Inspection on 23/08/06 for 9 Manor Road

This inspection was carried out on 23rd 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 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

9 Manor Road 21/08/08

9 Manor Road 21/11/05

9 Manor Road 06/05/05

9 Manor Road 28/02/05

9 Manor Road 15/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 9 Manor Road 9 Manor Road Leamington Spa Warwickshire CV32 7RJ Lead Inspector Jackie Howe Key Unannounced Inspection 23rd August 2006 09:30 9 Manor Road DS0000004480.V308418.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 9 Manor Road DS0000004480.V308418.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. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 9 Manor Road Address 9 Manor Road Leamington Spa Warwickshire CV32 7RJ 01926 832552 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) Eden Place Limited Richard Mark Bloomer Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Richard Bloomer (Registered Manager) must obtain his Registered Managers Award qualification by 1 January 2007. 21st November 2005 Date of last inspection Brief Description of the Service: 9 Manor Road is part of the Eden Place group of homes. It is a mid-terraced property approximately two miles from Leamington Spa town centre. The home has three bedrooms on the first floor and a lounge, dining room and kitchen on the ground floor. The bathroom is also on the ground floor to the rear of the kitchen. The house accommodates up to three persons in single room accommodation. The communal space is shared. There is a back garden, leading to a rear gated entry. The home offers accommodation to up to three persons with mental health problems. The service is designed for people that are self-caring in meeting their physical needs and require minimum support to maintain their mental health. Information about the service is available in the home’s ‘Statement of Purpose’, which is available in the home. The residents receive a minimal amount of support from staff, who provide house keeping, cooking and domestic duties but have daily access to qualified mental health nurses from Eden Place Nursing Home. The nursing home is close by (approximately 50 yards) and within a few minutes walking distance for the residents. Range of fees: £456 per week. Additional charges are made for hairdressing, personal sundries such as toiletries and newspapers, and private chiropody if required. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the inspection year 2006/07 and was unannounced. It was undertaken over seven hours, between the hours of 09.30 and 16.30. The inspection focused on the outcome for the three residents living in the home. The manager is not based at the home, but joined the inspection part way through the day. The inspector was able to tour the home, and spend time speaking with the residents, and one member of staff. Some comments from people who use the home had been received prior to the inspection, and the manager supplied a completed ‘Provider Information Questionnaire’ (PIQ) and a copy of a recent quality assurance audit, which had been undertaken this year. Information from these have been included in the report. One visitor was available to speak with on the day of the inspection. During the inspection the life style and care of all three residents was assessed, by conversation, observation, reading their care plans and documentation, and discussion with staff involved in their care. Records including staff files, policies and procedures, health and safety / environmental checks and risk assessments were also accessed. What the service does well: What has improved since the last inspection? Improvements have been made to the furnishings and a new settee and armchair have been provided for the lounge area. Residents have been involved in the choice of these, and feel satisfied with what has been bought. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 6 In one of the bedrooms, alterations have been made to provide more usable space, and work has been carried out in removing pipe work from a cupboard. The resident whose room it is, is pleased with the outcome. A training and development file is now in place for each member of staff and a training plan for the year identified, most of which has been met. The manager has been successful in introducing a quality assurance monitoring system, which reflects the views of the people who use the services of both Manor Road and the main home ‘Eden Place’, and the opinions of staff working there. The outcomes of this audit have been shared with the residents in the home. The manager has ensured that due concern has been shown to fire safety in the home, particularly with regard to the home not having staff on the site during the night. Drills have been undertaken regularly, and training has taken place involving the homes’ residents. 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. 9 Manor Road DS0000004480.V308418.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 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Information about the home for prospective residents to make an informed choice, is available but is not presented in an appropriate format to be accessible to all. Residents are assessed prior to admission. EVIDENCE: The home has a ‘Statement of Purpose’ and a ‘Service Users Guide’, which are kept though not displayed in the home and were developed by the previous manager. Residents in the home said they were unaware of the documents, although on questioning, they were available in an accessible cupboard. Residents currently living in the home, have lived there a number of years, and said they knew all about the home already. The present manager is hoping to review these documents especially the ‘Users Guide’ as they are currently very lengthy and potentially over wordy. He intends to involve the current resident group in rewriting the users guide to 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 9 ensure it meets the needs of the residents, but also provides the information requested in the standards. There have not been any new admissions to the home in the past 18 months, and the majority of new admissions come via the main home, Eden Place, where they are well known to the staff. It has not therefore been necessary for the manager to assess potential new residents. Due to the amount of time some of the residents have been living in the home, staff should not only undertake a continual reviewing process of the care plan, but also a formal reassessment of needs to ensure that the care plan reflects all the up to date information required. In order to do this, the manager has produced a re assessment document, and hopes to have this in place in the next few weeks as well as an annual ‘appraisal’ which staff will use to review the past year and set new goals for the next. