Inspection on 20/09/06 for 56 Monks Dyke Road

This inspection was carried out on 20th September 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

56 Monks Dyke Road 23/02/06

56 Monks Dyke Road 02/06/05

56 Monks Dyke Road 13/01/05

56 Monks Dyke Road 07/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 56 Monks Dyke Road Louth Lincolnshire LN11 0NY Lead Inspector Sue Hayward Key Unannounced Inspection 20th September 2006 12:30p 56 Monks Dyke Road DS0000002678.V312018.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 56 Monks Dyke Road DS0000002678.V312018.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. 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 56 Monks Dyke Road Address Louth Lincolnshire LN11 0NY 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) 01507 610877 www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Fiona Kennedy Care Home 7 Category(ies) of Learning disability (7), Sensory impairment (7) registration, with number of places 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to admit a maximum of 7 service users in the categories Learning Disability (LD) or Sensory Impairment (SI). 23rd February 2006 Date of last inspection Brief Description of the Service: 56 Monks Dyke Road is one of a number of care homes within the county operated by SENSE East and is located in a residential area in the market town of Louth. The building is owned by a housing association, which has some maintenance responsibilities. It was originally a family home. It provides personal care and support in single rooms for up to seven service users over the age of eighteen. Three bedrooms have en-suite facilities. The home has a safe, enclosed garden at the rear of the property and car parking spaces at the front and rear of the house. Transport is provided through the use of a minibus and staff cars. The stated aim of the home is to provide a safe and supportive environment for the people it cares for. The objectives are to provide a warm and homely place, to respect each individuals privacy and dignity, to support service users to be as independent as possible, to provide staff with training and to check on how well the service is doing through monitoring and reviewing it regularly. Information provided in April 2006 indicated that the current range of fees is from £1088.46 - £1817.68 per week. There are no additional charges. Information about the day-to-day operation of the home, including a copy of the last inspection report, can be found in the entrance hall. 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by one inspector and took place over 4 hours. It formed part of a “key” inspection. This is the checking of those standards considered to be “key” in terms of the health, safety and welfare of service users. It also included checking whether issues raised at the previous inspection had been addressed. Information already held on file was used to plan the visit and produce this report. This included checking the history of the service and records of any significant incidents and correspondence received since the last inspection. The manager had completed a CSCI questionnaire prior to the visit giving important information about the home. She confirmed that in view of the very individual needs of current service users they had been unable to complete the questionnaires sent to them asking for their opinions about the service. The main method used at the site visit was tracking the care and support received of a sample of two service users with a range of needs via their records and observation. In addition there was discussion with a staff member on duty, a visiting professional and the person in charge on the day of the visit. Bedrooms of service users being case tracked were seen, as were the lounge, kitchen/dining room, bathrooms and toilets. As service users have very individual communication needs they were not involved directly. Observation of staff working with service users was another method used to assess the manner in which care is provided. General feedback about the outcomes of the visit was given at the end of the visit. What the service does well: The home is a domestic style property providing, clean, tidy and well maintained accommodation for service users, which are furnished to meet individual needs. Service users independence within the home and community is promoted and there are a variety of social and leisure activities they can participate in if they wish. Service users healthcare is promoted through regular appointments with a range of health professionals. There is a consistent and committed staff team who have training opportunities to ensure they have sufficient knowledge and skills to provide a good standard of care for service users. Staffing levels are sufficiently flexible to provide the support that service users need. A visitor commented positively about the care and accommodation provided, was made welcome and felt there was good communication with staff. 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 6 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. 56 Monks Dyke Road DS0000002678.V312018.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 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a satisfactory system in place to assess the needs of service users and how they are to be met in the home prior to admission. This process ensures as far as possible that service users and their advocates are well informed about the home and that service users diverse needs are identified and planned for prior to admission. EVIDENCE: All the service users have been at the home for a number of years and there have been no further admissions since the last inspection. Records checked indicated that prospective service users and relatives have the opportunity to visit the home. Discussion with staff and a visitor present on the day from a funding authority confirmed that the admission process is a planned process including a number of visits and overnight stays before the decision is made for someone to become permanently resident at the home. There are satisfactory organisational policies and procedures in relation to the assessment and admission of service users. Part of this process includes consultation with other relevant professionals. Information about the home is available in symbol form as well as the written word. It is available in the hall for anyone to access. Discussion with staff 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 9 indicated that in view of current service users very individual communication needs none would be able to understand information in either forms. However, in view of the admission procedure being a planned process, service users have the opportunity to become familiar and get to know the staff, other service users, the layout and the layout of the home. The initial assessment information for both service users who were being case tracked on this occasion had been archived as they had been at the home for four to five years. However, their personal records contained detailed care plans and information from other health professionals and funding authorities indicating that there was full consultation. The visitor’s comments confirmed this. 56 Monks Dyke Road DS0000002678.V312018.