Inspection on 05/02/07 for 4a Geales Crescent

This inspection was carried out on 5th February 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 4a Geales Crescent Alton Hampshire GU34 2ND Lead Inspector Laurie Stride Key Unannounced Inspection 5th February 2007 10:55 4a Geales Crescent DS0000067951.V324948.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 4a Geales Crescent DS0000067951.V324948.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. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4a Geales Crescent Address Alton Hampshire GU34 2ND 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) 01420 542447 01420 549511 People Potential (UK) Ltd Mr Richard Robert Charles Roynane Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: 4a Geales Crescent provides accommodation, personal care and support for up to four adults with a learning disability. The layout of the home is modern, spacious and well equipped and service users are encouraged and supported to develop their communication skills. The current range of fees is £1, 634.00 to £2,300.00 per week. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first key inspection since it was registered and was unannounced. The visit lasted six hours, during which time the inspector met the three service users, three members of staff, the homes manager and the registered manager. The inspector was unable to converse with service users due to the nature of their disabilities, but was able to observe staff members working with the service users in their home. A tour of the premises was undertaken and samples of the homes records were seen. Information was also obtained from a pre-inspection questionnaire. The homes manager assisted throughout the inspection visit and confirmed that she will be applying for registration. What the service does well: 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. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 6 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 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 7 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is actively working to ensure that service users and their representatives have all the information needed to choose a home that will meet their needs. Admissions are not made to the home until a full needs assessment has been undertaken, involving the individual, their family or representative, where appropriate. EVIDENCE: The home has a Statement of Purpose and service users are issued with pictorial Welcome Packs. The home is currently working on a full Service User Guide, which the homes manager said is due to be completed by the end of February 2007. The services’ mission statement is to ‘provide a safe and comfortable environment, enabling all service users to reach their maximum potential and to live a valued and fulfilled life in their community.’ The home has an admission policy and prospective service users have their needs assessed before being admitted. The assessment is carried out by the company’s Head of Care, who is also currently the registered manager for the home, and is assisted by the homes manager. The Head of Care has a Registered Nurse in Learning Disability qualification. A sample of two service users’ assessments was seen and these were very comprehensive and detailed. Based on the assessment a funding calculation and staffing support 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 8 for residential/activities/weekends and waking nights is proposed. Although copies of the care managers’ own assessments had not been obtained, as advised in line with the National Minimum Standards, letters to the service users’ care managers showed that the assessment was copied to them, should they wish to discuss any of the report. The letters also showed that service users’ relatives are involved in assessments and reviews. The methodology used for the assessment included gathering relevant information from the manager of the person’s previous placement. The homes manager had also travelled to meet and observe the service user in their previous environment. The homes manager further described the process of assessment and admission. The prospective service user’s care manager is invited to view the home first to see if it is thought to be a suitable placement. The care manager meets and talks with the prospective service user’s relatives or representatives, who themselves then visit the home. The prospective service user’s strengths and needs are assessed in their current environment and funding is agreed. If this all goes well then the prospective service user is invited to visit the home; this avoids possible disappointment if the person sees and likes the home and is later not admitted. A structured transition is then put into action, the service user comes for further visits including overnight stays, staff from the home spend time with the service user in their current placement observing their routines, the service user is able to start bringing their own possessions to personalise their room and receive a welcome pack. During this time the compatibility of the prospective service user and service users already living at the home is also assessed. Staff members support current service users to prepare for the change through the use of photographs, signs and symbols, meeting and having meals with the prospective service user. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 9 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 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is further developing ways to enable service users and their representatives to play an active role in planning the care and support service users receive. Care plans could be improved through further documentation to evidence how the home is meeting people’s needs and keeping these under review. EVIDENCE: A sample of two service users’ care plans was seen. These included details of service users’ day and evening routines with guidance about the support needed and the individual’s preferences in relation to this. Also contained in the care plans were personal care support charts, risk assessments, communication and behaviour guidelines and timetables of structured activities and free time. One of the service users sat in while their care plan was discussed. Evidence was on file of a service users’ first care review since moving into the home and the report stated positive outcomes were being achieved. The 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 10 review meeting involved the individual’s care manager and relatives as well as the home’s staff. Risk assessments were recorded with the measures to be taken to control the identified risks. These were recorded in relation to individual service users’ regular and one-off activities, behaviour issues, healthcare, medication and environmental matters. Care plans were discussed with the homes manager. Overall, care plans give clear guidance in relation to the personal support required by individuals, but