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8, and 9. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents are aware that they have a care plan, which they feel reflects their needs and they are able to make decisions and have choice about life in the home. EVIDENCE: The management and staff of this home are well aware of the needs of the residents, and demonstrate a commitment to developing them as individuals, and involving them in all aspects of their care and in living in the home. Care plans in the home are well documented and include individual risk assessments. Each resident has an individual plan and residents spoken with confirmed that they were aware of their plan and said that they are involved in its development. Care plans read showed that although regular reviews had taken place, not all additions or amendments were dated so it was unclear when they had been made. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 11 Staff spoken with, demonstrated a working knowledge of the care plan and are involved in its development and review and evidence was seen that residents are involved in this process. Care plans are detailed and lengthy documents and include information on all aspects of their care, assessments undertaken, ongoing medical health care needs and areas of risk management including early warning signals for the deterioration in mental health. The lifestyle assessment reviews the present past and future aspirations of each resident. Goals set for the future include an amount of positive risk taking, and staff spoken with showed that they were aware of the reasons for this and the part they needed to play in supporting the resident. Monthly residents meetings are held with the staff and the manager and the minutes of these are displayed on the wall. Residents confirmed that they found these to be useful and during the inspection were heard to mention agenda items for the next meeting. Residents confirmed in the quality assurance audit that they were offered choice and a chance to state their opinion. ‘You are not over nagged, but treated as an individual with preferences’. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents take part in appropriate leisure pursuits, which involves being part of the community around the home. Meals are enjoyed, and there is sufficient choice available. EVIDENCE: Residents in the home on the day of the inspection were relaxed and appeared settled in the home, and had plans of how they were going to spend their day. The inspector was made welcome and offered refreshments and a tour of the home and the garden. Residents spoken with were positive about their life style and were enthusiastic about some of their pursuits and a recent holiday. Activities feature high in the agenda and it is clear that residents come and go from the home, going to the local shops and to visit Eden Place, either to visit friends, or to check in with the staff or have a meal. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 13 The recent quality assurance audit identified that residents are happy with the opportunities available. Comments made included: ‘You feel you are a member of the community, not a patient’. The recent caravan holiday to Mapplethorpe was enjoyed by one resident who is now looking forward to planning the next one, and was putting forward a suggestion to go to Wales. Trips out are really enjoyed, although for one resident this is quite a challenge to achieve. This was acknowledged as an area of development in his care plan, and staff were anxious to support and encourage him in this pursuit. Residents spoken with said that there was plenty of choice in regard to trips available, and said that they particularly enjoyed trips out in the mini bus to town, or to the local community centre. Visiting arrangements to the home are flexible and unrestricted unless requested, or assessed as necessary. One resident had a surprise visitor from a relative during the inspection, who visited following a phone call to the home. The resident was pleased to see his visitor and entertained him with other residents in the lounge. The weekly shopping trip to the supermarket is also an enjoyable event for the residents spoken with, where staff and residents undertake the food shopping for the week and then residents choose on a daily basis what they want to eat. On the day of the inspection the member of staff arrived at about 10.30 am. The residents were obviously pleased to see her and quickly filled her in with what had gone on from the night before. The meal for the day was collectively chosen, and a decision made that chips from the local fish and chip shop would be a welcome change to go with the gammon steaks. One resident volunteered to go to the chip shop at lunchtime. Menus seen show that the diet is normally well balanced and healthy, but obviously takes personal likes into consideration. On Saturdays residents tend to fend for themselves, and showed stocks in the cupboard of soup, and other snacks, which they prepare themselves. They also choose some ‘ready meals’, which can be reheated in the microwave. On Sundays residents are invited to join the residents at Eden Place for a Sunday roast dinner. Residents said that the food was ‘excellent’ and were satisfied with the choices available to them. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents receive support, which is aimed at all their individual needs, and are protected by safe procedures for medication administration. EVIDENCE: At the current time all of the residents living in the home are able to undertake their own personal care albeit with a level of support and encouragement. More support is required in some of the domestic areas such as laundry and ironing. On the day of the inspection, residents spoke openly with the staff telling them how they were feeling and discussions with staff indicate that staff are well aware of where closer observation and supervision is required. Records seen show that residents have good access to health care services. All residents are registered with a local GP who they go to see on a regular basis, supported by the staff. One resident has close monitoring of blood levels due to medication. These records are well maintained and visits to specialists are organised as required. Residents are also supported in attending chiropody, optician and dental appointments. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 15 Medication is dispensed weekly to residents in a blister system, from the stock, which has been ordered at Eden Place. Currently all the different tablets to be taken at a certain time i.e. all 9am medications, are mixed together. This is to avoid each resident being supplied with a number of individual blister packs. The manager said that although this was not ideal, the taking of the medications is very closely monitored, so that any problems incurred would mean that a daily dispensing service would be resumed. There is an amount of positive risk taking taken into consideration to promote independence. Residents are assessed and monitored to ensure the safety of self-medicating. Some residents have been assessed as requiring prompts in the form of a note, or a phone call from the home to remind them to take evening and nighttime medications. Staff when on duty also supervise that medications have been taken appropriately and residents are supplied with a secure facility in their room to safely store medicines. ‘Homely’ remedies such as paracetamol are only administered with an established protocol and these medications are held at Eden Place. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents feel that they are able to express their views and opinions and that they are taken seriously. Procedures in place to protect residents are robust. EVIDENCE: The commission has not received any complaints about the home, and a relative spoken with confirmed that he felt happy with the service provision. The home has a robust complaints procedure, which is reviewed annually and is on display in the home. The manager said that no complaints have been received since the last inspection, but all complaints received for any of the homes in the group are recorded in a log and all complaints are investigated and reported on by the manager. Information on how to access advocacy is also displayed and available to all. Residents spoken to feel that their views are acknowledged and taken seriously by the staff, and that they were given ample opportunity to express those views especially in the regular meetings, which they said ‘were useful’. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 17 Staff spoken with were aware of the procedures in the home with regard to responding to complaints, and those related to the Protection of Vulnerable Adults’ (POVA). The home now has on site a copy of the multi agency policy for responding to potential abuse, and a copy of the Department of Health ‘No Secrets’ document. Staff spoken to were aware of the documents and of the policy for ‘whistle blowing’. Staff working in the home have also attended training this year in POVA from an external trainer. A requirement was made at the last inspection that staff should have a working knowledge and access to these documents. This requirement has now been met. Staff records checked show that good procedures are in place to ensure that staff employed to work in the home, are of good character, and do not pose a risk to those that live there. 9 Manor Road DS0000004480.V308418.R01.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, 28 and 30 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents are provided with an environment, which is clean, comfortable and appropriate to their needs. EVIDENCE: Improvements have been made since the last inspection, to the maintenance and appearance of the house and there are plans for further improvements to be made. Residents spoke positively about the improvements made especially to the lounge furniture, and in the garden where there has been some planting and is tidier and more cheerful. Residents are clearly involved with the choices made for replacement furniture and feel happy to raise issues about areas that they feel require further improvement. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 19 The carpet in the living rooms is highly patterned and a little dated, although clean and unworn. Residents have expressed a dissatisfaction with the carpet which they do not think goes with the new decoration. There are plans to change most of the existing carpeting within the next financial year, especially the carpet on the stairs and in the bedrooms, which is well worn in places. The bathroom is located downstairs and is typical of that in a small terraced house. One resident has some ideas for improvement in the bathroom, and feels that a shower could be included over the bath, which would offer choice from having a daily bath. He voiced his opinions to the manager during the inspection, and they were taken seriously, and the manager said would be put up for discussion. The bedrooms are of differing sizes. One bedroom is large and spacious whereas the smallest room is a little cramped. As previously mentioned some work has been undertaken to improve this room. The old boiler has been removed which has allowed the room to be moved round providing more usable space and a wardrobe has been built. The owner of the bedroom appeared pleased with the changes made, and has now space for all his personal items. The majority of the pipe work related to the old boiler has been removed. There are a few unlagged pipes at the bottom of the wardrobe, but on the day of the inspection these were not at a temperature to cause a risk. The manager said that he would review these via a risk assessment once the central heating was back on in the house, and would lag the pipes as appropriate. Residents all said that they were happy with their rooms, that they contained their personal possessions, that they have a safe lockable storage place and that they could be decorated as to their own personal choice. The living rooms also contain some personal items such as videos and books, and generally provide all furniture and equipment such as a TV, video player and music system, required. Secure fencing surrounds the garden to the home. The back gate, which is used daily as it allows access to a rear passageway, which is near to Eden Place, is not lockable and is currently kept secure by the use of a large rock. One resident said that this made him a little nervous, and he felt a lock or bolt would make him feel a little more secure. This was raised with the manager during the inspection, who said that he would look into providing a suitable lock. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 20 The home, including the kitchen and bathroom, was found to be in a clean condition. Laundry facilities are domestic in nature but are suitable to the needs of the residents, who where possible are supported in undertaking some laundry and cleaning duties. There were no obvious unpleasant odours in the home. Maintenance work is undertaken by staff employed by the group, and these workers are well known to the residents. 9 Manor Road DS0000004480.V308418.