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improving the review of care plans and risk assessments needs to be completed to ensure that service users care needs will be fully met. Service users are enabled to make choices and decisions about their lives. EVIDENCE: Both service users files checked had detailed care plans in place. Other information was also available demonstrating the plans in place to ensure service users welfare such as behaviour and eating guidelines. A requirement was made at the last inspection about care plans expressing clearly how service users needs are to be met, being reviewed monthly and showing evidence of service users involvement. Care plans seen indicated that work is in progress to address these matters but there is still a lack of recorded information to demonstrate ways in which service users are involved, dates of review and who by. Discussion with staff indicated that none of the current service users would be able to sign their care plans nor would they be able to fully understand them in symbol form. The person in charge at the time of the visit said that she was in the process of ensuring that care plans were updated 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 11 and that this task would be completed by 01/10/06. As there is evidence that this matter is being addressed this requirement has been removed. Reviews are held a minimum of twice yearly and records and discussion confirmed that relatives and other professionals such as funding authorities are invited to attend. A review was in the process of being held on the day the visit. The visitor from a funding authority confirmed that care plans are fully discussed at these and it was noted on a review record that a valid reason had been included for why the service user did not attend it. The care records of both service users being case tracked contained risk assessments, however these did not specifically detail some of their needs identified in the care plan. This has the potential to put service users and staff at risk. For example, a service user was noted to require the help of two staff with walking. An individual risk assessment was not in place about this although it is acknowledged that there was a general risk assessment in place for staff relating to manual handling. Staff discussion indicated how service users are given choices in the home, for example when shopping for clothes. Staff comments indicated that observation and knowledge about the individual ways in which service users communicate is a method used to judge their preferred choice and wishes. For example a staff member said that if shown a choice of two items a service user would push the clothes away from her if she did not like them. Service users were seen to be able to come and go around the house as they wished, staff providing support and intervening only as needed. 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to experience and participate in a range of occupational, recreational and leisure opportunities within the home and community. Activities are based on service users individual preferences and promote their independence. There are good links with families and visitors who are made to feel welcome. Well balanced meals are provided, which incorporate service users individual preferences, specific dietary needs and promotes their independence. EVIDENCE: Discussion with a visitor confirmed that the service user she was involved with participated in a range of activities within the home and community. Discussion with staff and care plans confirmed that there are various social, vocational and leisure opportunities, which service users participate in. Most attend a local resource centre four days during the week. Three service users were on holiday in Norfolk at the time of the visit. The three who were at home had also had a holiday earlier in the week. In addition service users 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 13 have opportunities to increase their independent living skills by assisting with activities of daily living such as light domestic, catering and gardening tasks with staff support, which is tailored to their individual abilities. A service user helped a staff member to collect apples from the garden during the visit and a staff member said that one had helped to prepare the vegetables for the evening meal. Another service user was listening to music in the conservatory whilst another was with a staff member in the lounge. There are opportunities for service users to be involved in art and craft activities and items made were seen in service users rooms. There is a mini-bus to take service users out, although staff said that during the week when service users attend the resource centre it stays with them there. Discussion with a visitor and records confirmed that there are good communication links maintained and service users are able to visit and stay with relatives. The visitor said that staff made her feel welcome at the home, she was always kept well informed and both her and her clients relative were invited to the reviews held. Records also confirmed this to be the case. All service users, in view of their needs, require support from staff to assist them with decision-making and to ensure their safety. However, service users were noted to be able to come and go around the house as they pleased with staff support as necessary, their rights only being limited if health and safety risks were being posed to them. For example, the use of a stair gate has ensured that a service user with mobility difficulties at risk of falling downstairs has lessened. Records of menus were checked. There is a four weekly rotating menu, which has been based on service users known likes and preferences. The meal on the day of the visit was a tuna pasta dish with salad. It smelt and looked appetising. It was noted that service users were provided with equipment to increase their independence such as plates with raised edges to enable service users with poor eyesight to eat more independently. Fresh fruit was noted to be available in the lounge. Staff were aware or service users food preferences and special dietary requirements such as fortified drinks and deserts and records and mealtime guidelines were in place demonstrating that service users nutritional needs are monitored. A visitor said that she thought the meals were varied and staff always asked service users what they would like. 