Inspection on 16/01/07 for 8 St Winifred`s Road

This inspection was carried out on 16th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 St Winifred`s Road 17/07/08

8 St Winifred`s Road 26/01/06

8 St Winifred`s Road 15/09/05

8 St Winifred`s Road 21/10/04

8 St Winifred`s Road 16/04/04

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 8 St Winifred`s Road Shirley Southampton Hampshire SO16 6HP Lead Inspector Janet Ktomi Unannounced Inspection 16th January 2007 11:30 8 St Winifred`s Road DS0000011806.V318889.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 8 St Winifred`s Road DS0000011806.V318889.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. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 8 St Winifred`s Road Address Shirley Southampton Hampshire SO16 6HP 023 8070 5506 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) H4012@mencap.org.uk www.mencap.org.uk Royal Mencap Society Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: 8 St Winifred’s Road is a large detached family home situated in a quiet cul-desac close to Shirley High Street and local amenities. The home is registered to accommodate 8 residents with learning disabilities between the ages of 18 65. The current residents are all over the age of 30. The home comprises eight single bedrooms, which are spacious and suitably furnished. There is a lounge, lounge/dining room and large kitchen and the home has a rear garden for recreational use. Hyde Housing Association owns the property and the Royal Mencap Society are the registered providers. At the time of this inspection the home was being managed by an experienced acting manager. Fees: weekly fees are from £610.00 basic plus additional to cover assessed needs not included in the basic fee. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first ‘Key Inspection’ for 8 St Winifreds Road, a ‘Key Inspection’ being part of the new inspection programme, which measures the service against the key National Minimum Standards. The visit to the home, was conducted by one inspector over one day lasting a total of six hours, where in addition to any paperwork that required reviewing the inspector met with all service users and staff (on duty) and undertook a tour of the premises. The inspection process also involved pre fieldwork visit activity, with the inspector gathering information from a variety of sources, the commission’s database, pre-inspection information provided by the service, questionnaires completed by residents and their relatives and linking with previous inspectors who have visited the home. 8 St Winifreds Road provides a homely environment on a domestic scale for up to eight younger adults with learning disabilities. All current residents have lived at the home for several years. The home currently has one vacancy. The home has a staff team who are experienced and well trained. What the service does well: What has improved since the last inspection? The home has complied with all the requirements made following the previous inspection undertaken in January 2006. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 6 At the time of the previous inspection the home was required to ensure that staff received training in the administration of eye drops. The acting manager explained that it had not been possible to arrange training, however information was obtained in the form of a leaflet and all staff read this. The resident no longer requires eye drops. The service has included additional information for care staff about as needed medication, this was seen to state not only the name and dose of the medication but what it should be given for and for some residents who may not request medication what may indicate that this is required, ie behaviour changes which may indicate the person is in pain. The kitchen was in the process of being completely refurbished at the time of this visit, new and more fitted cupboards, changes to lighting, redecoration and new flooring were being provided. Care staff and the acting manager confirmed that they had received training in infection control and fire awareness. Following consultation with the local fire authority the home has fitted automatic door closures to all communal rooms. Bedroom doors were no longer held open by inappropriate items. The home has also worked to address recommendations made following the previous inspection. The inspector was shown the new care plann format which has so far been completed with two of the people who live at the home. The acting manager stated that this process will be completed with the remaining people over the next few months. The new care plans follow a clear person centred approach and contain detailed information and goals aimed at ensuring the people who live at the home enjoy the kind of lifestyle and opportunities they want. 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. 8 St Winifred`s Road DS0000011806.V318889.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 8 St Winifred`s Road DS0000011806.V318889.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): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users individual needs are assessed and they have the opportunity to visit the home and meet existing service users as part of this assessment process. EVIDENCE: At the time of the unannounced inspection visit the home had one vacancy. The seven people living at the home had all lived there for several years. The acting manager informed the inspector that they had been approached by social services with a referral in December 2006. Discussions with the acting manager indicated that appropriate information had been sought and the proposed new resident invited to visit the home on several occasions during which further assessment work was undertaken. This had resulted in the acting manager deciding that it would not be appropriate for this person to move into the home. The acting manager explained her reasons in that the new residents needs might impact adversely on the existing residents, two of whom are currently receiving additional input from the community team. During discussion with the people living at the home it was apparent that their views had also been taken into consideration when the decision not to admit the new 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 9 person was made. Existing residents knew the potential admission from day services and it was evident that they agreed with the decision made by the acting manager not to admit the new person. 8 St Winifred`s Road DS0000011806.V318889.