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents are supported by staff who have the necessary skills, are of good character and well supervised in their role. EVIDENCE: The manager of the home ensures that the staff working there are of a suitable character and understand the needs of the residents. There are currently two members of staff who work approximately four hours per day, Monday to Friday on a rota system, but residents also have regular access to the staff at Eden Place. Whilst these are the average hours worked, the manager was able to demonstrate that this could be changed according to the needs of the residents at any one time, and that the start and end times of a shift were flexible to respond to trips, outings or appointments. During the inspection it was noted that staff from Eden Place telephone the home when they know the staff are not there, to pass on reminders such as to take medication, or just to offer reassurance, where this has been identified as a need by individuals. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 22 There are photographs of the two staff who work at Manor Road, displayed on the notice board, and a copy of the rota. Residents are aware which member of staff works on which day, and what systems are in place to cover leave and sickness. All the residents spoke highly of both members of staff and it was clear from observation that they had a good relationship with the member of staff on duty. A requirement was made at the last inspection that a training and development programme for each member of staff be put in place that is in keeping with the needs of the staff and the residents living there. This has now been put in place, and the majority of the training needs met. Both members of staff are to attend a new course available in ‘challenging behaviour’. The manager said that the plan would be reviewed annually, he is also introducing a training matrix where training needs can be identified at a glance. One member of staff spoken with felt she was offered training according to her needs, but was keen to develop further, by attaining her National Vocational Qualification (NVQ) at level 3, but also by attending training giving more detailed information on specific psychiatric conditions which she felt would help her understand even more the needs of the residents in the home. She was able to demonstrate a good working knowledge of the residents’ needs and of the policies and procedures for the home Staff are supervised regularly by the manager, informally almost on a daily basis, but formally in one to one sessions, care plan reviews and in the meetings both in the home and the staff meetings held for all staff employed by the company. Staff spoken with said that they felt supported by the manager and by the rest of the staff team. Staff records checked showed that thorough recruitment practices are undertaken and that staff suitable to work with vulnerable people are employed. 9 Manor Road DS0000004480.V308418.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 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 group is good. This judgement has been made using available evidence including a visit to the home. The home is well managed and residents’ health, safety and welfare are considered at all times. EVIDENCE: The manager of the home is also the manager for Eden Place and another small home in the group. He has now been in post for over a year, and has successfully made and maintained improvements. The manager is a qualified nurse with experience working with people with a broad spectrum of psychiatric conditions. Since the last inspection he is now the registered manager for the home, and continues to work towards achieving his NVQ level 4 in management. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 24 Staff and residents spoke positively about the manager saying that they found him to be approachable and supportive, and were pleased with the changes he had helped introduce in to the home. A quality assurance audit has been undertaken since the last inspection. Part of this audit included seeking the views of the staff and professionals such as local GP’s, nurses and social workers who use the service. Comments made indicate that the home is well run and that communication is good. The manager, apart from the staff contribution, undertook the quality assurance audit. The audit was thorough and included all of the residents and one relative who returned the questionnaire. The manager has acknowledged that the audit next year will be undertaken by a more independent member of staff who is not so involved in the day to day running of the home, so as to ensure that the presence of the manager is not influencing the answers given. The results of the audit have been published and the results shared with all interested parties. Information received is helping the manager draw up the aims and objectives for the home, and identify where improvements if required can be made. Generally the results of the audit are positive, with those involved being satisfied with the services on offer, and that services have improved. Policies and procedures related to health and safety were assessed at the last inspection and generally found to be in place. A requirement was made that all routine fire tests are carried out at regular intervals and recorded. Fire safety is taken seriously by the home, and residents spoken with had received training in the form of a quiz and demonstrated that they were aware of what actions to take. A fire drill had been undertaken in July. It was noted that the door leading to the kitchen from the dining room was held open by a ‘wedge’. This was brought to the attention of the manager during the inspection who said that he would take advise on the use of a fire safety devise, and also ensure that all residents were aware that this should be removed at night. 9 Manor Road DS0000004480.V308418.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 3 25 3 26 x 27 x 28 3 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x 9 Manor Road DS0000004480.V308418.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. 1. Standard YA42 Regulation 23 (4) Requirement The registered manager must seek advice on the use of the door wedge, and take adequate precaution against the risk of fire. Timescale for action 30/11/06 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. Refer to Standard YA1 Good Practice Recommendations The inspector recommends that the Statement of Purpose and Service Users guide are reviewed to ensure that they are accessible to those using the home and produced in an appropriate format. The inspector recommends that to supplement the system of care plan review, a process of re assessment is introduced to show clearly the year on year development of each resident. The inspector recommends that risk assessments be undertaken on the pipes in the small bedroom and on the back gate, and actions taken to maximise safety and security. DS0000004480.V308418.R01.S.doc Version 5.2 Page 27 2. YA2 3. YA24 9 Manor Road 4. YA35 The inspector recommends that training in specific psychiatric conditions is included in the staff training programme. 9 Manor Road DS0000004480.V308418.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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