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive care that promotes their health, welfare and independence and respects their individuality. Service users are protected by the medication procedures in place. Any errors are appropriately dealt with to ensure service users safety by prompt action being taken to improve the systems in place. EVIDENCE: Staff were noted to assist service users appropriately when providing care and were attentive to them such as ensuring they had support with personal hygiene needs. Staff communicated well with service users and respected their privacy. Care records included detailed information about communication needs such as whether the spoken word, sign language, symbols or objects of reference could be used. Individual communication needs of service users were known by staff. There is a “key” worker system in place giving specific staff responsibilities for specific service users. Staff comments indicated that they had a good knowledge of the needs of service users and how to meet them. 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 15 Discussion with staff and records seen provided information that demonstrated service users health care is promoted. Care records included information detailing the involvement of other health professionals such as dentists, opticians and doctors. Records indicated that service users are accompanied by staff to attend health appointments. This aids communication. The information a staff member gave about a recent death at the home indicated it had been managed in a sensitive manner. Service users seen during the visit looked well cared for and comments from a visitor confirmed when issues arise staff are prepared to “think outside of the box” and try different ways to resolve situations. Staff comments also confirmed this when an example was given of a service user whose mobility was becoming an issue who has moved to a downstairs room. Behaviour is also well monitored and both files checked contained individual guidelines for staff to follow should challenging behaviour occur for example. The CSCI has been appropriately notified of any accidents and incidents that have occurred which affect the welfare of service users and of the action taken to address them. There have been some errors notified about medication not being administered when it should have been. Steps have been taken to address this through staff training, discussion at staff meetings and a review of the medication administration protocol. Storage arrangements were checked and were satisfactory. Records are being kept of the temperature of the medication cupboard to ensure that medicines are stored appropriately. There is a system in place were medications are pre-packed by the pharmacist. Two staff check and sign administration records and on the whole they were well maintained however it was noted that some crossing out had occurred due to an error in recording which could lead to confusion. A pharmacist visits the home periodically and checks the medication systems in place. The last visit occurred on 29/03/06 and a stock control check was carried out. The pharmacist discussed a key storage matter and how it may be improved. Staff confirmed how this had been addressed. Records checked indicated that staff administering medication had had training and a competency assessment prior to being able to do so. There are organisational policies and procedures in place relating to the storage, administration and disposal of medication and protocols in relation to the use of homely remedies. All current service users need assistance from staff with the administration of medicines. 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are effective procedures in place for dealing with complaints and safeguarding adults’ issues, ensuring that service users are protected. EVIDENCE: The complaints record was checked at the time of the site visit. No complaints or concerns have been raised since the last inspection visit to the home. Records are also kept of any compliments received and one had been recorded. There are satisfactory organisational policies and procedures in place relating to complaints and safe guarding adults’ issues including a “whistle blowing” policy. The complaints procedure is also available in symbol form. Staff spoken to had a good knowledge of the procedures, how to report such incidences to and the forms that abuse can take. Safe guarding adults training is incorporated into the training programme and records checked confirmed this. A visitor said she knew how to make a complaint and would feel comfortable to raise any concerns. She confirmed when reviews are held she was always asked whether there were any issues she wished to raise. Staff said that in view of communication needs service users may not be able to make their concerns known however staff would rely on their own observations and knowledge of ways in which service users communicate, as well as any changes in behaviour to determine their well being. 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A comfortable and homely environment is provided for service users, which is well maintained and clean. EVIDENCE: The property is of a domestic style and is well maintained, looked clean and smelt fresh. Communal areas of the home were well maintained. The kitchen and dining area was clean and records were in place to monitor cleaning routines and food storage temperatures. It was noted that the refrigerator temperatures on occasions were above those recommended to keep food fresh. Staff said there was no set time for checking temperatures and agreed to do this as this may affect readings. The temperature of the refrigerator was also changed immediately. Contact should be sought from the Environmental Health Officer about this matter. Two bedrooms were seen as part of the case tracking process. Both were well decorated and furnished according to the needs of the individual service user and contained personal effects. A spare vacuum cleaner was being stored in the dressing room of a service user. It was noted that this matter had been highlighted in a monitoring visit 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 18 as needing removing. The storage of such items may impinge on service users privacy and alternative arrangements need to be made. Action has been taken since the last inspection to protect the privacy of a service user who cannot tolerate curtains in her bedroom by applying some frosted covering to the main part of the window. It was also understood through discussion with a staff member that consideration is being given to providing shutters instead of curtains. Equipment is provided to assist service users with mobility problems including a passenger lift, handrails in bathrooms and a ramp to the front door. With regard to the latter a health and safety audit has identified a need for handrails as well as a ramp to ensure service users ease of exit from the building in case of fire. Records demonstrated that this has been highlighted for attention. There is an on-going programme of redecoration and records checked indicated service users likes are considered in relation to the choice of decoration and furnishings of rooms. There is a garden to the rear of the property, which is well maintained. Staff said service users are involved in the general tidying and cleaning of their rooms and garden maintenance with support from staff. This