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know their assessed and changing needs and personal goals are reflected in their individual plans. Residents are encouraged to make decisions about their lives with assistance as needed. Residents are consulted, on and participate in, all aspects of life in the home and are supported to take risks as part of an independent lifestyle. EVIDENCE: The acting manager explained to the inspector the new person centred support plans that she has introduced. These have so far been produced with three of the people who live at the home. The acting manager stated that the same format will be used to rewrite the care plans for the remaining residents over the next months. The inspector viewed two new style care plans and one of the 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 11 existing care plans not yet completed in the new format. The new format follows a person centred approach and includes clear evidence that the resident has been central to the process of determining how his/her care will be provided and in identifying short and long term goals. Risk assessments and risk management plans are integral to the care plans and aim to ensure residents can lead as full a life as possible and not restrict them unnecessarily. Throughout the inspection residents were seen to be encouraged and supported to undertake activities such as making cups of tea or preparing snacks (using a microwave as the kitchen was being replaced). Care plans state residents lifestyle goals and how these will be achieved. Discussions with residents indicated that they were aware they had care plans and all named their key-workers. Care plans were seen to be reviewed monthly with progress towards goals identified. The monthly reviews ensure that care plans continue to be working documents. Residents are involved in their monthly care plan reviews that was evident in one where the resident had changed his mind about a previous leisure goal. Care staff sign to confirm that they have read care plans with a list of staff signatures seen at the front of each plan viewed. Prior to the inspectors visit residents and some relatives completed and returned comment cards about the service. Residents stated that they felt well cared for and relatives were satisfied with the overall level of care provided. Throughout the inspection visit residents were seen to be actively encouraged to make decisions about all aspects of their lives. As stated individual lifestyle aspirations are included in care/support plans. Comment cards from residents confirmed that they are able to do what they want during the day, evening and at weekends. Comment cards from residents also stated that they were able to make decisions and that staff listened and acted on what they say. The inspector was able to spend time with all everyone who lives at the home. Discussions with residents confirmed that they are able to make decisions and that these decisions are respected. During the inspection visit residents were observed making comments and suggestions to staff and the acting manager. At the time of the inspector’s visit the home was half way through having a new kitchen fitted, as they came in from external activities residents were seen to go to the kitchen door to see how work had progressed during the day and all stated they were very pleased with the new kitchen. Residents are encouraged to take responsibility for some domestic activity in the home and discussions indicated that they had chosen the task they preferred. All service users require a level of support with their personal finances. The procedure used was explained by the acting manager with records seen. The procedures in place would appear appropriate to ensure that residents are as independent as possible but receive the necessary support. All have individual named bank accounts. Discussions with residents indicted that they were fully aware of their responsibility to pay their rent weekly (assessed financial contribution) and that they are able to choose what they spend their remaining money on. One resident showed the inspector a CD he had purchased when 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 12 out with his support worker on the day of the inspection. This had clearly been his selection and he enjoyed playing this for everyone. The necessary records were seen. 8 St Winifred`s Road DS0000011806.V318889.R01.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. 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 are actively encouraged and supported to enjoy a full lifestyle undertaking a range of social and leisure activities. Relatives and friends are able to visit and a varied diet (including that for special dietary needs) is provided. EVIDENCE: The inspector was able to meet with everyone who lives at the home and viewed individual weekly timetables in the care plans seen. Discussions were also held with care staff and information about resident’s lifestyles was provided in resident and relative comment cards. As previously mentioned residents are encouraged to undertake domestic tasks in the home. Residents confirmed their responsibilities for keeping their 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 14 bedrooms tidy and doing their own laundry with staff support. Residents also confirmed that they helped staff go shopping for food items like bread and milk. The home is situated close to Shirley high street and residents talked about the shops there. Each resident has at least one day at home during the week. Towards the end of the inspectors visit residents were seen preparing their own packed lunches ready for the next day. Residents confirmed that they are able to help with the preparation of meals and one was seen independently organising a snack, selecting a tin of soup from a range of tinned produce. Although none of the people who live at the home have paid employment one told the inspector about a voluntary position he has in a local charity shop. The resident told the inspector what he does at the shop and that he enjoys working there. Residents all attend day services or courses at local colleges providing opportunities to meet with friends and develop new skills. It was evident that residents were fully involved in the choice as to how they spent their time. One resident was aware that he had to select a different college course for the new term as there had not been enough people for the course he had originally selected to run. Individual weekly routines were seen in care plans and contained a