to use them to comfort themselves by rocking or to feel safe. Staff confirmed that service users were able to get in and out of the beanbags independently but that one service user is encouraged to sit in a particular manner in the beanbag because of their current behaviour. This was observed to be the case for one service user on the night of the inspection. However, service users’ plan of care did not provide clear guidance around the use of this furniture, and this could lead to inconsistent and inappropriate use. Staff were asked about how service users made choices. Examples were given around clothing, food and social interests. Care plans give clear guidance to staff in how to interpret service users’ body language so that service users are enabled to express choices. For example, whether they wish to interact with staff or need time to themselves, or whether they wish to participate in an activity. One service user was seen exercising choice about where they relaxed, including spending time in their room away from communal areas. The service users’ plans of care contain individual plans and risk assessments for dealing with restrictions of freedom. This includes clear guidance about the safe use of transport, supporting service users to access the local community safely, and instructions on how to minimise self-harm or abuse or harm to others. This means that there are some restrictions on freedom for service users. For example, the use of wrist straps when service users go outside of the home. The use of such straps are to enable service users to access the local community safely by staff ensuring the risks are kept to a minimum. One service user currently wears a specialist sleep suit to assist with personal hygiene but consultation about its use is not contained in their record of care. However, any practices that may infringe upon service users’ freedom of movement should be discussed with other professionals, such as a Good Practice Committee. This would ensure that such decisions are made using a multi-disciplinary approach and are in the best interests of service users. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 12 Service users are supported to take part in a range of activities, including an overseas holiday, swimming, art and music therapy. Behavioural charts are kept and staff complete incident reports. These are generally well written, and show that staff follow guidance in the risk assessments and take appropriate action to minimise identified risks, which is good practice. Detailed information is kept to provide to the police so that staff can respond appropriately to unexplained absences. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with the community are good and ensure that service users benefit from a broad range of experiences despite the challenges that their complex care needs present. The service users’ benefit from a well balanced diet, which is provided in a supportive environment. EVIDENCE: Service users’ benefit from a range of activities, these include art, food preparation, gardening, computing and pet care. Evidence of the service users’ activities was seen, which included photos of residents participating in hobbies and trips out. Discussion with staff and care records show that service users also take part in swimming, music and art therapy, going out for coffee and visiting shops in the local area. Due to the complexity of the service users’ needs, they are unable to participate in employment opportunities. 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 14 Staff and the manager spoke about a recent holiday abroad, which the people living at the home had been supported to go on. Photographs showed the service users looking relaxed, enjoying swimming and eating out. Previously the owner has confirmed that this was part of the basic contractual price. Records show that people living in the home are supported to visit their families or meet them outside of the home. They are also supported to write to them. Staff confirmed that families are encouraged to stay in contact. One relative responded to the CSCI survey and said that they were made welcome and could see their relation in private. Service users were seen making choices about whether they spent time alone or joined in with communal living. During the inspection, this included choosing to watch television alone, and eating together. Due to the complexity of service users’ needs, keys are not provided for their rooms. Staff explained that service users chose their menu by using pictures to help them make an informed choice. The home has a weekly menu that is changed when service users indicate that their tastes have changed or that it has become repetitive. On the last inspection, the provider explained that a dietician had been consulted and that where possible healthy eating was promoted. However, service users’ personal preferences are also met. For example, one person likes to go into town to have a bacon sandwich. Service users’ care plans detailed the individual support that each person required and showed that service users are supported to maximise their independence. Daily notes reflected the support required. Staff explained how service users’ nutritional and fluid intake is monitored and recorded if they become unwell, which was seen in care records, and the steps that would be taken to address concerns. 49 Regents Park DS0000067537.V296976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and health care is provided in a manner, which is acceptable to service users, therefore recognising their individuality. Medication is well managed, which promotes the safety of service users. EVIDENCE: Care plans clearly state the preferred routines of each service user. For example, choice of bedtime, which was shown in their daily records. They detail the approach needed by staff to enable service users to feel in control of personal routines i.e. having their hair brushed. They emphasis the need for staff to pick up on non-verbal signs to ensure that their approach is suitable for the service users’ moods. Staff spoke about this skill and gave examples how they adapted their approach. There is also the recognition of the need for privacy balanced with safety i.e. bathing. Staff spoke of the fluctuating levels of need for service users and how to respond to them. They spoke about aiming to achieve an approach that provides continuity for service users. This was confirmed by a written message from the provider to staff reminding them of an agreed approach to address a 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 16 service user’s behaviour. Staff surveys gave a unanimous response that staff felt they knew what to do when a service user was unwell and if their needs changed. Staff felt the manager gave them clear instructions and they are told about the particular needs of each service user. One person commented that ‘the manager and proprietor always give full support and guidance, can contact them anytime’. The health needs of service users are well met. For example, the manager and records confirm