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Inspection on 18/01/07 for 5 Trinity Street

Also see our care home review for 5 Trinity Street for more information

This inspection was carried out on 18th January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was, based on the evidence found, providing a service that met the expectations of the residents living at the home, with access to a good quality of lifestyle and appropriate support from staff. Outcomes indicate that the home has an effective and supportive manager of whom both residents and staff spoke of highly. The home provides an extremely comfortable environment for the accommodation of the service users that presents a domestic ambience whilst providing ample space for resident`s privacy. Staff spoken to showed an interest in their work and a commitment to the ethos of the home. There was seen to be an excellent level of training provision. There is a commitment to ensuring that resident`s health is monitored with assistance from community health care services.

What has improved since the last inspection?

All the requirements from the last inspection have been addressed in full with there now been over 50% of the staff team with at least an NVQ level 2 in care, better documentation of staff`s working history prior to their employment at 5 Trinity, and no sign that residents have refused meals they were offered in the recent past. In addition the manager has completed her Registered Managers award.There has also been significant improvement in the development of the homes systems for self-monitoring and audit. There has also been on-going training of staff in a number of areas including person centred planning, and there was clear evidence that staff have been working with residents to develop person centred plans with them.

What the care home could do better:

There were only a few areas where improvement was needed, two related to medication administration. Whilst documentation of medication receipt and administration was generally good it was not carried out for prescribed creams. It was also noted that there were a few instances where typed labels where used on medical administration records, this not acceptable. It was also noted that one residents bedroom had windows without restrictors, this not risk assessed. There was one instance where a new employee file did not contain a reference from their last social care employer as is required.

