Inspection on 07/11/07 for 66 St Edmunds Road

This inspection was carried out on 7th November 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 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

66 St Edmunds Road 27/03/07

66 St Edmunds Road 28/11/05

66 St Edmunds Road 20/06/05

66 St Edmunds Road 01/03/05

66 St Edmunds Road 25/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 66 St Edmunds Road Stowmarket Suffolk IP14 1NU Lead Inspector Julie Small Key Unannounced Inspection 7th November 2007 11:20 66 St Edmunds Road DS0000037220.V354481.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 66 St Edmunds Road DS0000037220.V354481.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. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 66 St Edmunds Road Address Stowmarket Suffolk IP14 1NU 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) 01449 626210 david.gilbert@socserv.suffolkcc.gov.uk Suffolk County Council Post Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th March 2007 Brief Description of the Service: 66 St. Edmunds Road is a registered care home for five adults with learning disabilities, owned and administered by Suffolk County Council. It is situated in a residential area of Stowmarket and within easy reach of local amenities and resources. The accommodation is single storey and comprises of five single bedrooms, communal lounge and dining facilities, two communal bathrooms and one shower room. There is limited parking to the front of the building. The fees for the home appeared in the Statement of Purpose and Service Users Guide and were £66.85 per week. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Wednesday 7th November 2007 from 11.20 to 16.15. The inspection was a key inspection which focused on the core standards relating to adults and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The acting manager was present during part of the inspection. A staff member was present during the morning of the inspection and both the acting manager and staff provided requested information in a prompt and open manner. During the inspection a tour of the building and observation of work practice was undertaken. Four service users were met and four staff members were spoken with. Records viewed included three service user, staff training, four staff recruitment and health and safety records. Further records viewed are detailed in the main body of this report. Prior to the inspection an annual quality assurance assessment (AQAA) was sent to the home and returned within timescales. Service user, staff and relatives surveys were sent to the home October 2007. None were returned at the time of the inspection. What the service does well: Interaction between service users and staff was observed to be positive, professional and friendly. Service users were observed to be included in the inspection process, which included introducing the inspector and encouraging a service user to accompany the inspector during a tour of the building. The home was clean and comfortable. Service user’s bedrooms viewed reflected their individuality and choice. Complaints were acted upon and clearly recorded. Care plans were detailed and were regularly updated. The plans were updated yearly and identified how each service user had improved in independence tasks in their daily living, such as with personal hygiene. There were regular staff meetings, where service user’s well being and issues in the home were discussed. There was a staff meeting during the inspection, communication between staff members was observed to be good and informative. 66 St Edmunds Road DS0000037220.V354481.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. The summary of this inspection report can be made available in other formats on request. 66 St Edmunds Road DS0000037220.V354481.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 66 St Edmunds Road DS0000037220.V354481.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect that they are provided with the information they need to make an informed choice about where to live and that their individual aspirations and needs are assessed. EVIDENCE: The home’s statement of purpose and service user’s guide were viewed and had been updated May 2007, both documents had been forwarded to CSCI. The statement of purpose included details about the home and the service that it provided, such as the aims and objectives of the home, admissions and discharge, the qualifications and experience of the manager and the staff working at the home, consultation, protection, fire and complaints procedures. The service user’s guide included photographs of the home, fees and the care that service users could expect from the home. The statement of purpose and service user’s guide included the contact details of CSCI, however, the local CSCI office had recently relocated from Ipswich to Colchester. The documents should be amended to reflect the contact details. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 9 Service user’s records were viewed and evidenced that needs assessments had been undertaken when they were newly admitted into the home. There were ongoing updated needs assessments and care plans, completed by the home and the local authority, which identified how their needs would be met with their changing needs and preferences. 66 St Edmunds Road DS0000037220.V354481.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, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their needs are reflected in their individual plan, that they are supported to make decisions and participate in aspects of the home and are supported to take risks as part of an independent lifestyle. EVIDENCE: Three service user’s care plans were viewed and each included all aspects of their day to day living needs, including personal care, eating and drinking, all detailed each service user’s likes and dislikes. The care plans clearly explained the step by step support that each service user needed and preferred. Care plans were regularly updated along with service user’s changing needs and regular review meeting were undertaken where the service user, family and others involved in their care could participate in the care planning process. Each service user had an allocated key worker who advocated on their behalf during team meetings, such as choices that they had made. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 11 A service user’s records viewed included details regarding their behaviour, which included triggers and methods of de-escalation of displays of aggression. Incident reports were routinely completed and identified the nature of the incident and actions which staff had taken. Service user’s records included a document which identified the support that each service user required for each task in their daily living, for example when brushing their teeth and if they required support to put toothpaste on the brush etc. The documents were updated annually and identified if the service user’s abilities had developed or they required further support. The care plans reflected the information identified in the document. A service user’s records included details and incident reports when they had seizures. Records included regular weight checks and when issues had arisen with continence. Each service user had detailed risk assessments which identified the risks and prevention or minimisation of risks in their day to day living, activities in the home and in the community and displays of aggression. Daily records viewed detailed how service user’s had made choices in what they wanted to do each day. The daily records identified each service user’s wellbeing and activities throughout the day. The AQAA stated that service users made daily choices in their lives, such as with menu planning, household routines and what level of participation they wished to take in their own homes. The hand over book was viewed and included activities that service users had participated in and booked appointments. Throughout the inspection staff were observed responding to service user’s expressed preferences, including what they wanted to do, where they wanted to go in the home and what they wanted to eat and drink. The staff were attentive to the service user’s wishes and methods of communicating their preferences. 66 St Edmunds Road DS0000037220.V354481.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, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they are supported to take part in appropriate activities, that they are supported to maintain contacts, that their rights are respected and that they are provided with a healthy diet. EVIDENCE: Three service user’s records viewed included details of activities which they enjoyed and had participated in, which included eating out, theatre, swimming, shopping and games in the home. During the inspection service users were observed participating in several activities, including going shopping, having lunch out, painting their nails and hand massage, listening to music, cutting up pictures and playing the guitar. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 13 During a tour of the building it was noted that there were several items in the home which service users could use, including televisions, video’s, DVD’s, musical instruments and games. Service user’s bedrooms reflected their interests. One service user’s bedroom had models, pictures of tractors and musical instruments. During the inspection one service user was in attendance at their day services. The manager and a staff member spoken with explained a pilot project, which was being provided by day services and the home. Day services staff attended the home and undertook intensive one to one activities with service users, such as outings and independence skills. The manager reported that the project was on a trial period and the home were due to report the outcomes to the project after six months and decisions would be made if it was more beneficial to service users. The AQAA stated ‘I have regular meetings with the Day Service Manager and I am planning within the next two months to audit all the information gained from the day service pilot project and present my findings to the teams involved and relevant line management, highlighting where we have made improvements as multi-agency workers and the quality of life improvements for the residents within the home that have been accomplished within this project. Service user’s records viewed evidenced that they enjoyed regular contact with family members and friends. The care plans viewed clearly explained the support that each service user required in maintaining contacts. The AQAA stated that social gatherings were organised, to which service users could invite their family and friends. During the inspection staff were observed discussing how Christmas Day celebrations involved families. The home had a mini bus, which could be used to transport service users to their chosen activities. There were clear records which explained the day to day and night living routines of each service user, which directed staff in their care provision and the support they required. Service user’s records identified each individual’s preferred form of address. During the inspection it was observed that staff and service users enjoyed positive, friendly and professional interaction. The staff members included the service users in all discussions and they consulted with them throughout the day. The inspector was introduced to service users and a service user was encouraged to accompany the inspector on a tour of the building. Staff were observed to knock on bedroom and bathroom doors, where a service user was present, before entering. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 14 There was a bowl of fresh fruit and there was a good selection of fresh fruit and vegetables in the home. Items of opened food had been labelled identifying the date it was opened or cooked. Staff were observed to provide service users with their choice of drinks throughout the day. The menu was viewed and evidenced that a healthy diet was provided. There was a record of what each service user had eaten each day. Service user’s records viewed identified their likes and dislikes. During the inspection staff were observed in a discussion with the manager about plans to provide a healthier diet, including freshly made foods, following a discussion in the staff meeting. The AQAA stated ‘The Service, over the last three years, has been introducing healthy eating gradually by a step by step process as it recognised that Service Users for many years had what is now considered an unhealthy diet. This had evolved from choice making by the residents but was not informed choice making. The Service now only buys quality foods and the ingredients to make foods, but does not buy pre-made cakes, pies and ready meals. Although the Service does plan a weekly menu, an alternative meal is always available if and when a resident wants to make an alternative choice.’ 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Service users can expect that they are provided with personal support in the way that they prefer, that their physical and emotional needs are met and that they are protected by the home’s medication procedures. EVIDENCE: Care plans viewed include information regarding the support required by each individual including personal care, their likes and dislikes and their day to day routines. The care plans detailed what service users needed support with and what they could do independently, which was reviewed regularly. Service user’s records held documentary evidence of where they had received support from professionals such as doctors, dentists and physiotherapists, to meet their individual needs. Records included dates, reasons for and outcomes of the health care provision and health appointments attended. Records detailed weight checks and issues with, and support provided with incontinence. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 16 The AQAA stated ‘The Service has in place prompts within the Care package for dental checks and healthcare checks and all residents are registered with a GP. Any other healthcare needs, i.e. Chiropodist, Therapists, Health Care team are all organised through the Service and supported where appropriate. The Service has involved other professionals to ensure that the residents physical and emotional health needs are supported, for example the Intensive Support Team have on several occasions monitored and observed people around specific care needs, e.g. Autism and have advised and given training to the staff team. The Service also links into Psychiatric Services for two of the Service User group.’ A service user’s records viewed identified support that they required with issues of their behaviour and displays of aggression. The records identified signs, triggers and de-escalation techniques. Service user’s records viewed showed that resident’s had a key worker in the home. The statement of purpose and service user’s guide detailed that key workers advocated on behalf of service users in staff meetings with regards to their preferences. Each service user’s medication was stored in a metal, locked cabinet, which was secured on a wall in a room in the office. The MAR (medication administration records) were viewed and evidenced that incoming medication was checked. The MAR charts were completed appropriately, including dates and reasons for PRN (as required) medication and a running total of medication. There were clear guidelines and procedures provided relating to the safe handling of medication. Service user’s records clearly identified support that each resident required with regards to their medication. Training records viewed evidenced that staff were provided with medication training. Staff spoken with confirmed that they had been provided with medication training, which was confirmed by training records viewed. The AQAA stated ‘All residents within the Service have their medication administered for them. The Service employs a measured dosage system and has its own specific in-house medication procedure for staff to follow in addition to Suffolk County Councils policy on medicines.’ 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their views are listened to and acted upon and that they are protected from abuse. EVIDENCE: The home had a complaints procedure, which was viewed and included in the statement of purpose and service user’s guide. The home had a complaints, comments and compliments book, which was available to service users and visitors to the home. The book was viewed and evidenced that concerns and complaints were dealt with in a timely manner and the complainant was advised of the outcomes. Staff training records viewed evidenced that staff had been provided with POVA (protection of vulnerable adults) training. Staff spoken with had a clear understanding of their role in the protection of service users. The financial records of three service users were viewed and there were records and receipts kept of all transactions made. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 18 The inspector was asked for identification on arrival at the home and recorded their times for arrival and departure in the homes visitors book. The visitor’s book evidenced that it was a routine procedure. The AQAA stated ‘The Service also has systems in place that safeguards against all forms of abuse, physical, financial, psychological, etc. these being comprehensive financial records, where all transations are data tagged protected, incident and accident records that are monitored by myself (the manager) and the Health and Safety Department to look for any re-occurring or patterns of concerns that can be directed to an individual or the Service itself.’ and ‘All staff are trained in control and restraint, (Unisafe) - this is to ensure that any aggression, physical or verbal that is exhibited by the Service User group towards staff or other Service Users is dealt with appropriately and that physical restraint is only used as a last resort.’ 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to live in a clean, homely and comfortable environment, which meets their needs. EVIDENCE: The home was clean, well maintained, comfortable and homely. The home was bright and airy and the decoration and furnishings were well maintained and attractive. The carpets in the hall, lounge and office were stained and were in need of cleaning or replacing. The double glazed windows were observed to have condensation between the two pieces of glass, which partly obscured the views out of the windows. The seals to the windows needed repairing or replacing. There was a large kitchen which had a large dining table and chairs, a dining room, which provided a choice of dining areas and a large lounge which service users could use. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 20 Three service user’s bedrooms were viewed and reflected their individuality with the décor and their personal belongings such as posters, photographs, stuffed animals and memorabilia. There were music centres and televisions in the bedrooms which belonged to the service users. Three service users showed the inspector their bedroom and two confirmed that they had chosen the décor and furnishings in their room. The AQAA stated ‘The home reflects the Service User groups collective and individual tastes. All the Service Users bedrooms are individual to that person, all have their own bedroom furniture and fixings, pictures and have made choices for bedroom colours and general decoration. The home is well provided for communal space and again the furniture and decoration reflects the age, likes and interest of the people living there.’ The home had a toilet, two bathrooms consisting of a toilet, hand wash basin and bath and a shower room with a shower, hand wash basin and toilet, which provided a choice of bathing facilities for service users to use. There was a musty odour of stale water identified in the shower room during the inspection. The smell was still present after the domestic assistant had thoroughly cleaned the room. A staff member said that there had been suggestion of replacing the shower and that staff had reported that excess water had run onto the floor from the inclined shower floor. Hand washing facilities in bathrooms, laundry and kitchen provided hand wash gel and disposable paper towels. There were sufficient stores of disposable gloves and aprons for staff use when undertaking personal care duties. The home had an infection control procedure and staff spoken with had a good knowledge of infection control procedures. The laundry was viewed during a tour of the building, which contained a washing machine, tumble dryer and a hand wash basin. The AQAA stated ‘The Service has in place strict regimes and protocols to follow in the handling of foul laundry and has washing facilities that have a sluice programme and boil wash programme that ensures cross infection or contamination cannot occur.’ The domestic assistant was spoken with and said that they had achieved an NVQ (National Vocational Qualification) level 1 in cleaning. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they are supported by a competent and trained staff team and that they are protected by the home’s recruitment procedures. EVIDENCE: Staff training records were viewed which evidenced training undertaken which included induction, health and safety, unisafe, POVA, food and hygiene, medication, manual handling and specific training which related to the service user group such as intrusive medication and autism. The AQAA stated ‘All staff receive mandatory training which includes Manual Handling, Basic Food Hygiene, Control and Restraint (Unisafe), Protection of Vulnerable Adults, Equal Opportunities, Epilepsy, Medication training, Challenging Behaviour Policy and Personal and Intimate Care.’ and ‘All staff attend the Skills for Care Induction Standards training within six weeks of commencing at the Home. All staff also follow a comprehensive in-house induction programme and shadow under the direct supervision of permanent, 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 22 fully trained and inducted staff until they have completed their in-house induction.’ Staff spoken with confirmed that they provided with a good training programme. Staff said that they were provided with regular supervision and fortnightly team meetings where they could discuss their work practice and training and development needs. Staff said that they felt supported in their work role. Four staff recruitment records were viewed and evidenced that appropriate checks had been undertaken prior to the individuals commencing work at the home. Checks included satisfactory CRB (Criminal Records Bureau) checks, two written references and identification. Staff records held a photograph of each staff member in the form of an original of a photograph or copy of a passport or driving license. Staff records included application forms, including a history of their work experience and interview notes. The AQAA stated ‘All staff appointments are subject to two positive references and a minimum of three months probabtionary period - (three reviews being held within this probabtionary period). All staff have an enhanced CRB check before taking up post.’ During the inspection interaction between staff and service users at the home was observed to be positive and respectful. Staff training records and the statement of purpose viewed included details of staff NVQ (National Vocational Qualification) achievement which was nine care staff, five had not yet achieved their award and four staff had. The AQAA stated that one staff member was working on the award. The home had met the 50 target of staff to have achieved a minimum of NVQ level 2 by 2005. The rota was viewed and showed that the home provided staff support 24 hours each day. A staff member was spoken with and said that care was taken to ensure that inexperienced and unqualified staff worked alongside experienced staff. A staff member said that there were two staff on sick leave. The manager was observed showing an agency representative round the home. The manager reported that they were attempting to obtain agency cover from allocated workers, to ensure consistency to service users, to cover at times of staff sickness. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they benefit from a well run home, that their views underpin self monitoring of the home and that their health, safety and welfare is promoted and protected. EVIDENCE: The registered manager position was vacant and managerial responsibilities were being undertaken by a registered manager from another service, who had achieved a NVQ level 4 in care and a diploma in management. The qualifications were identified in the homes statement of purpose and in training records, which also identified that the manager attended regular training to update their knowledge. Staff spoken with reported that they thought that the home was well run. A staff member who was acting up in a senior position 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 24 supported the management of the home. They were spoken with and said that the senior role was being advertised in the press. Staff spoken with said that service users were consulted with regarding their care and issues in the home. Service user’s records viewed evidenced that they were participated in their care planning, through identifying their likes and dislikes and attendance at review meetings and family and others involved in their care were also invited. There were records service user surveys, which expressed their satisfaction with the service that they received and the complaints, comments and compliments book was available to service users and visitors to the home to record comments they had about the home. The book evidenced that any concerns or complaints were acted upon and outcomes were fed back to the individual. Staff training records viewed and evidenced that staff received food hygiene, health and safety, first aid and manual handling training. Staff members spoken with confirmed this. The homes accident and incident records were viewed and were appropriately completed. Fire records evidenced that regular fire safety checks were undertaken. During a tour of the building the homes locked COSHH (control of substances hazardous to health) cupboard was noted to be situated in the laundry. There were well stocked first aid boxes situated in the kitchen and laundry. Health and safety records viewed evidenced that electrical items, water and boilers were regularly checked. There were records which showed that fridge, freezer and water temperature checks were undertaken on a regular basis. There were environmental risk assessments, which were viewed. The AQAA stated ‘The Service has appointed a staff member with Health and Safety responsibilities to ensure that all necessary weekly and monthly checks are completed and to heighten awareness of health and safety within the team. The staff member provides health and safety feedback statements and these are minuted within the fortnightly staff meeting minutes.’ 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 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 X 3 X 3 X X 3 X 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 1. 2. Refer to Standard YA27 YA24 Good Practice Recommendations It is recommended that an investigation to the musty smell in the shower room be undertaken and action taken to remedy it. The windows, which have condensation between the double glazing panes of glass, should be repaired or replaced. 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 66 St Edmunds Road DS0000037220.V354481.R01.S.doc Version 5.2 Page 28 - 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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