that the service users have attended the dentist this year, and the manager confirmed that sight tests would also be arranged. One person has received an assessment for a new wheelchair. The provider and/or manager attends full multidisciplinary reviews, and records show examples of the home working with health care professionals, including medication reviews, whilst discussion with the manager illustrated advocating on service users’ behalf for an appropriate service. The home’s communication book gave clear instructions about medication changes, and staff confirmed that staff handovers between shifts are comprehensive and informative, and supplement written information. Three health and social care professionals said that service users’ medication is appropriately managed in the home. The manager described the medication training for staff. This is provided by the pharmacist who visits the home to talk to staff about safe practice i.e. how to recognise and deal with problems in use. The manager explained that half of the staff have completed a medication distance learning course, and that newer staff are in the process of completing this. Medication records were checked and on the second day of inspection two members of staff were both signing changes to the medication sheets, which is good practice. The consultant has also signed records, and there is now a staff list of signatures to help audit the quality of administration. The manager audits the use of medication that is used less regularly. 49 Regents Park DS0000067537.V296976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an adequate complaints procedure but would benefit from being more accessible to service users. Staff are knowledgeable about their role and duty in the protection of vulnerable adults, and service users’ personal allowances are protected. EVIDENCE: The complaints procedure is on display in the hall and contains relevant information. It has been transcribed into widget to enable the service users to understand it. However, it is still quite complex in its format and it was suggested this could be simplified to make it more useable. Staff acknowledged the service users’ limited verbal communication skills, and highlighted the need to observe negative changes in behaviour to pick up on service users’ unhappiness. During the inspection, staff were clear as to what action they would take if they observed a negative change in service users’ behaviour, which may suggest they were unhappy. They felt they could speak to the home’s management about any concerns. No complaints have been received by the home or CSCI. Four health and social professionals in their survey responses confirmed this. Staff have now received external training for the Protection of the Vulnerable Adults. This was confirmed by two members of staff, who spoke about the training they had attended, and could demonstrate an understanding of their responsibilities to whistle-blow on poor practice, which they could give 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 18 examples of. There is a clear audit system in place to show service users’ personal allowances and how this is managed. This can be cross referenced, and is overseen by an external book keeping company, which the manager said was monitored on a weekly basis. 49 Regents Park DS0000067537.V296976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The maintenance and décor of the home is well maintained, and provides a clean and homely atmosphere for the service users living there. EVIDENCE: The home blends into the local surroundings. The décor and furnishings are well cared for, domestic in style, and create a homely atmosphere. Service users’ work is displayed on the walls, and work related information is kept to a minimum to prevent an institutional look. There is a downstairs room, which gives service users a space to play music and express themselves. There is a large garden, which has been extended to incorporate the gardens of No. 47 and No. 51. Both of these properties belong to the owner. There are plans for this to provide further space for activities. There have been delays in making the whole garden accessible to the people living at the home, although staff explained they have use of day care facilities at a separate house. Day care is not regulated by CSCI. Each service users’ room is personalised, and thought has been put into how these rooms remain looking attractive and appealing, whilst practically being 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 20 able to be easily maintained due to the impact of service users’ behaviour. Rooms are decorated in an individual style, and reflect service users’ tastes and interests. There is one bathroom on the first floor, which includes a toilet and bath. This door has a lock on it, with an override system in case of emergencies. There is a second toilet next door to a communal area in the basement. There is a variety of communal space. The home has a large and comfortable lounge with a piano and an attractive dining room. The home was clean and tidy on both days of the inspection. Staff are to be commended for maintaining an odour free environment, despite the high care needs of the people living at the home. 49 Regents Park DS0000067537.V296976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the service users, and show a commitment to training and to providing quality care. However, the home’s staff recruitment process has the potential to put service users at risk. EVIDENCE: Staff spoken to were able to reflect on their role and their duty to the service users. They also recognised their own limitations and when to seek advice from people with more expertise. In discussion and through their survey responses, staff described working as a team, making one another aware of the changing moods of residents, and how to respond appropriately to maintain staff and service user safety. One person said ‘we all work as a team and the manager is hands on with staff and clients’. Another person said ‘I feel we are a unique care home, the home is run as a team’. Staff demonstrated a commitment to the ethos of the home. Staff showed an appreciation for the communication needs of service users and a commitment to ensure they are meeting these needs. There were three members of staff on duty during the evening inspection, which was confirmed as being the norm, and reflected the rota. The manager said that extra staff assisted with trips out to allow for a flexible response, and 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 22 if service users’ needs dictated extra cover. The manager said that due to the complexity of the service users’ needs; a senior experienced member of staff was always on duty. This was confirmed by four health and social care professionals, who said in their surveys that a senior member of staff was on always on duty to confer with. Staff spoken to during the inspection showed a range of skills, and were able to recognise the skills of others in the staff team. Both had NVQ in care qualifications. Currently, three members of the