CARE HOME ADULTS 18-65 5 Trinity Street Old Hill Cradley Heath West Midlands B64 6HT Lead Inspector Mr Jon Potts Key Unannounced Inspection 18th January 2007 11:00 5 Trinity Street DS0000004854.V330245.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 5 Trinity Street DS0000004854.V330245.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. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Trinity Street Address Old Hill Cradley Heath West Midlands B64 6HT 01384 823048 NONE 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) info@Inshoresupportltd.com Inshore Support Limited Mr Adam Webb, Mr Ian Forrest-Jones Tracey Lake Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12th December 2005 Brief Description of the Service: 5 Trinity Street provides long term care to 3 adults with a learning disability who are of mixed gender. The house is sited near the centre of Old Hill in an established residential area that affords easy access by foot to a range of local facilities, including public transport. Staff also have access to a car for transporting the residents between venues. The house is a terraced property that has been adapted for its current use and consists of two living rooms, a kitchen/diner and three single bedrooms as well as bathroom and toilets. The main stated aim of the home is to provide a service that reflects the expectations of the residents: identifying and fulfilling their individual needs by means that are valued by society; this in order to develop and support individual and personal experiences and characteristics which are culturally valued and maintained. There is a staff group that consists of a manager, senior support and support workers. There are waking staff available 24 hours per day. The manager is responsible to a service manager and directors of Inshore support who have a number of homes of similar size and purpose. The current charges range between £2078.88 to £2125.51 per week with the only additional charges relating to personal requirements such as hairdressing, clothing etc. 5 Trinity Street DS0000004854.V330245.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 over two half days and involved the inspector assessing the homes performance primarily against the key national minimum standards for younger adults. Evidence was drawn from a number of sources and including case tracking the care for two residents (this involving looking at all the documentation in respect of their care and cross checking this with outcomes), observation of practice, discussion with the registered manager, staff and review of management records. There was some discussion with the residents. Information was also supplied pre inspection by the home and via resident’s comments cards (that they were assisted with in some cases by the staff). The residents and staff are to be thanked for their assistance with the inspection. What the service does well: What has improved since the last inspection? All the requirements from the last inspection have been addressed in full with there now been over 50 of the staff team with at least an NVQ level 2 in care, better documentation of staff’s working history prior to their employment at 5 Trinity, and no sign that residents have refused meals they were offered in the recent past. In addition the manager has completed her Registered Managers award. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 6 There has also been significant improvement in the development of the homes systems for self-monitoring and audit. There has also been on-going training of staff in a number of areas including person centred planning, and there was clear evidence that staff have been working with residents to develop person centred plans with them. 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. 5 Trinity Street DS0000004854.V330245.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 5 Trinity Street DS0000004854.V330245.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 This judgement has been made using available evidence including a visit to this service. Prospective people looking to use a service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells about the service they will receive. EVIDENCE: The home has not admitted any service users since the time of the last inspection so judgement was based on the knowledge of the manager and the homes policies and procedures in addition to other documentation that was available to the inspector (such as statement of purpose, lifestyle agreements etc) The manager clearly understands the importance of having sufficient information available for a prospective service user when choosing a care home. There was clear information available that could be understood by the current service users accommodated at the home although the development of more pictorial based information and other formats would be advantageous. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 9 There is clear information in the homes statement of purpose/service users guide as to the service that the home can provide. The Statement of Purpose/ service user guide is based on a generic format for a company that operates a number of homes of similar purpose, but has information that is specific to the individual home, and the resident group they care for. It clearly sets out the objectives and philosophy of the service. The guide details what the prospective individual can expect and gives a clear account of the services provided, quality of the accommodation, qualifications and experience of staff, how to make a complaint, recent CSCI inspection findings and contains comments and experiences of residents living at the home. All residents are given a copy of the Guide, this accessible within their personal case file. Practice and information giving is informed by the services written procedures. Admissions are not made to the home until a full needs assessment has been undertaken. All the residents accommodated are funded through care management arrangements and there were assessments available for all current residents in addition to social services reviews (updating the original assessments information) and the homes own assessments processes. Any assessment for a new service user would be conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Such an assessment would be carried out by an experienced member of the management and involve members of the staff team, this at the service users present location with staff working alongside them. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment/ care plan. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The staff management team (including senior management and the home manager) may consider the application together with input from staff, where all information is shared. The manager saw compatibility between new residents and existing service users as critical. Prospective individuals are given the opportunity to spend time in the home with day visits extending to overnight stays. New residents are provided with a Statement of Terms and Conditions/ Contract (called a lifestyle agreement); these settings out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. This is clear, jargon free, easy to understand and gives a very clear understanding of what residents can expect. The manager actively promotes opportunity for discussion and clarification, and the service users relatives are fully involved as and when appropriate. 5 Trinity Street DS0000004854.V330245.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): 6,7,9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive, with support from the manager and staff team as needed. EVIDENCE: The key principles of the home for delivering a quality service are based on the belief that residents should be able to have the opportunity to take control of their lives. The staff of the home are strongly committed to supporting all service users to understand factors that allow them to make informed decisions, understanding the range of options which are available to them and have the right to take responsible risks. The service user plan is developed in partnership with the service user, based on an efficient assessment. The plan clearly sets out how specialist requirements will be met through positive and planned interventions. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 11 The manager or staff meet with residents at least monthly on an individual basis to discuss any issues, this allowing them chance to communicate their views, which can influence the development of their care plan and the review process. The plan focuses on current needs, development of skills, and future aspirations of the individual. The manager and staff are aware of the principals of person centred planning, and individual plans have been developed with the service users, these documents that they have ownership of and have contributed to. Staff have the necessary training and skills to support and encourage the individual to be fully involved. All residents have verbal and a degree of written communication, although staff are pursuing development of alternative communication methods. The home does not employ a key worker system this for valid reasons relating to individuals needs. The care plan is presented in a way that shows how a number of steps can contribute to overall short and long term goals. There is also information as to which documents would contain evidence that it is carried out, to assist with any audit or review process. Whilst written in plain language service users may need some support in understanding it, this through support of the staff. The care plan is used as a working tool and is understood by the individual and all staff, and can be used in an emergency by people who are not familiar with its content. Care plans include a comprehensive risk assessment. Management of risk takes into account the specialist needs and age of people who use the service, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, it is in the person’s best interest. The resident understands and agrees the limitations. Any limitations are fully documented. Residents know what records the home holds about them, and about their individual rights. Residents are made aware of advocacy services and the staff do promote individuals understanding of their rights. Residents are actively consulted on how the service runs, this as stated previously through individual monthly meetings. They are involved in decisions about day-to-day life, the environment and the development of the service. Some limited policies and procedures have been presented in pictorial formats although work was stated to be on going to develop these further. Staff were stated to support residents understanding of the homes processes and key information is made available to parents. The home acts upon the outcomes of consultation with the person who uses the service and their families. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Individuals that use the service are able to make choices about their lifestyle, within agreed limitations, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community appropriate to their peer group, and to enjoy all the rights and responsibilities of citizenship. The manager understands the importance of enabling younger adults to achieve their goals, follow their interests and be integrated into community life and leisure activities. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 13 Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. Routines are flexible, with any potential barriers to this documented within the care documentation following assessment. Residents are however encouraged to make choices in all areas in respect of their lifestyle. The routines, activities and plans are resident focused, regularly reviewed, and can be quickly changed to meet individual residents needs. The service actively encourages and provides imaginative and varied opportunities for residents to develop and maintain social, emotional, communication and independent living skills. The service has a strong ethos and focuses on involving residents in all areas of their life, and actively promotes the rights of individuals to make informed choices, providing links to specialist support when needed. This includes developing and maintaining family and personal relationships. Whilst residents are not currently in paid employment they access colleges or similar with the potential of progression towards employment opportunities possible in some instances. Outcomes for residents are positive, and there is evidence that they are enjoying the life opportunities that they experience. The service actively supports residents to be independent and involved in all areas of daily living in the home. This includes where appropriate, taking some responsibility for shopping, planning meals, and meal preparation within a risk management framework. Individuals are supported to be independent with the assistance of appropriate training and support. Mealtimes are relaxed, staff are patient and helpful, and allow residents the time they needed to finish their meal comfortably, with choice as to the foods taken given, this with support and guidance about a balanced healthy diet. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 14 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 principals of respect, dignity and privacy are put in place. There were limited oversights in respect of the management of medication. EVIDENCE: Efficient systems are in place to ensure residents receive effective personal and healthcare support. The homes policies and procedures set out how the service is to address these with this process delivered effectively through a skilled, trained and knowledgeable staff group. Staff are aware that the way in which support is given is a key issue for younger adults. Resident’s individual plans clearly record their personal and healthcare needs and detail how they will, and are delivered. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 15 Staff ensure that personal support is flexible, consistent, and responsive to the changing needs of the residents. Staff are aware of and respect service users preferences and self-determination, and have accurate knowledge as to residents individual personal needs, relating to such as the provision of intimate care. The staff group is balanced to enable choice of male, female and age related preferences when delivering personal care. Staff respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in privacy and that they support residents to be as independent as possible. The residents are encouraged to have involvement in their own healthcare including visual, hearing and oral care. They have the opportunity to access their GP and have access to all NHS healthcare facilities in the local community with support from the staff team. Regular appointments are seen as important and systems are in place to ensure they are not missed. The home arranges for health professionals to visit residents at home when necessary. Staff are aware of health care triggers and warnings and fully understand how they should respond and take action, although access to advice on selfscreening for breast/testicular cancer for residents was discussed. There were no Health Action Plans developed with the PCT however and the manager was advised to discuss this matter with the appropriate health care professional, this in line with current good practice guidance. The home has been seen to arrange training on health care issues that relate to the health care needs of the residents. The home has developed efficient medication policy, procedure and practice guidance. Staff all have access to the written information and understand their role and responsibilities. The home strongly promotes independence and whilst no individuals are currently assessed as being able, they are encouraged and facilitated to understand what tablets they are taking and have involvement in administration of their medication. Medication records are seen as key to the efficient management of health care matters, and the home was seen to consistently keep them up to date with the exception of booking in all prescribed creams, and then signing them out when administered. There was also evidence of use of labels on these records, which is not advisable. The home has systems to assist with compliance with the administration, safekeeping and disposal of Controlled Drugs if and when used and homely remedies are identified and agreed with the residents G.Ps. Care staff have the required accredited training. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 16 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. People who use the service are able to express their concerns and have access to a robust effective complaints procedure and are protected from abuse. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It is also available in a pictorial format. The complaints procedure is sent to parents annually with questionnaires in respect of service quality, and has a high profile within the service. Residents and others associated with the home understand how to make a complaint and they are clear of what can be expected to happen if a complaint is made, staff making them aware verbally and through the use of such as flash cards. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures regarding protection of individuals are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to. Training of staff in the area of protection is regularly arranged by the Home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 17 The outcomes from any referral are managed well and issues being resolved to the satisfaction of all involved. The home has an open culture, which enables residents to express their views, and concerns in a safe and none blame environment. Residents and others associated with the service state that they are very satisfied with the service provision, feel very safe and well supported by an organisation that has their protection and safety as a priority. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 18 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 This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence EVIDENCE: The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the residents who live there. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 19 Residents are encouraged to see it as their own home. It is a very well maintained, attractive home, which is accessible to community facilities and services. As residents are physically able there is little current need for specialist equipment and adaptations. The changing needs of residents are met, along with their cultural and specialist care needs. The home is designed to provide small group living where residents can enjoy maximum independence in a discrete non- institutional environment. Residents are fully involved in decisions about the décor and any changes to the accommodation. They say that they are satisfied with the rooms they live in and they all have single rooms. As there are only three residents toilets and bathrooms are usually available to them when needed. The fixtures and fittings are of a good quality, well maintained and adapted to meet the wishes of the present service user. Individuals personalise their rooms and bring in their own furniture if they wish, this within a risk assessment framework. There is a selection of communal areas both inside and outside of the home, this means that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. All bedrooms enable privacy and have locks on the doors. Residents have control and ownership of their own space, with residents having keys to their rooms unless a risk assessment indicates otherwise. The home was found to be clean, tidy and smelt fresh. There was however one room where no restrictors were fitted to the windows without any risk assessment in place. The management has a proactive infection control policy and they would work closely with external specialists as and when needed. All staff have received training in this area. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 20 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): 31,32,34,35 & 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people that use the service, this in line with their terms and conditions and supporting the smooth running of the service. EVIDENCE: Residents have confidence in the staff that care for them based on discussion with the inspector. Rotas show that they are maintained to ensure that staffing levels are not compromised with use of staff from other homes within the company in place of external agency staff. This has the advantage that staff that cover the rota are familiar with the companies aims, policies and procedures, also usually knowing the residents from prior working at the home. Particular attention given to busy times of the day and changing needs of the residents. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 21 Staff members undertake external qualifications beyond the basic requirements. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. There was evidence, including comment from the individuals that use the service that staff working with them are very skilled in their role, and are consistently able to meet their needs. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. This training can be small scale and individualised if necessary in order to promote the delivery of person centred services. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services although there was one issue in respect of an employed staff member where, although there were two references, there wasn’t one from the last social care employer, and no explanation as to any reasons why this should be the case (as was seen to be the practice for other staff). The manager stated that involvement of people who use the service in the recruitment process was through observing their interaction with potential/new staff. There was clear documented evidence that staff new to the service were well supervised and involved in a robust induction process that covered all the necessary core skills required. A staff member who had recently commenced working at the home stated that they had felt well supported by the manager and other staff through the induction process. Staff meetings take place regularly. Supervision sessions are regular and staff find them helpful. Notes are taken of meetings and sessions. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 22 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 excellent This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on the openness and respect, with effective quality assurances systems developed by a qualified and competent manager. EVIDENCE: The registered manager has recently achieved the required management qualification and has appropriate experience to allow her to run the home competently and meet its stated aims and objectives. The manager has sound knowledge of how to carry out effective management of the home, communicating a clear sense of direction to staff. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 23 There are clear support networks in place for the manager from senior managers in the company, and the provider’s representatives deal with tasks for which the manager may not have responsibility. Staff and residents spoken to were complementary as to the manager’s approach and supportive leadership. The manager ensures that staff follow policies and procedures. Staff have practice handbooks and easy access to all documents, which are discussed during supervision, staff training and team meetings. Spot checks and quality monitoring systems provide management evidence that practice reflects the homes policies and procedures. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. The home has very efficient systems to ensure effective safeguarding and management of individual’s money including record keeping. Residents have access to their records whenever they wish. Residents expressed no concerns as to the way the home handled their money. Overall record keeping is of a consistently high standard, and there are systems in place to identify shortfalls. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Residents can get access to their records and contribute to them. All the working practices in the home are safe and there are no preventable accidents. The home has a full range of policies and procedures to promote and protect residents’ health and safety, which staff are aware of and follow. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. The home proactively consults other experts and agencies about health and safety issues as needed. There is a good understanding of risk assessment and this is taken into account in all aspects of the running of the home. The quality assurance system confirms that the findings from risk assessments have been actioned and the home continuously improves its systems for health and safety. The systems are regularly reviewed and updated and are developed on the basis of experience in the home and learning from external developments. The manager ensures that all staff are trained in health and safety matters and have regular planned updates. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 24 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 3 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 x 3 X 3 X X 3 x 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement All prescribed creams/ointments must be signed in and a record of administration kept as for any other medication. Self-adhesive labels with directions for the administration of medication are not to be used on medical administration records. To carry out a risk assessment in respect of resident O having no restrictors on the bedroom windows. To obtain a reference for new staff from their last period of employment with children or vulnerable adults where applicable. Timescale for action 15/03/07 2. YA20 13(2) 15/03/07 3. YA24 13(4) 15/03/07 4. YA34 19 Schedule 2 (3) 15/03/07 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 26 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 To continue developing personal care planning as a tool for involvement of residents in life and care planning. 5 Trinity Street DS0000004854.V330245.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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. 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