Inspection on 24/08/06 for 72-74 Walsingham Road

This inspection was carried out on 24th August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

72-74 Walsingham Road 10/02/06

72-74 Walsingham Road 25/08/05

72-74 Walsingham Road 05/01/05

72-74 Walsingham Road 06/07/04

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

CARE HOME ADULTS 18-65 72/74 Walsingham Road Hove East Sussex BN3 4FF Lead Inspector Niki Palmer Unannounced Inspection 24th August 2006 15:30 72/74 Walsingham Road DS0000014208.V308007.R02.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 72/74 Walsingham Road DS0000014208.V308007.R02.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. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 72/74 Walsingham Road Address Hove East Sussex BN3 4FF 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) 01273 888077 www.caremanagementgroup.com Care Management Group Limited Mrs Sandra Elizabeth Stinton Care Home 12 Category(ies) of Learning disability (12) registration, with number of places 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home is registered to accommodate up to twelve (12) service users Service users should be aged between 25 and 65 years upon their admission That the category of service users admitted have a learning disability, not falling within any other category 10 February 2006 Date of last inspection Brief Description of the Service: 72-74 Walsingham Road is a care home, which is registered to provide personal care and accommodation for up to 12 residents with mild to moderate learning disabilities, however currently only accommodates 11 residents as the twelfth bedroom, which is located on the second floor is used as an office. The home is owned and run by Care Management Group (CMG) who are a large organisation that provides care for people with learning disabilities. The home is located in a quiet residential area in Hove near to the seafront. There is good access to local amenities and public transport. There is no parking available at the home, but free parking is available in the adjacent streets. Accommodation consists of nine single and one double bedroom. Only two of these have en-suite facilities. All bedrooms are located over the ground and first floor. Residents must be able to mobilise independently as stairs and other access arrangements would make it unsuitable for residents with significantly restricted mobility. The layout of the home is not suitable to accommodate wheelchair users. Communal facilities include a good-sized lounge area, separate dining area and well maintained rear garden. There are two bathrooms, which are located on the ground and first floor. The home provides personal care and support to residents who are funded by Social Services. The home’s fees as of 24 August 2006 range between £883.84 and £1068.17 per person per week. Additional costs are charged for hairdressing (£15 - £20 every eight weeks), personal toiletries (£3 - £5 per week) and social activities (£variable). Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. A copy of the home’s most recent inspection report is available on request. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 72-74 Walsingham Road will be referred to as ‘residents’. This unannounced inspection took place on Thursday 24 August 2006 between 3.30pm and 9pm, which enabled the Inspector to spend time with residents and observe the evening routine. 11 residents were accommodated on the day of the inspection, six male and five female aged between 50 and 77 years of age. In order to gather evidence on how the home is performing, individual discussions took place with three residents, whilst others commented on their care during the evening meal, the Inspector having been invited to join and eat with them. In depth discussions took place with the Registered Manager and three members of care staff. Three care records were examined in some detail for the purpose of monitoring care. Other records and documentation inspected included: the home’s Statement of Purpose and Service Users’ Guide, medication practices, the provision of activities, quality assurance systems, the home’s complaints procedure and the systems in place to safeguard residents from harm. The Inspector was shown all communal areas and most individual rooms by two of the residents. A pre-inspection questionnaire was received prior to the visit to the home. This provided the Inspector with information relating to the premises, maintenance and associated records, details of the homes policies and procedures, staffing details and relevant training. 11 residents’ survey questionnaires were sent to the home prior to the inspection, 4 of which were returned. Despite feedback being requested from relatives/advocates/friends and a local General Practitioner, nothing had been received by the Inspector at the point of publication of this report. In order that a balanced and thorough view of the home is obtained, this report should to be read in conjunction with the previous inspection report carried out on 10 February 2006. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has worked hard to meet the majority of requirements made at the last inspection, with the exception of ensuring that a suitable assisted bath/showering facility is available, although this work is due to be completed by the end of December 2006. All residents are now provided with a detailed copy of their terms and conditions of contract inclusive of the method and payment of fees. The home’s Whistle-blowing policy has been updated to state that it refers to any practice in the home and not just abuse issues. Two bedrooms and the dining area have been redecorated, whilst residents are better protected by the home’s robust recruitment procedures. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 7 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. 72/74 Walsingham Road DS0000014208.V308007.R02.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 72/74 Walsingham Road DS0000014208.V308007.R02.