staff team of ten have a NVQ in care qualification. The expectation that fifty percent of care staff achieve a NVQ 2 in care by 2005. The home has received two previous requirements to improve practice in the area of staff recruitment. Current practice is still potentially unsafe. Four files for new members of staff were inspected. All contained the necessary identification documents and application forms. However, all four files did not contain evidence of POVA First clearance, although the staff members started work prior to the CRB being received. This is not safe practice. POVA First is the first stages of a Police check to help ensure that staff are appropriate people to work in a care setting. References for two people had been received after they started work, and for two staff members there was a reference in place from jobs, which were not listed in their employment histories. There was also an unexplained gap on their employment history. Some specialist training is provided by the home i.e. awareness of autism and complaints. The manager has audited staff training and is working to ensure all mandatory courses are up to date. He showed written evidence that a health and safety course is booked for November and explained that Breakaway training is due to be booked, as is an update on food hygiene. Staff have attended a ‘safer food’ course. Staff surveys confirmed that new staff had an induction period, which was confirmed by induction records. A member of staff spoke about how they were closely observed during this induction period, and worked for a while as an additional member of staff. This is good practice. All staff who responded to the survey felt well supported in their care role and said their practice was observed. 49 Regents Park DS0000067537.V296976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run by a manager who is open to further specialist training to benefit the service users. However, improvements are needed in relation to practices that fully protect service users. The home monitors its performance to ensure it provides a good service and safety checks are up to date to help keep service users safe. The Commission is not kept informed of all events affecting the well being of service users, and therefore cannot monitor how risks are managed and service users’ safety protected. EVIDENCE: The home now has a registered manager, who has an appropriate NVQ 4 qualification. The manager has recognised that they need to further their knowledge in the area of learning disability and plans to attend some 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 24 appropriate training courses. Further improvements are needed in the management of staff recruitment to help work towards providing a safe service for service users. See standard 34. The manager and the provider work closely. A staff member commented ‘I think the management do well in getting on top of issues, they don’t have any bad feeling and they deal with it quickly before it gets out of hand’. Another person said ‘Excellent employer, great place to work. Enjoy everyday as everyday is rewarding and different’. A third staff member said staff are ‘treated with respect’. Four health and social care professionals said in their surveys that the home communicates clearly and worked in partnership, and that they were satisfied with the overall care provided to the service users. A quality assurance survey took place in 2005 and the results were read. Feedback about the service provided at the home was positive. This included responses by service users, families and visitors to the home. The manager understands that any issues that arise from quality assurance must be acted upon. The manager said that the radiators have a low surface temperature, and that the windows in first floor windows are fixed to a restricted width. On the last inspection, the owner said the taps are fitted with thermostatic valves. Staff rota records were looked at. For one week in September, three nights were not covered by a trained first aider. However, there is an on-call system and staff have clearly stated they feel well supported. The fire logbook was inspected; and training and safety checks were up to date. The home is currently in close contact with health care professionals regarding the deterioration of a service user’s health, which was evidenced through discussion with staff and the content of care records. Comprehensive records of recent incidents were seen.This is good practice. However, this deterioration has impacted on other residents and staff but the Commission (CSCI) has not been informed. 49 Regents Park DS0000067537.V296976.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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 1 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 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 2 3 3 x x 1 x 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 26 Yes. 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 YA34 Regulation 19 Schedule 2 Requirement The registered person shall not employ a person to work at the care unless he/she has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. (Staff must not start working at the home until the required information and safety checks are in place). This requirement has been made for a third time, and enforcement action is being considered. The previous timescale of 30/04/06 has not been met. The registered person shall give notice to the Commission without delay of the occurrence of any serious injury or adverse event in the care home. (The home must provide to the CSCI, information relating to any injuries, such as self-harm, or injuries to service users and staff. CSCI must be informed of any event, which may adversely affect the well-being or safety of any service user). Timescale for action 15/12/06 2. YA42 37 (1) 31/12/06 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Care plans need to reflect changes to service users’ lives and be regularly reviewed. Guidance should be provided on the use of ‘time out’ on beanbags to ensure continuity of approach and prevent misuse. Any decisions made on behalf of service users, that may infringe upon their rights or freedom of movement should be discussed in a multi-disciplinary setting to ensure such decisions are made in their best interests. Such as a local best practice committee, which can be accessed through Social Services. Agreements should be recorded and reviewed regularly. Advice should be sought to ensure that the complaints policy is made more accessible to service users. Fifty percent of care staff should hold a NVQ 2 in care. The manager should undertake appropriate training to broaden their understanding of the needs of service users with complex learning disabilities. 2. YA7 3. 4. 5. YA22 YA32 YA37 49 Regents Park DS0000067537.V296976.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 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 49 Regents Park DS0000067537.V296976.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. 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