it was agreed that more information would be useful linking the initial assessments to the outcomes being achieved. This could take the form of individual goals and objectives and provide a rationale for doing things and the way they are done. It was noted that reports of visits to the home by a senior manager had also identified that this would be beneficial to service users and work had started on this. The homes manager reported that a meeting was scheduled for 12/02/07 with regard to implementing more person centred planning and this was linked to staff training being set up. It was agreed that this would provide a good opportunity to begin discussing objectives with all the relevant people involved. One service user has ‘as necessary’ (PRN) medication prescribed by their doctor and records were kept of when members of staff give the medication and if it is effective. The homes manager was able to clearly describe the indicators the service user is likely to give when PRN is needed but this information was not recorded in the care plan. It was agreed that the indicators would be recorded, this could be important if the home used agency workers who were not as familiar with the service user as more regular staff. Further care plan documentation was also advised in relation to staff monitoring a service user at night and an agreement about personal care arrangements. (See also the section on Personal and Healthcare Support). The homes manager agreed to expand the contents of the care plans discussed and a requirement was therefore not made on this occasion. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home promotes service users’ right to live ordinary and meaningful lives. Service users are supported to take part in social, educational and recreational activities, which are tailored to suit individual choices. Service users are supported to develop skills and this is being further enhanced by the development of clear individual goals and objectives. EVIDENCE: The homes manager reported that schedules of activities were based on individual service users preferences and needs. Opportunities for trying new activities are provided through the use of pictures and books as well as visiting places. The home had pictorial ‘activities you can choose from’ packs. Discussion also takes place with service users’ relatives in order to get a fuller picture of the things service users like, or don’t like to do. Service users’ relatives visit and also keep in contact with the home via email. The home has a communication room set up with two computers where service users are 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 12 supported to keep in touch with people and also develop communication skills. One service user kept in regular contact with friends who live in another country and visited them in October. Two other service users were also planning a holiday by the coast. An example of a service user’s scheduled activities included swimming, walks, day trips, aromatherapy and relaxation, horse riding, trampoline, sensory suite, activity centre and personal hobbies. The home was in the process of setting up a voluntary work placement for the service user at a gardening centre. Daily diaries are kept of the activities service users take part in and any related events. At the start of the visit, service users had gone out swimming supported by staff. A member of staff said opportunities for activities, particularly at weekends, were made more flexible for service users, as staff will work long days so that an activity is not rushed to fit in with staff shifts. Staff who do this have the following day off, which prevents staff from becoming tired and providing less effective support to service users. The member of staff said they felt that the activities programme works well. Staff members were observed involving service users in activities within the home, such as developing communication skills. As mentioned in the previous section, the service had identified that it would be beneficial to service users and staff if individual goals and objectives (e.g. skills development) were recorded in care plans, this would give more of a focus to why particular activities are undertaken and provide a way of measuring success in achieving positive outcomes for service users, based on their assessed strengths, needs and preferred lifestyle. Work on this had started. Service users scheduled activities also support and encourage them to take responsibility for some of the daily routines of the home. For example, cleaning their bedroom, preparing meals and using the dishwasher. The home supports service users to help plan their meals through the use of pictorial menus. Nutritional needs are individually recorded and monitored and healthy eating is encouraged. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 13 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 This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are promoted and could be further improved in relation to specific areas. EVIDENCE: Care plans contained information on how staff should provide personal care to individual service users. Specialist healthcare needs and support were clearly identified and recorded. Dietary requirements, health appointments and the outcomes of these were also recorded. There is a staff key working system in place and staff members were observed interacting with service users in a friendly and respectful manner. Through discussion with staff it was evident that they understood service users’ individual preferences and had the knowledge and skills to meet their needs. There was evidence of innovation and good practice taking place in relation to developing service user’s communication skills. Service users are supported in communication sessions twice a week by an external facilitator, who writes 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 14 guidelines for staff who continue the work. Staff use communication books, pictures, objects and symbols and progress is recorded each day. Previous to the visit the home had notified the Commission for Social Care Inspection about a change in staffing personnel, which has resulted in one of the staff teams being an all male team. This presents issues regarding the provision of personal care to female service users. In order to safeguard service users and staff, the home had implemented a system of 3 minute recorded checks where personal care is administered by one of the males on this team. This is mainly at weekends. The homes manager is available Monday to Friday and provides personal care support on arrival in the mornings. Service users parents and care managers had been made aware of the situation and, while the management were expressly aware that it was not ideal, felt that it was being dealt with appropriately. It was advised that all such agreements are clearly recorded in service users’ care plans. A service user who was diagnosed with epilepsy had a sound monitor in their bedroom