gives opportunities to increase their independence and skills. Protective clothing was seen available for staff to use in bathrooms. Doors are lockable to ensure privacy. All baths and wash hand basins have had thermostatic mixer valves fitted to regulate hot water temperatures and ensure the safety of service users. In addition records indicated temperatures are taken on a regular basis to ensure they are working satisfactorily. There is a bidet in a bathroom which a staff member confirmed is not used by service users however the hot water tap on this has not been fitted with a thermostatic mixer valve and therefore has the potential to pose a risk to service users. It is however noted that this matter has been raised for action in area manager reports and health and safety audits. Room doors had symbols to assist service users to realise their function. There is a utility room equipped with laundry equipment. The washing machine has a sluice programme and a staff member gave a good description of how soiled linen is dealt with to ensure good infection control procedures are followed 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff are employed in sufficient numbers to meet the current needs of service users and the training programme in place helps to ensure they have the necessary knowledge and skills to provide appropriate care. There is a thorough recruitment procedure in operation. This ensures as far as possible that service users are protected. EVIDENCE: On arrival to the home the doorbell was answered promptly by a staff member. Three service users were on holiday in Norfolk and three were attending a local resource centre and returned later during the site visit. Two staff were on duty at the home plus the deputy manager who was attending a service user review. A staff member spoken to described staffing levels as generally meeting service users needs. It was said that there is a minimum of four staff on duty when six service users are at home. Some service users need one to one support. Comments and observations made indicated that this is provided as a staff member was with a service user who required this support during the site visit. At night there is one wakeful staff member and one sleeping in who is on-call if needed. Agency staff are not used. Staffing shortfalls are covered by existing staff members working additional hours or using SENSE East’s own relief staff to ensure consistency of care. There are currently two part time staff vacancies. Rotas checked on the day of the visit 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 20 confirmed the staffing levels in place and staff were noted to be attentive to service users needs. Information provided in April demonstrated that there was generally a consistent staff team as no staff had left since the previous inspection helping to provide continuity of care for service users. SENSE East has a satisfactory training programme in place, which all new employees attend over a six-week period. This includes a modular training programme covering matters such as manual handling, food hygiene, first aid, challenging behaviour, communication and protection issues. This ensures staff have the appropriate skills and knowledge to care for service users. After staff have gone through the initial induction programme training is updated periodically. Information prior to the inspection confirmed that four staff had achieved a National Vocational Qualification award at level II. The person in charge at the time of the inspection confirmed that two new staff members have been employed since the last inspection and records of their recruitment process was checked. In one-instance records in place were thorough and demonstrated that there was an equal opportunities process followed consisting of ensuring relevant checks were undertaken such as criminal records bureau checks and employment references prior to commencing work. In the other instance records of the recruitment process were not fully in place. It was understood that this information is still with SENSE East’s headquarters. The person in charge provided confirmation after that this appointment had also been based on a satisfactory recruitment process. 56 Monks Dyke Road DS0000002678.V312018.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed. There are good systems in place to monitor the quality of the service to help ensure the health and welfare of service users. EVIDENCE: There has been no change to the management arrangements since the last inspection. Discussion with a staff member on the day of the visit indicated that the staff team worked well together and she felt well supported by the manager and deputy. It was said that the manager or deputy were always oncall and if unavailable there is an organisational on-call system in place. A staff member confirmed that there is an annual appraisal system and six to eight supervision meetings although it was said that the frequency of these had lapsed a little recently. However, it was said the manager or deputy were always available to speak to if necessary on request and records of monthly visits by the area manager indicated this matter is monitored on a regular basis. In addition records demonstrated there are regular staff meetings held. 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 22 Other means that are in place to monitor the service are through quality monitoring systems such as health & safety audits and a minimum of twiceyearly reviews of service users at which significant persons such as funding authorities and relatives are invited to attend. The person in charge at the time confirmed that the last quality audit was undertaken the week prior to the site visit and had included an audit of service users monies held in safe keeping. Staff are waiting for the report of the outcomes of this to be issued. The CSCI has been receiveing monthly reports of visits carried out by an area manager who also comments on the quality of the service and how it can be improved. Information provided prior to the inspection indicated that there are organisational policies and procedures in place relating to health & safety issues and staff knew where to locate these. Of the sample checked on this occasion fire risk assessments were in place, monthly checks were being made on hot water temperatures to ensure they were not posing risks to service users and a certificate was in place demonstrating that there had been a gas safety check on 01/09/06. Fire records demonstrated weekly tests of the alarm system and monthly of the emergency lighting. Information provided through reports seen and discussions with staff on the day of the visit indicated that any health, safety or maintenance issues raised are addressed promptly thus ensuring the welfare of service users and staff. 56 Monks Dyke Road DS0000002678.V312018.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 56 Monks Dyke Road DS0000002678.V312018.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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