range of activities. Care staff confirmed that they are able to go out most days with residents. As stated residents are encouraged to participate in their local community, using local shops and leisure facilities. Residents confirmed they used local hairdressers. Comment cards returned prior to the inspectors visit to the home stated that they were able to choose what they do during evenings and weekends. One comment card stated that at weekends there were insufficient staff for 1-1 activities. From viewing duty rotas this may be the case, however 1-1 time is possible on home days during the week when other people are at day services. The acting manager stated that she could provide staff flexibly to cover social and leisure activities and that at weekends she aims to have an additional staff member at times when service users may want to go out. Five of the residents enjoyed a short break holiday last year, two going to London for some shows and stayed in a hotel and the other three enjoying an activities holiday. The acting manager confirmed that she has a budget for activities and this is also used for the staff costs of holidays so that residents only pay for themselves. Relative comment cards were received from three relatives who confirmed that they could visit whenever they wished. Staff and residents confirmed that post is given to the resident to open and that support is then provided to respond to mail if necessary. Throughout the inspection residents were observed moving about the home and spending time wherever they wished, either in the communal rooms or their bedrooms. Service users stated that staff knock on their bedroom doors before entering. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 15 Three of the people who live at the home require special diets for diagnosed health problems. As stated the homes kitchen was being completely refurbished at the time of the inspectors visit. On the evening of the inspection the flooring was still being laid and the kitchen could not be entered, therefore the planned evening meal (which required to go in the oven) could not be cooked. All service users were involved in the discussions as to what they would do, each selected their choice of ‘take away’ food and one person accompanied the acting manager to collect the orders. Those on special diets were given choices. Discussions with residents confirmed that they help cook main meals, are involved in menu planning and like the food provided at the home. The acting manager has introduced a new menu planning system with each resident assisting to cook the main meal one day per week and prepare their own lunch on their home days. The home has a group home meeting on a Sunday during which they select the menu for the next week. The acting manager stated that the food budget was reasonable to provide a varied nutritious diet. As stated residnets were seen preparing their packed lunches for the following day, suitable options for those on special diets were available. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 16 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. Residents receive personal support in the way they prefer and their physical and emotional health needs are met. Medication is appropriately managed within the home. EVIDENCE: Care plans seen contained information about the level of personal support each person requires. The home operates a key worker system that provides for one to one support and monitoring of residents’ daily needs. Everyone who lives at the home is fully mobile however a shower chair has been provide to meet the needs of one person. Risk assessments are in place in respect of residents using shower and bathrooms on their own. There is a mix of male and female staff to ensure flexibility for personal care if this were required. Residents confirmed that times for getting up and going to bed are flexible. Staff on duty also confirmed this. Residents’ rooms were personalised and there was evidence of their exercising choice in the clothes they wear, fashion preferences and room decorations. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 17 Care plans seen contained information about how individual residents healthcare needs should be met. A record is maintained of visits to health professionals. Residents confirmed that they went to dentists, opticians, chiropody and could see their GP if they were ill. On the day of the inspectors visit one resident had an appointment with a member of the community team and was supported to attend by his key worker and the acting manager. Later in the day another member of the community team visited the house to support a resident with communication tools as part of a wider plan to address behaviour issues. As previously mentioned three people require special diets and these were seen to be provided. Staff were fully aware of what was appropriate for these residents to eat and suitable alternatives were available for packed lunches. The residents on special diets seemed aware of what they could and could not have. The arrangements for the storage, administration and recording of medication were viewed. These were found to be appropriate although the home should consult their local pharmacist to determine if the large metal filing cupboard used to store medication is acceptable as it is not secured to a wall. Following the previous inspection the home was required to provide protocols for the administration of as required medication. These were seen with medication administration records and stated the name of the as required medication, what it is used for, and also information as to when it should be administered. Additional information was also seen as to indicators that service users may require as needed medication such as pain relief for people who may not say that they are in pain. Medication administration records were fully completed. Care staff and training records indicate that staff do not administer medication until they have received training to do so. Following the previous inspection the home was required to provide training for staff in the administration of eye drops. The acting manager confirmed that staff had been provided with information about eye drop administration and that the person no longer required eye drops. The previous requirements in respect of medication have therefore been met. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 18 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. The people who live at the home are able to make complaints that would be appropriately investigated and resolved. Residents are protected from abuse, neglect and harm. The home would respond appropriately to adult protection concerns. EVIDENCE: All residents completed comment cards prior to the inspectors visit. Responses stated that people either did not understand the question or said that they knew how to make a complaint with some naming staff or the deputy manager as the person they would talk too. (NB service user comment cards were completed prior to the acting manager being appointed). Two of the three relative comment cards received stated that they knew how to make a complaint but that they had not made any complaints. The pre-inspection questionnaire stated that the home had received two complaints in the past year, one substantiated and one ongoing. During the visit to the service the inspector discussed with residents what they would do if they had any complaints. Some did not seem to understand the hypothetical question, stating they had no complaints, others said they would tell staff. The acting manager explained the Royal Mencap Society complaints procedure that ensures that complaints are investigated by the area manager. Care staff confirmed that complaints are covered in induction and they were 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 19 clear as to the actions they should take if a complaint was made by a resident or relative. Throughout the inspectors visit service users were seen responding verbally and non-verbally to staff, making suggestions and requests. Staff have a good understanding of service users individual communication methods and would be in a position to realise if service users were unhappy. As stated one person is being provided with communication support from a speech and language therapist. The home has in place appropriate guidance for responding to suspicion or evidence of abuse or neglect, to ensure the safety and protection of residents. Staff training records indicate that staff have attended adult protection training and that this is included within the company induction all staff undertake. Staff spoken with during the inspection were very clear about the need to report all issues of concern without delay and were aware of how concerns should be reported. Residents attend a variety of external day services and some would also be able to report concerns to staff within these settings. The home is working with members of the community health team to support one person who may self-harm. The arrangements in respect of recruitment and residents personal finances are described elsewhere in this report but should ensure that only suitable people are employed at the home and personal money is secure. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a warm, clean, home that is suitable for their individual and collective needs. EVIDENCE: The home is a large detached house situated in a quiet cul de sac in a residential area close to Shirley high street and with bus stops close by. The home is pleasantly decorated and furnished throughout. All bedrooms are for single occupancy and equipped with a wash-basin. Bedrooms seen were individually decorated with their occupants being able to arrange their furniture and personal effects as they wish. One resident informed the inspector that he had moved from another room in the house at his request as he now had a better bedroom. The home has one vacant bedroom. This was viewed during the inspection and it was noted that although recently decorated, one area of the external wall appeared to be 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 21 suffering from water infiltration/damp. The acting manager must ensure that the cause of this problem is identified and rectified prior to a service user moving into this room. The home has ample communal space, with a good sized lounge, separate dining room and large kitchen providing space for dining as well as cooking. The previous report identified that the kitchen was looking worn and in need of refurbishment. As previously stated this was being completely refurbished at the time of the inspectors visit. The home has ample bathing and toilet facilities and a spacious utility room containing the homes laundry and providing storage space. The home was very clean and tired and has appropriate systems and equipment to minimise the risk of infections. The manager and staff confirmed they have received infection control and fire awareness training as required following the previous inspection. The previous inspection identified that some bedroom doors were being held open with inappropriate items, this was not the case on this visit. Automatic door closures have been fitted to all communal doors that will ensure they are closed automatically should the fire alarms be sounded. These are also on a timed devise and close automatically at night. The inspector was shown the certificates in respect of the checks undertaken by the landlord on the homes gas equipment and water supply. The pre-inspection questionnaire confirmed that the home had a valid electrical certificate. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 22 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides appropriate numbers of suitably recruited, trained and supervised staff to support residents individual and collective needs. EVIDENCE: The inspector viewed staff duty rotas during the visit to the home that indicated that a minimum of two and at times three care staff are on duty with one sleep-in staff at night. Three care staff are provided at weekends as day services are not provided. The acting manager is generally additional to these numbers. Discussions with care staff, residents and evidence in records indicates that staff are able to provide a variety of external activities for people both individually and as small groups. Care staff stated that they work well as a team and this was observed throughout the time the inspector spent at the home. Comment cards from relatives indicated that they felt there were sufficient members of staff provided at the home. Resident comment cards stated that staff were nice and would do what they (the resident) asked. Interactions between staff and residents throughout the inspectors visit were 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 23 warm and friendly with residents clearly feeling able to make comments and suggestions to staff which were listen to and responded to appropriately. Duty rotas indicated that the homes existing staff or regular bank staff cover any additional shifts