so that staff can hear if this person has a seizure at night. The homes manager reported that the service user had suffered one seizure in six months and this had been detected through the monitor, but was aware that the monitor was not conducive to the service user’s privacy and dignity. It was agreed that this would be kept under review. A follow up telephone call was made on 09/02/07 when the inspector spoke with another member of the management team. It was agreed that the service users care plan and risk assessment will be updated to include details of when and how the monitor is being used and arrangements for reviewing the situation. A service user was attending a medication review at the time of the visit. The home has a written policy and guidelines for the control and administration of service users’ medications. Medication is stored in a suitable locked cabinet and there were no controlled drugs. ‘Homely remedies’ were used, as prescribed by the service users’ GP. The three service users all required assistance with their medication. Up-to-date records were seen of the administration of medication carried out by staff members who had received training. Records showed that the remaining staff members were completing this training. Detailed records were also kept of any medicines returned to the pharmacy, signed by the staff member returning and the chemist receiving the medication. A medication hand over record is maintained when service users go to visit their relatives. Staff had certificates of training in administering rectal diazepam although it was reported that this had not been needed to date. This medication was signed in and out of the home by the staff supporting the service use. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 15 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 This judgement has been made using available evidence including a visit to this service. Service users and their representatives have access to a suitable complaints procedure, the home promotes an open culture and service users are protected from abuse. EVIDENCE: The home has a complaints policy and procedure including a pictorial version for service users. The home uses a range of communication tools and techniques and a good rapport was observed between service users and staff. The open and inclusive atmosphere in the home would be conducive to service users feeling able to express any worries or concerns. A staff member said that they would be able to detect changes in service users’ individual behaviours and that service users relatives have a lot of involvement. Some months previous to the visit the home had notified the Commission for Social Care Inspection about a concern that had been reported to them. The homes manager reported that a senior manager had dealt with this, but there was no record of the outcome available in the home. There had been no other concerns or complaints received by the home. It was advised that a system of recording any concerns, complaints or allegations be put in place, to include details of the actions taken and the outcome. This would provide a clear audit trail and enable any patterns of concerns or complaints that arose to be analysed. The homes manager said this would be done. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 16 Adult protection and prevention of abuse policies and procedures were in place. All staff had received relevant training during their induction. A member of staff spoken to during the visit demonstrated a clear understanding of the procedure for recording and reporting any allegation, disclosure or suspicion of abuse. Service users in the home had been assessed as not able to handle their own financial affairs and records are kept of the management of their personal allowances. A sample of the records was seen and the actual balance matched the record. Receipts were also kept and access to service users money is restricted to the acting manager and senior staff members. Service users have building society accounts so only small amounts of money are held individually in a secure place in the home. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 17 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 good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the environment enables service users to live in a safe, well-maintained and comfortable environment. EVIDENCE: The physical environment is suitable to the needs of the service users, is well maintained, spacious and homely. Service users’ bedrooms all have en suite facilities and are personalised to reflect their individual lifestyles and tastes. Communal space comprises of a large and a small lounge, large kitchen and dining area and a well-kept garden. The small lounge is equipped with an additional TV and sensory lights and is also used for arts and crafts. A small upstairs room has been utilised as an area for developing communication skills. The homes manager reported that two service users upstairs bedrooms had the large windows locked, although ventilation was still possible through the smaller windows. Risk assessments were in place and the possibility of fitting 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 18 window restrictors was discussed. The homes manager said she would look into this. A report by the home’s management showed they were aware of the need to devise a way of ensuring that soap and hand drying facilities are always available in the communal toilet for staff and service users. These have to be managed carefully as one service user will tip out the contents down the sink if the opportunity arises. The homes manager said that the service user prefers to use their en suite toilet and the other two service users required assistance to use the toilet. Therefore the communal toilet is sometimes locked when not in use and this did not appear to cause any problems at the time of the visit. When staff members were in the vicinity the communal toilet was unlocked. This situation will need to be reviewed again if the two service users who require assistance become more independent or another service user is admitted to the home. The radiators in the home have covers fitted and the taps in the toilet and en suite facilities are fitted with thermostatic mixer valves to prevent the risk of scalds. The homes manager reported that a new kitchen cooker hob had been ordered. Double handrails are in place on the stairway and there is a carbon monoxide detector in the hall outside the utility room where the boiler is housed. The utility room was clean and tidy, equipped with modern washing and drying machines and infection control procedures were in evidence. Service users laundry is kept in separate laundry baskets. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained and there is a programme of training in place to ensure staff have the skills to meet service user’s needs. The home has systematic recruitment procedures to protect service users, although the relevant records must be kept in the home unless other arrangements have been agreed. EVIDENCE: The home operates a three-week rolling rota of staff cover and a pictorial rota is provided to enable service users to know which staff will be on duty on a daily basis. The registered manager reported that the home uses the same agency staff to provide consistent cover for staff holidays and sickness and had advertised to recruit relief staff. Regular staff members have designated responsibilities for different areas, for example health and safety, communications, medication and activities. The homes manager had recently started supervising staff on a formal basis, had recorded these and a schedule for the next staff supervisions was seen in the office. On-call telephone numbers to support staff were displayed in the office. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 20 The homes manager confirmed that the structured staff induction training was in line with the Skills for Care Common Induction Standards and supporting documents were seen. The programme of training is linked to the three-week rolling rota and every three weeks one of the teams has a training day. Records of training completed by individual staff members were held in the home. The induction training pack included guidance on adult protection and dealing with violence toward staff, racial harassment and equal opportunities. In addition to the induction pack, staff had completed training in first aid, health and safety, manual handling, fire safety, food hygiene and infection control. The homes manager said that all staff members had undertaken training in Strategies for Crisis Intervention and Prevention (SCIP) on 19/12/06 and certificates were being sent. Further training was planned in relation to person centred planning, autism and managing challenging behaviour. The home also has links with the learning disabilities community team. Records showed that the combined staff team had a range of training and skills from previous jobs. Staff members work at the home for a year to demonstrate their commitment before being registered for NVQ training. At the time of the visit, the homes manager and a senior support worker had obtained NVQ awards, one member of staff was half-way through the training and another was about to start. A member of staff said they felt the team have the necessary knowledge and skills to meet current service users needs. There was some evidence that the organisation carries out the required checks on potential staff members before they are employed in the home. A sample of three staff member’s recruitment records was seen. A form is used to record the details of CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks, the originals being held at the head office. The reference numbers and dates of the checks were recorded and two written references for each staff member were held on file in the home. However, all relevant records of staff checks must be held in the home for the required time, unless held centrally through agreement with the Commission for Social Care Inspection (CSCI). The inspector spoke with the company’s personnel manager and advised that they consult the guidance on the CSCI website about holding staff records centrally. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 21 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 This judgement has been made using available evidence including a visit to this service. The home is well managed and regular quality checks are in place, this would be enhanced by having a full-time registered manager in post and through the development of a formalised quality assurance system. There are systems and procedures in place to ensure that the health, safety and welfare of service users and staff are promoted. EVIDENCE: The home’s registered manager also works three days a week as the company’s Head of Care and supports the homes manager who takes care of the day-to-day running of the home. The homes manager confirmed that it is planned that she will apply for registration. Throughout the key inspection visit the homes manager demonstrated knowledge, skill and understanding in relation to her role and the service users. Staff said that the homes manager is very professional, focused and approachable. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 22 The home was registered in August 2006 and does not currently have a formal quality assurance system, through which the views of service users and other stakeholders can be obtained to measure success in achieving the aims of the service. An email to the home from a service user’s relatives was seen, praising the home for the good care provided. Reviews of the care and support provided for individual service users are held, which include the service user’s care manager and relatives. Records of regular monitoring visits to the home by senior management were seen and these were comprehensive and detailed, indicating that the organisation has clear vision and values and intends to maintain and develop a quality service. The majority of action points identified in these reports had been implemented at the time of the key inspection visit. The homes manager said that staff meetings are held on a monthly basis at the main office. Evidence was seen that safe working practices are promoted in the home. Up to date certificates were on file in relation to gas safety, electrical wiring and the fire officer’s inspection. Fire safety systems and equipment are checked and monitored by the home’s maintenance person and staff team and records of this were seen. Staff members were up to date with fire instruction and drills. There are checklists that day and night staff members complete, which also ensure that it is a safe environment for service users, staff and visitors. The home had been awarded the Food Safety Award for hygiene and safe methods. A car-seating plan had been drawn up for when service users travel in the home’s vehicle. There are designated staff members responsible for areas of health and safety in the home. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 23 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 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 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 24 N/A 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 must ensure that all relevant records of staff recruitment checks must be held in the home for the required time, unless held centrally through agreement with the Commission for Social Care Inspection. Timescale for action 30/04/07 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 YA34 Good Practice Recommendations The registered person should consult the guidance on the CSCI website about holding staff recruitment records centrally. 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 4a Geales Crescent DS0000067951.V324948.R01.S.doc Version 5.2 Page 26 - 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. 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