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 at least once during a 12 month period. 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. Residents are provided with sufficient information prior to admission in order to support their decision of where to live. Good systems are in place to ensure that only residents whose needs can be met are admitted to the home. EVIDENCE: The Inspector was provided with a copy of the home’s Statement of Purpose and Service Users’ Guide, copies of which were seen in residents’ individual bedrooms. The Statement of Purpose provides the reader with an introduction to CMG including the home’s organisational structure, details of the Registered Provider and Manager, admissions criteria including the arrangements in place for accepting emergency admissions, residents’ specification, facilities within the home including room sizes, staffing structure and relevant training courses, leisure facilities and the arrangements in place for visitors, care planning, meeting religious and cultural needs and the residents’ complaints procedure. The Service Users’ Guide provides residents with a summary of the Statement of Purpose, residents’ charter, the terms and conditions of contract, information in relation to what residents can expect from the home on and shortly after admission, the arrangements in place for meeting their personal 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 10 and healthcare needs, contact details of the CSCI and a copy of the home’s inspection report dated 21 July 2003. The Service Users’ Guide is presented in an easy to read and understand format, which incorporates the use of colour pictures and symbols. Residents spoken with confirmed that they were all provided with a copy of both documents prior to admission in order to support their decision of where to live. Albeit that the Manager said that both documents had recently been updated, there was no date to evidence that they are current. A recommendation has been made in respect of this. In addition, the home is required to ensure that a copy of the most recent inspection report is included within the Service Users’ Guide. Many of the residents have lived at Walsingham Road for a number of years and have developed good relationships with each other. It was noted throughout the duration of the inspection that the compatibility between residents is exceptionally good. Although there have been no new admissions to the home since the last inspection, discussions took place with the Manager of the home in respect of how new admissions are assessed. CMG employs a team of centrally based Assessment Referral Officers, who are responsible for considering and assessing all initial referrals for each of the homes. The Manager confirmed that she is very involved in this process and has made the final decision with regards to whether or not the home can meet the assessed needs of prospective residents bearing in mind the compatibility and needs of existing persons. The home has appropriate terms and conditions of contract for residents, copies of which are included within the home’s Service Users’ Guide and individual care plans. Those seen were inclusive of the amount and method of fees payable. 72/74 Walsingham Road DS0000014208.V308007.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are mostly supported by the home’s care planning procedures, however the current format is in need of reviewing. Residents are consulted about all aspects of the home and are supported to make decisions in all aspects of their lives. Clearly assessed and managed risks enable residents to undertake a wide range of activities. EVIDENCE: Three individual plans of care were examined in some detail for the purpose of monitoring care, although the current care planning format is quite difficult to understand and follow. Whilst all were noted to contain a current colour photograph of the individual, a pen portrait and life picture, the home currently uses a number of different recording methods for example, in addition to the care plan separate daily entries are kept, additional healthcare records, a daily diary which residents are involved in maintaining and another file for letters of correspondence. It was therefore not possible to clearly establish how residents’ needs were currently being met. Two care staff spoken with during 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 12 the inspection also commented on this and said that they would benefit from a combined, yet simplified care-planning system. A requirement has been made in respect of this. Residents are supported to make decisions in all aspects of their lives. They were observed being supported to make choices about activities, the food they wanted to eat and holidays. The staff team is innovative in using photographs and pictures to help residents make informed choices. It was pleasing to note that where it is deemed that a person is deemed not to have the capacity to make an informed decision or choice, that guidance is in place to support the staff team alongside the relevant health and social care professionals to act in their best interests. There was evidence to support that this is happening on a regular basis particularly in relation to having dental work carried out. Care staff encourage residents as much as is possible to participate in all aspects of life in the home. They are encouraged to help with meal preparation, make their own hot and cold drinks, go shopping, attend to the laundry and in the past have taken part in the home’s recruitment and selection of staff. There was documentary evidence of detailed risk assessments and management plans to enable residents to undertake a wide range of activities in the home and in the community. All of those seen had been recently reviewed and updated as necessary. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 13 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, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in a wide range of activities to lead fulfilling lives, meet their needs and ensure their personal development. Residents play and active and fulfilling role in the life of their community. They are supported to maintain positive relationships with family and friends. The ethos of the homes promotes the right of residents to make choices in all aspects of their lives. EVIDENCE: Residents are supported to access a wide range of activities to meet their individual needs and preferences. Two of the residents showed the Inspector their daily diaries that keep a pictorial record of the activities they do on a daily basis. Activities undertaken include college courses, swimming, going on walks, going to church, leisure clubs, going to cafes and pubs and trips out. The home has a barbecue in the garden, which is used when the weather permits. Residents spoke about the recent World Cup, which they thoroughly enjoyed watching either at home or in their local pub. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 14 Residents play an active role in their local community, including going to the local Church, advocacy groups, beauticians, meeting up with friends and family and participating in events organised by CMG. Indeed one of the residents spoke about a recent event in which they gave a talk to other people living in CMG homes about what it has been like for him since moving from his family home into residential care. The majority of residents have been away on holiday this year, some of which were abroad. All of the residents spoken with said they were able to choose their activities and enjoyed the range of opportunities they had. They also said that they had been able to choose where to go on holiday and had an enjoyable time whilst they had been away. Residents confirmed that they are well supported by staff to keep in regular contact with their families and friends and that visitors are always made to feel welcome to the home at anytime. Throughout the duration of the inspection all staff were observed to knock on residents’ bedroom doors prior to entering and address them by their preferred term as indicated within individual plans of care. Two residents currently have appointed advocates in order to support them with exercising their rights and choices, whilst others are supported by their relatives and care staff. All meals are prepared within the home by care staff and residents based on the choices and preferences of the individuals. Specialist diets and smaller snacks are appropriately catered for including low sugar alternatives. Residents are encouraged to dine together alongside staff in the pleasantly decorated dining room, however those who choose to do so, can remain in the lounge area or in their own rooms, although most choose to dine together. Residents were observed to lay the tables prior to the meal and help clear away the kitchen afterwards. The main evening meal served on the day of the inspection looked appetising and plentiful with fresh vegetables available. Care staff were observed to be attentive to residents’ needs and offer discreet support where needed. Residents spoke highly of the variety and taste of the food provided. 72/74 Walsingham Road DS0000014208.V308007.R02.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 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 this service. Staff provide sensitive and dignified support to meet the individual needs and preferences of residents. Residents are supported to access a range of healthcare services to meet their physical and emotional well-being. Residents are safeguarded by the homes policies and procedures for the safe administration of medicines. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all healthcare appointments as necessary. Specialist advice from the Community Learning Disability Team (CLDT) is requested on an individual basis. All of the residents spoken with said that the daily routines within the home are quite flexible. For example they can determine what time of day they would prefer to have a shower or bath and in most instances can choose the member of staff that they would like to support them. All personal care needs are carried out in either one of the bathrooms or in the privacy of residents’ own bedrooms. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 16 A small number of the residents are older and are therefore more susceptible to developing additional healthcare needs for example, reduced mobility, eating and drinking difficulties, epilepsy and early onset dementia associated with Downs Syndrome. Whilst there was evidence to suggest that appropriate action had been taken by the home in respect of specialist referrals to the CLDT and the appropriate interventions were being carried out, care plans were insufficiently detailed in respect of this. This was discussed in length with the Manager of the home. The home is required to update all care plans for those residents who have developed additional healthcare needs to ensure that they reflect the current personal and healthcare needs of residents. Two of the residents have experienced a deterioration in their cognitive and mental state, which they are currently being assessed for. It would appear that they may possibly be experiencing early onset dementia, which the home is currently not registered to provide for. The home is required to undertake a comprehensive assessment of need alongside health and Social Care professionals in order to identify whether or not the home can continue to meet their needs in accordance with their conditions of registration. This must take into account the layout of the building and future care needs as the dementia progresses. The home’s medication records and storage systems were inspected. The home uses a pre-packed blister pack issued by the local pharmacy, which is easy to use and monitor. Only six members of staff who have received the appropriate training and have been assessed as competent in the administration of medicines are able to carry out this task. Senior members of staff are responsible for the reordering and returning of medicines to the pharmacy. It was pleasing to note that all records were accurately maintained and there were clear guidelines in place for all medicines that are prescribed on an ‘as and when’ basis (PRN). It is recommended that all signatures that appear on the medication administration record are written in black ink. 72/74 Walsingham Road DS0000014208.V308007.R02.