Inspection on 08/08/07 for 59 Bury Road

This inspection was carried out on 8th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

59 Bury Road 13/08/08

59 Bury Road 26/06/06

59 Bury Road 08/11/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 59 Bury Road Gosport Hampshire PO12 3UE Lead Inspector Marilyn Lewis Unannounced Inspection 8 and 14 of August 2007 09:50 th th 59 Bury Road DS0000064247.V342910.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 59 Bury Road DS0000064247.V342910.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. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 59 Bury Road Address Gosport Hampshire PO12 3UE 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) 020 8544 8900 www.caremanagementgroup.com Care Management Group Limited To Be Confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 Brief Description of the Service: This service was registered in May 2005 and is owned by the Care Management Group. The provider has two houses next door to each other in Bury Road and they are registered separately. The house has been refurbished to a good standard and provides a home for up to six people who have a learning disability and/or autism and challenging behaviours. At the time of inspection there were five residents living in the home. Each resident has a single room with en-suite facilities and have access to the lounge with dining area, a quiet room and the garden. Residents also have access to the kitchen and laundry room with staff supervision. Current fees range from £1,600 to £2155 per week with additional charges for services such as the hairdresser, chiropody and toiletries. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made to the home on the 8th August 2007, when the inspector met with residents, looked around the home and saw records including care plans and those for medication, complaints and fire safety and drills. The manager and deputy manager were not on duty on that day and the inspector returned to the home on the 14th August to meet the manager and look at additional records including those for staff recruitment and staff training. Information provided by the manager of the home prior to the visit, in the Annual Quality Assurance Assessment (AQAA), regulation notices and past inspection reports was taken into account when writing this report. What the service does well: Residents said that they liked living at the home and Very good interaction was observed between staff and the residents. Staff supported the residents to make their own decisions. A resident said that the staff ‘help me to do what I want to do’. Residents were able to participate in talks about life at the home and were able to express their wishes. A visitor said that his relative received very good care at the home and that he ‘had no complaints whatsoever about the quality of care provided’. Residents said that they liked their rooms and had been involved in choosing the colour for decoration and the furnishings. One resident said that they ‘had everything they wanted’ in their room. The home looked clean, comfortable and homely. Residents said that they liked the food provided and were able to choose the meals they wished. Residents discussed the menus during their resident meetings and some residents went with staff to buy the groceries and assisted in preparing the meals. One of the residents attends college sessions and two other residents are due to start courses at the college in the autumn. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 6 Residents are supported by staff to participate in their chosen activities. The range of activities varies from resident to resident and includes horse riding, shopping, visits to the library and drum classes. What has improved since the last inspection? What they could do better: The home’s service user guide is provided in a general format for all the care homes belonging to the organisation and is not personalised for 59 Bury Road. The goals and wishes of all the residents should be documented in their care plans together with the actions required by staff to support the residents to meet their individual goals and wishes. Although staff spoken with were aware of the procedures to follow should abuse be suspected, not all had received training in the protection of vulnerable adults. Some staff have not received training in food hygiene and in topics very relevant to the residents such as autism and communication skills. This could result in staff not being able to fully support the residents. The manager of the home has been in post for almost a year but has not yet applied to register with the commission. Staff attendance at fire drills was not recorded and it was therefore not possible to confirm that all staff had attended fired drills. This could put the safety of the residents at risk if staff were not aware of the appropriate actions to take should an incident occur. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care needs assessments are undertaken for all people before a place at the home is offered, to ensure the home can meet their care needs. Residents would benefit from the service user guide being provided in a more user friendly format. EVIDENCE: Each resident is provided with the home’s service user guide. These documents seen in three residents files had not been personalised for the home. The document was an organisational one and there were headings such as ’give the name of the home’, but this had not been done, making the document not user friendly. One of the residents recently admitted to the home said that they did not remember seeing any information about the home before they moved in, but a copy of the service user guide was in their file. Two residents have moved into the home this year. One of the residents had lived in another of the organisations’ homes and had been visiting the home before asking for a move there. The resident had chosen the home as the place they wished to live. The manager of the home had visited the other resident in their current home and the manager and a senior member of the organisation had undertaken a care needs assessment. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 10 The assessments covered all aspects of care needs including cultural, religious, personal and emotional needs. Information from the current care staff and health professionals including psychiatrists and psychologists was included in the assessments. The information obtained in the assessments was used as the basis for the initial care plans. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to make their own decisions and participate in all aspects of life at the home. The goals and wishes of all the residents should be documented and staff should act to ensure the residents are supported in meeting them. EVIDENCE: Care plans were seen for the two residents recently admitted to the home and for one resident who had lived in the home for two years. Two of the care plans documented the goals and wishes of the residents but plans seen for one resident admitted early in the year did not. The manager said that discussions were taking place with the resident regarding them attending college sessions later in the year but the plans seen did not identify this as the residents wish. The resident said that his wish was to move bedrooms but this was not documented. Care plans for the two residents where goals had been identified would benefit from the goals being broken down into sections, such as if the goal was to go 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 12 on holiday, the plan would document where and when the person wished to go, who they wanted to go with them and did they need to book accommodation. It would then be possible to track how the goals were being met. One of the residents did wish to go on holiday and the date to achieve this was September but there was no indication as to whether this had been arranged. Some of the documents in the care plans including risk assessments had not been dated when written and it was difficult to follow which procedures were in current use. The plans seen had been reviewed regularly. A relative said that they were always asked if they wished to attend reviews. Records for one resident said that the resident had been present for part of a review but had then wished to leave the room and the review had continued with the care manager in attendance. Records for another resident documented changes the resident had made to their goals and wishes during the review of their care plans. Daily records seen provided good information including the residents’ enjoyment of the activities they had been involved in during the day and any behavioural issues. Staff spoken with said that they found the information provided in the care plans good and easy to follow. Residents spoken with said that they were able to say what they liked and did not like about life at the home and during the visit staff were observed encouraging residents to make their own decisions. A resident who was going out shopping was asked if they would like to look after their own money during the trip and another resident who had risen late was asked if they would like breakfast or if they would prefer to have lunch. One resident had said at a review that she wished for changes to be made to the decoration and furnishings in the lounge. Arrangements had been made for the resident to choose new furnishings for the room. Care plans seen contained risk assessments and also behaviour guidelines. The behaviour guidelines gave clear information to staff on the actions to take if there were behavioural issues. The guidance indicated that pro- active strategies such as talking with the resident and the use of ‘as needed’ medication were to be used in the first instance and that physical intervention was to be used as a last resort. All staff had received training in the Dignified Management of conflict. During the visit two residents showed signs of challenging behaviour and staff handled the situation very well, quietly talking with the residents in a very sensitive and patient manner. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 13 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents participate in activities of their choice and enjoy the meals provided at the home. EVIDENCE: One of the residents has been attending a local college and will be returning to sessions there when the new term starts in September. Two other residents are due to start college sessions in the autumn. Some of the residents go to a social club occasionally and visit an activities centre where they can participate in activities such as canoeing and horse riding. One of the residents said that she enjoyed playing the drums, a hobby that she has been interested in for many years. The resident attends sessions at a drum workshop and has a set of drums in a shed at the bottom of the garden. The resident said that she plays the drums three times a day and occasionally when she feels tense and agitated. The times of the day when the drums are 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 15 normally played have been agreed with the neighbours and the drums are padded so that they are not too loud. During the visit to the home residents were all involved in different activities. One resident went shopping with a support worker, one assisted with preparing lunch, one was writing a letter, one had one to one support and spent time in the garden and one had a lie in. The resident who had the lie in said that she had enjoyed it as she had not slept well the night before. The resident who went shopping said that she usually went into town most days. Records seen indicated that the residents accessed the community with visits to pubs for a soft drink or a meal, local shops, library and seafront. In house activities included arts and crafts, watching videos and assisting with household chores such as making their bed and setting the table for meals. Records seen for one resident recorded that the resident who had been attending services at a local church, did not wish to go at present. Staff had discussed this with her during a review and told her she was able to start going again when she wished. A visitor to the home said that his relative visited him at his home every couple of weeks for lunch, accompanied by staff. The visitor and his relative said that they enjoyed these times together. Staff support one resident to visit the library where he uses the computer system to email his parents. Some of the other residents telephone their relatives and the relatives of two visit the home regularly. Staff asked the residents what they would like to do and gave them some ideas to help them chose what they wished to do. A resident helping prepare lunch worked alongside the support worker and was asked if he would like to carry out some of the tasks. Staff interaction with the residents was good and they supported the residents in a friendly and caring manner. The residents said that they could choose what they would like for their meals, if they did not wish the main choice. Three of the residents chose the main meal for lunch and two had different meals. One of the residents said that the food was good and they all indicated that they enjoyed their lunch. The residents sat with staff at the table in the dining area. During the second visit to the home, a relative joined the residents at the table at lunchtime. Residents decide the menu on a weekly basis during resident meetings and some of the residents go with staff to do the grocery shopping. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 16 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 17 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care needs of the residents are met. Staff adhere to the home’s clear procedures for dealing with medicines, protecting the safety of the residents. EVIDENCE: Residents’ preferences for how they wished to be supported for personal care was documented in their care plans. One of the residents said that staff ‘do things the way I like’. Records seen showed that residents visited the GP, dentist, opticians and chiropodist as needed. Appointments made at hospital outpatient clinics had been attended and the residents had received an annual health check. However records for one resident admitted to the home in the spring indicated that there was a possibility that the person could be allergic to nuts. This had not been followed up and there were no risk assessments in place should there be an occasion when a reaction to nuts occurred. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 18 At the second visit, staff had addressed these concerns and the resident had visited the GP for blood tests to ascertain whether there was an allergy to nuts or whether the resident did not like nuts. The home has policies and procedures in place for dealing with medicines, including the systems for recording medicines brought into the home and on disposal of unwanted items. The name of the staff member responsible for the administration of medicines on each shift is highlighted on the rota. A staff member said that only staff who had received training in the administration of medicines could give out the medicines. Records seen confirmed the staff who had received training. The majority of medicines prescribed are provided in blister packs. Medication records seen had been completed appropriately and medicines were stored safely. Information was available on the medicines in use at the home including the side effects. The staff member said that no controlled drugs were currently being prescribed for residents. The home does not have a controlled drugs cupboard and this would need to be addressed should a resident be admitted who was taking a controlled drug. Some of the residents were prescribed medicines to be taken ‘as needed’. The staff member said that when these medicines were required they were to contact the person on call, if the manager or deputy was not on duty, before giving the medicines. This was to minimise the risk of error. The reasons for giving the medicines and the dosage were documented on the medication records and two staff members signed the records. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 19 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that staff will act to resolve any complaints and they are protected by staff awareness for the prevention of abuse. EVIDENCE: During the visit staff were observed interacting well with residents and they asked the residents what they wanted to do and how they wanted procedures done. A staff member spent time talking to one resident who wished to write a letter and this was done in a sensitive manner. At one time two residents became very angry with one another and staff intervened well and supported the residents while they calmed down. Two residents said that if they were unhappy or did not like something at the home they would tell the manager or a member of staff. The home’s complaints procedure was included in the service user guide and records seen indicated that all complaints were taken seriously. A visitor to the home said that he felt any complaints would be listened to and acted upon quickly. The home has procedures in place for the protection of vulnerable adults and these were readily available for staff. Staff had received training in abuse awareness but fourteen had not attended training in the protection of vulnerable adults. The manager said that this training was being arranged. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 20 A copy of the home’s procedures stating what is abuse and what a resident should do if they felt they were being abused was displayed in each of the residents’ rooms. The procedures were provided in a symbol format suitable for the residents. Staff spoken with were aware of the procedures to follow should abuse be suspected. The home holds small amounts of money for the residents. The monies are kept in individual containers in a safe place. Receipts and records are kept for all transactions. Records seen for one resident matched the amount of money held. During the visit one resident asked for some of their money to go shopping. Staff explained to the resident how much money was in her container and they discussed how much would be needed for the shopping. The resident was given the money to put in their purse and a staff member accompanied them to the shops. On return the records were updated and the change put back into the container. Residents have a second account where money is kept for items such as leisure activities and reflexology. Residents do not pay for items such as furniture or fittings for their rooms. This is provided by the organisation. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 21 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, 25, 26, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The property provides a clean and homely environment for all who live and visit there. EVIDENCE: The home is a large semi detached property situated in a residential area of Gosport, within walking distance of the shops and the seafront. The property next door is also a care home owned by the same organisation. Accommodation is provided on three floors. Residents each have a single room with en-suite facilities and have access to the lounge with dining area and a quiet room. The kitchen is domestic in style and laundry equipment is available in a small room off the lounge. A small staff office is located on the ground floor. The home looked clean and homely. Two residents showed the inspector their rooms. One of the residents said that they had chosen the colours for the room 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 22 and both rooms contained many personal items such as pictures and audio equipment. One of the residents said that they really liked their room and the other resident said that they liked their room but were hoping to move to another room that was currently vacant, as they preferred that one. A staff member said that this move was being discussed. The vacant room had been furnished for use should a resident be admitted in an emergency. Sufficient bathroom and toilet facilities are provided and those seen looked clean and in good order. The garden to the rear of the property has a seating area. Colourful artwork is displayed on the fencing. One of the residents, who likes to play the drums, has a shed at the bottom of the garden which houses the drums. The drums have been padded to prevent them being played loudly and upsetting the neighbours. Car parking is available at the front of the house and on the road near by. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 23 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, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by the robust procedures used for the recruitment of staff. Not all staff have received the training they require to ensure the residents needs are fully met. EVIDENCE: At the time of the first visit the manager was on annual leave and the deputy manager was attending a training course. Staff on duty at the home were aware of who was responsible for the running of the home that day and the home appeared to be running smoothly. On the second visit to the home the manager said that the organisation has a policy where the days he will not be at the home are recorded on the rota but the actual time of his attendance is not noted. However when the inspector asked on two different occasions when the manager would be on duty staff did not know. Staff said that they received job descriptions when they applied for a position at the home and copies of job descriptions were filed in staff records. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 24 Rotas seen indicate that four staff members are on duty in the morning, four in the afternoon and two at night. The manager works as an additional staff member on some days to provide time for managerial tasks. The manager said that staffing levels were flexible to allow residents to follow activities of their choice such as going out to the shops or for visits to places of interest. A staff member said that an on call system provides them with support, as they need it. A senior member of the home or the home next door is on call each day and also the manager or deputy of each home. Five of the nineteen staff employed at the home hold or are in the process of obtaining NVQ level 2 or above and one staff member is due to commence the course later in the year. The manager is aware that this is below the 50 required and is looking to address this. Two staff members who held the qualifications have recently left the home. Records were seen for two staff members who have been employed in the last six months. One of the staff members said that he had not been able to start work at the home until a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been completed. Records confirmed that the checks were undertaken and two written references obtained before staff started work at the home. The manager had commenced an audit of staff training needs. New staff completed an induction programme which included fire safety and health and safety. All staff had received training in the Dignified Management of Conflict which included the management of challenging behaviour. Fourteen staff members required training in food hygiene, with four of these booked to attend a training course at the end of August. Staff had received training in the awareness of abuse but fourteen required training in the protection of vulnerable adults. Only eight staff had received training in communication needs and six in caring for people with autism. These areas are very relevant to the residents at the home and need addressing. A trainer visits the home on a two weekly basis to support a resident who uses Makaton as a method of communication. During these training sessions a staff member attends with the resident and is able to train alongside the resident. However the majority of staff have not received any training in this method of communication. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 25 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, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives feel able to express their views on the quality of care provided at the home. The manager requires to be registered with the commission. Some staff require training in health and safety issues such as food hygiene to ensure the health, safety and welfare of the residents are protected. EVIDENCE: The manager holds NVQ level 4 and the Registered Managers Award and has managed the home for a year. He has worked in the care sector for fourteen years and has previously been a registered manager of another care home. Since the home registered with the commission in June 2005 no one has registered as manager of the home. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 26 The manager has not yet applied to be registered with the commission as manager of the home and needs to start the application process. Staff spoken with said that they receive good support from the manager and one said that they could see improvements in the quality of care being provided since the manager took up his post. A relative of a resident said that communication with the home was good and that he was able to attend reviews and discuss the care provided for his relative as he wished. A resident said that meetings were held where they could talk about life at the home and records seen confirmed this. Two residents said that they could talk to the manager or any member of staff if they were unhappy or wanted to change the way their care was provided. They also felt able to discuss their wishes with staff. The organisation obtains the views of the residents, relatives and health professionals on an annual basis through surveys. Quarterly forum meetings are also held which give people involved in the care homes an opportunity to meet and discuss the quality of care provided. Managers of the homes are not invited to the meetings but feedback is given as a whole on issues where the quality requires improvement or positive comments on areas where the quality is felt to be very good. Fire records seen indicated that fire drills were taking place but the names of staff attending the drills were not recorded. This meant that it is not possible to confirm that all staff have attended fire drills and are aware of the appropriate procedures to follow should an incident occur. Records and certificates seen indicated that the services in the home such as electrical systems and gas supply were checked on a regular basis. A new staff member said that they had received health and safety training during induction and records seen confirmed this. As previously stated in standard 35, not all staff had received training in food hygiene. 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 27 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 2 2 3 3 x 4 x 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 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 3 x x 2 x 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 (1) Requirement Timescale for action 30/09/07 2. YA35 18 (1)(c) The goals and aspirations of the residents need to be documented in their care plans. Staff should act to ensure they support the residents to meet these goals and aspirations. Staff should receive the training 31/12/07 they require to fully support the residents, including food hygiene, protection of vulnerable adults, communication skills and autism. 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 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 29 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 59 Bury Road DS0000064247.V342910.R01.S.doc Version 5.2 Page 30 - 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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