required such as resulting from annual leave or sick leave. residents, the acting manager and duty rotas confirmed that continuity of staff is provided to the people who live at the home. Care staff confirmed that management support is always available and that they felt able to contact the deputy or acting manager should the need arise. The home employs a total of five care staff three of who have at least an NVQ level 2 in care. Of the remaining two care staff one is undertaking the NVQ level 2 in care and the other will be registered for the NVQ once he has completed the Mencap induction programme which the deputy manager states meets the skills for care requirements for induction standards. The home has therefore met and surpassed the 50 ratio recommended within the National Minimum Standards. The acting manager listed training undertaken by staff and that planned for the future. Care staff were positive about the training provided and stated that they felt they had the necessary skills to meet service users needs. Care staff confirmed that they had received fire awareness and infection control training as required following the previous inspection. Training certificates were seen in staff files. The home has recruited one new staff member since the previous inspection. The acting manager described the homes recruitment procedures and records were viewed. The procedures in place and records seen would indicate that a thorough recruitment and checking process is in place that should ensure that unsuitable people are not employed at the home. The inspector was able to speak with the new staff member who confirmed that he had met service users as part of his interview and that all the necessary recruitment checks had been undertaken. The new staff member also confirmed that he had received an appropriate induction and had not been asked to undertake sleepins until he was confident to remain in the home on his own. The acting manager stated that she aimed to recruit new staff from the providers staff bank, in this way she could discuss with residents who they would like to become permanent staff. Care staff and staff files viewed indicated that all staff receive regular formal supervision in addition to indirect supervision whilst the acting manager is in the home. Staff were clear that they could discuss concerns with the acting manager and that they were aware of the company structure such that issues could be taken to senior managers in the company if they felt this was necessary. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 24 8 St Winifred`s Road DS0000011806.V318889.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, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the home does not have a registered manager it does have an experienced and qualified acting manager and continues to be well run in the residents best interests. The residents can feel confident that views are listened to and the future direction of the service takes this into consideration. Records are appropriately stored and maintained and the health, safety and welfare of residents, staff and visitors is protected. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home has been without a registered manager since the previous manager left in November 2006. The provider has transferred an experienced manager from another service it provides. The acting manager is supported by an experienced deputy manager. The acting manager was unsure what the long term management arrangements for the home would be, her secondment being for a period of six months. The acting manager transferred to the home in December 2006. The provider must make a decisions about the long term management of the home and inform the commission of the action it intends to take in respect of the recruitment of a new permanent manager who should then apply to the commission for registration. Following the previous inspection the provider was recommended to ensure that the person carry out the providers responsibilities under regulation 26 monthly visits talks to service users as part of the quality monitoring process. Care staff confirmed that regulation 26 visits by a member of the area management team do occur and that residents are consulted during these visits. The Royal Mencap Society undertakes yearly resident questionnaires. Residents are supported to complete the questionnaires by a manager of another service provided by Mencap. Staff confirmed that they the home receives feedback information from the completed questionnaires and if this information would be used to alter the service provided. As previously stated residents are fully involved in their monthly care plan reviews and in weekly group house meetings were menus are planned and any other issues discussed. Throughout the inspectors visit residents were seen to be encouraged to give opinions and their views or wishes were respected. The evidence indicates that residents are encouraged to participate in care reviews and the development of their care plans, as well as activities/entertainment and changes within the home. Records viewed during the inspectors visit were well maintained and appropriately stored. The evidence indicates that the health and safety of the residents and staff is being appropriately managed. The home was clean and appropriate measures in place to prevent the spread of infection. There were no immediate health and safety concerns were identified with regards to the fabric of the premises during the tour of the premises. The pre-inspection questionnaire establishes that full health and safety policies/guidance documents are made available to the staff. Staff have undertaken appropriate induction and ongoing training. Residents stated they felt safe living at the home. 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 27 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 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 X 2 X 3 X 3 3 X 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 29 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 YA37 Regulation 8 Requirement The provider must inform the commission of the action it intends to take to provide the service with a permanent manager who must apply for registration. Timescale for action 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 30 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 8 St Winifred`s Road DS0000011806.V318889.R01.S.doc Version 5.2 Page 31 - 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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