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 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 this service. The home has good systems in place to ensure that all complaints are dealt with appropriately. Residents are protected from potential harm, neglect and abuse through the home’s robust policies and procedures and through staff receiving appropriate training. EVIDENCE: The home has a detailed complaints procedure in place, which is included within the home’s Statement of Purpose and Service Users’ Guide. It gives clear guidance with regards to how a complaint can be made and how the complainant can expect it to be dealt with. All of the returned residents’ questionnaires confirmed that all residents would know how and who to raise any concerns with at the home, namely their keyworker or the Manager. No complaints have been received by either the home or the CSCI since the last inspection. The home has a detailed Adult Protection and Whistle-blowing policy and procedure in place in order to safeguard residents from potential harm, neglect and abuse. Both are in accordance with local multi-agency guidelines. Since the last inspection the home has updated it’s Whistle-blowing policy to state that it refers to any practice in the home and not just abuse issues and the Manager has written a simplified practical guide for staff in relation to the Protection of Vulnerable Adults and ‘No Secrets’. Staff spoken with confirmed that both in-house training and external training has been provided by CMG. No alerts have been raised since the last inspection. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 72-74 Walsingham Road offers a friendly and relaxed environment that is kept in good decorative order and offers sufficient communal space. It presents as a clean, well-maintained and homely place to live. EVIDENCE: 72-74 Walsingham is a large home, which was originally two semi-detached properties that have been made into one. Accommodation is provided over three floors, although residents’ bedrooms are on the ground and first floor only. There are a number of photographs displayed throughout the home of each of the residents, all of which have been nicely framed and presented. In addition to this at the main entrance of the home there is an ‘in/out’ board, which has photographs of all residents and staff. Each photo is placed on the appropriate side to demonstrate quickly and easily who is in or out of the home. Residents are involved in ensuring the information board is kept up to date. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 19 Residents’ bedrooms were found to be exceptionally well decorated and reflective of individuals’ personalities. All rooms contained personal belongings and furnishings, a TV, video and DVD player, CD player and a large poster entitled ‘Important Things for Me’, which contained personal photographs of the person and people that they are close to. Communal facilities include a sitting room, separate dining area and large conservatory and well-maintained rear garden at the back of the property. Residents are encouraged to help with the gardening and look after the fishpond. There are two bathrooms located on the ground and first floor, however there is currently no assisted bathing or showering facilities available at the home. This remains an outstanding requirement from the last four inspections, however the Manager confirmed that funding has recently been agreed to install an assisted bath in the ground floor bathroom. It is anticipated that this work will be completed by the end of December 2006. This will be of great benefit to those residents who have reduced mobility. There is currently minimal specialist equipment in place, although at this time it is not necessarily required. The home will need to ensure through their assessment and reviewing processes that either suitable adaptations and equipment are provided or alternative placements are found, as stairs and other access arrangements would make it unsuitable for residents with significantly restricted mobility. Care staff informed the Inspector that they are responsible for undertaking the majority of cleaning duties although residents are encouraged take part in the upkeep of the home. All areas were noted to be clean, tidy and wellmaintained. One resident wrote on their returned questionnaire ‘the home is always nice and clean’. CMG employs a team of maintenance persons to carry out any repairs or redecoration. Any areas that are in need of addressing are recorded in a maintenance book, which staff confirmed are usually promptly dealt with. Two bedrooms and the dining area have been redecorated since the last inspection. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by a skilled and dedicated staff team who continue to work hard to meet the needs of residents. Residents are supported and protected by the home’s robust recruitment procedures. The staff team are supported to provide consistent care and meet the needs of residents through regular supervision and staff meetings. EVIDENCE: The home employs a total of 10 Support Workers and a Deputy Manager in addition to the Registered Manager. Residents, staff and duty rotas confirmed that there are always three members of staff on each shift with one waking night person and a sleep-in. This is sufficient to meet the current needs of residents at this time. At present only two of the staff team have achieved at least NVQ Level 2 in Care, whilst five are currently working towards this. Recent training includes: medication, Person Centred Planning, the Protection of Vulnerable Adults, Health and Safety, food hygiene, epilepsy, manual handling and team building. It is anticipated that staff will attend dementia training, personal relationships/sexuality and a course aimed at understanding the physical needs 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 21 of older people in the near future. Training courses are sought both internally and externally. During the course of the inspection it was pleasing to note that all members of staff on duty interacted exceptionally well with the residents. They were open, honest, friendly, used appropriate humour and were professional. All of the residents said that they like all staff, whilst one of the care staff said ‘we all have a real laugh, they [residents] are all really upbeat people’. Staff vacancies are usually advertised internally throughout the Organisation, in local newspapers and/or job centres. The Registered Manager promptly sends out an information package and application form, prior to short-listing for interview. One resident confirmed that they had been involved in the selection and recruitment of staff. Two recently appointed staff recruitment files were checked. It was pleasing to note that since the last inspection, the home’s recruitment procedures are greatly improved. Both files were found to contain all the required checks, including photograph identification, two written references, evidence of a PoVA First check and Criminal Record Bureau (CRB) check prior to employment. All staff spoken with and a sample of supervision records confirmed that there is a programme of regular supervision for all staff, as well as team meetings. Staff also reported that they felt well supported by the management team in the home. All staff spoken with said they felt able to raise any issues or concerns they may have. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected 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 excellent. This judgement has been made using available evidence including a visit to this service. A skilled and experienced Manager provides clear direction and support to enable care staff to provide a high quality care to the residents. The views and rights of residents underpin the ethos and development in the home. EVIDENCE: The Registered Manager has been in post for three years. Prior to this she worked as the Deputy Manager of the home. She has worked at 72-74 Walsingham Road for a total of six years, prior to CMG taking over the running of the home. She is currently undertaking the Registered Manager’s Award (RMA). The Manager ensures that the home continues to provide a high quality of care to the residents, but constantly reviews the home’s practices to identify and meet any changes in needs. All of the residents and staff spoke very highly of her managerial skills. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 23 Residents’ meetings are held every six weeks, which are minuted by a member of staff. Minutes seen confirmed that most residents attend the meeting. Topics discussed include: the provision of day care, activities, keyworkers, holidays, food and Health Action Plans. One resident said that if they wanted anything changed, he could talk to staff or talk about it in the residents’ meeting. In addition to this a residents’ questionnaire was given to each of the residents in June 2006. This incorporated colour pictorial symbols and pictures. This was to seek feedback from residents regarding: their last keyworker session, residents’ meetings, communication with staff, the home’s complaints procedure, meeting religious and cultural needs and food. A sample of those seen were all very positive. Evidence provided within the home’s returned pre-inspection questionnaire identified that all equipment is well-maintained and regularly serviced including: fire equipment, environmental health issues, electrical appliances central heating system and emergency call system. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 4 25 4 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 4 X X 3 X 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard YA1 YA6 Regulation 5(1)(d) Requirement Timescale for action 30/11/06 31/12/06 3. YA19 4. YA19 5. YA27 That the Service Users’ Guide contains a copy of the home’s most recent inspection report. 15(1)(2) That the current care planning (a-d) format is reviewed in order to clearly identify how residents’ needs in respect of their health and welfare are to be met. 12(1)(a)(b) That care plans for those residents who have developed 15(1) additional healthcare needs are updated to ensure that they reflect the current personal and healthcare needs of residents. 12(1)(a) That a comprehensive (b) assessment for those residents who have experienced a 13(1)(b) deterioration in their cognitive skills is undertaken alongside health and Social Care professionals in order to identify whether or not the home can continue to meet their needs in accordance with their conditions of registration. This must take into account the layout of the building and future care needs as their condition deteriorates. 16(2)(c) That assisted bathing or showering facilities be provided DS0000014208.V308007.R02.S.doc 31/10/06 31/10/06 31/12/06 72/74 Walsingham Road Version 5.2 Page 26 6. YA32 12(1) 18(1) in the home for residents who require this [Outstanding from last four inspections]. That at least 50 of care staff are trained to NVQ Level 2 in care. 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA20 Good Practice Recommendations That both the Statement of Purpose and Service Users’ Guide are dated in order to evidence that they are current and up to date. That all signatures that appear on the medication administration record are written in black ink. 72/74 Walsingham Road DS0000014208.V308007.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI 72/74 Walsingham Road DS0000014208.V308007.R02.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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