Inspection on 05/10/06 for Ash Lodge Residential Home

This inspection was carried out on 5th October 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ash Lodge Residential Home 13/03/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Ash Lodge Residential Home 262 - 264 Beverley Road Kingston upon Hull East Yorkshire HU5 1AN Lead Inspector Janet Lamb Key Unannounced Inspection 5th October 2006 09:15 DS0000065410.V314639.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 DS0000065410.V314639.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 Older People and 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. DS0000065410.V314639.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Lodge Residential Home Address 262 - 264 Beverley Road Kingston upon Hull East Yorkshire HU5 1AN 01482 440359 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) Michael Joseph Healand Ms Amanda Jayne Bennett Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (20) DS0000065410.V314639.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration category of MD (E) is to enable service users already resident in the home to remain there when they reach the age of 65 years. 13th March 2006 Date of last inspection Brief Description of the Service: Ash Lodge is situated on Beverley Road, which is a busy main road into the centre of Hull. It is approximately two miles from the city centre. There are a variety of local amenities close by including shops, pubs, library, swimming baths and a park. The home is owned by a single provider and offers support to 20 service users who have mental health needs, and the age range is between 18 and 65. Currently there are four residents over the age of 65 who have lived at the home for some years, and their needs continue to be met by the service. The home has 18 single rooms, two with en-suite and one double without an en-suite. There are two lounges one of which is the designated smoking area; in addition there is a dining room. Outside to the rear of the building is a patio and parking area. DS0000065410.V314639.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began with the sending of a pre-inspection questionnaire to the home in late June 2006, requesting information on the service provided and the names of those service users living there, as well as the names and addresses of their relatives and any health care professionals involved in their care. Survey comment cards were then issued to as many of these people as possible, including service users, to obtain their views and opinions of the care provided within the service. Then on the 5th October 2006 Janet Lamb visited Ash Lodge, without prior warning and as part of this inspection. Several of the service users were spoken to in passing and two were interviewed, but most of them were observed throughout the inspection. The Manager and the Deputy Manager and one relative were interviewed, and another three carers were interviewed to determine their views. The main parts of the house were inspected, as were only selected service users’ bedrooms. Care plans, risk assessment documents and some records were read and staff files and training records were seen. All personal and private areas and documents were only seen with the permission of the people they belonged to. What the service does well: Service users are well assessed before they take up residence in the home and information about their assessment of needs is put into a working care plan. Service users enjoy making many choices in their lives and are provided with whatever support is necessary to make those choices. Service users are encouraged to take risks as part of their independent lifestyle. Service users enjoy a variety of pastimes in the home and the community that are appropriate to their ability and preference, and they lead fulfilling lives in respect of the activities they do and the relationships they have. Their rights are fully upheld and they experience a high level of respect. All service users enjoy a varied and nutritious diet that they assist to devise. Service users receive a good level of personal support when necessary and in a manner, which meets their preferences. Their physical and emotional needs are well met. Service users’ views and complaints are listened to and acted on if possible, and they are well protected from self-harm or abuse. DS0000065410.V314639.R01.S.doc Version 5.2 Page 6 Service users live in a safe, homely and comfortable environment that is also clean and hygienic. Service users are cared for by a sufficient number of competent and welltrained staff, and the number of qualified staff should soon increase with the completion of the NVQ course. Staff are well recruited and so service users are well protected from undesired workers. Service users benefit from a consistently well-run service of care that considers their interests, their views and their wishes as part of the monitoring, reviewing and development of the home. Service users and staff benefit from good systems and checks for securing their health, safety and welfare. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000065410.V314639.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) DS0000065410.V314639.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (adults 18-65), 3 and 6 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Three service users gave permission to view their files and two were spoken to about living in the home. One could remember having an assessment undertaken and also remembered the home Manager visiting to discuss the move to Ash Lodge. The other could not remember too much despite becoming a resident recently. A relative could remember the process though and pointed out that the home Manager had been very proactive in seeking DS0000065410.V314639.R01.S.doc Version 5.2 Page 9 the information needed about benefits, possible support, and the action to take before the service user came to live in the home, and in providing information about the home itself. Council community care assessment and Ash Lodge assessment documents are held on files and there is evidence that they are updated accordingly – one service user originally had a council assessment done in 2002, which was up dated in 2005. The home’s most recent assessments on these two service users were done in January and September 2006. Where possible service users sign their documentation, or their relatives do so for them. Usually service users are admitted to the home on a planned basis, but sometimes and emergency admission takes place. In these instances the Manager or staff seek as much information as possible from the placing authority, in order to be able to provide a service of care and support that is suited to the service user’s needs. The home has a statement of purpose and a service user guide for service users and their relatives to view before admission to the home, so that they can make an informed decision on whether or not the home is suitable. DS0000065410.V314639.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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, 9 (adults 18-65), 7, 14 and 33 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have good care plans that enable them to be independent and to make choices. Service users enjoy making their own decisions in life, with risk assessments being put into place where necessary. EVIDENCE: Permission was obtained from service users to inspect their care plans and related documents, and these showed the areas of need for action. Care plans are written to suit individuals’ specified needs and evidence is available to show they are reviewed regularly in line with the requirements of the standard and the placing authorities. Care plans are in appropriate formats and show DS0000065410.V314639.R01.S.doc Version 5.2 Page 11 the signature of the service user where possible. One of those seen is in large print. There are now care plans in place for respite or short stay service users. Evidence was seen in diary notes of decisions and choices made by service users and of the care they receive, which corresponded to the care plans. Restrictions on freedom and choice imposed by specialist programmes are not necessary for everyone, although some service users have prescriptive care plans for their safety and for example going out of the building. These situations are handled sensitively and in confidence and service users are not made aware of each other’s specialist safety needs. Staff maintain service users state of involvement with one another and the community by including them in conversations, seeking their opinions and asking them questions about their day etc. Staff provide information on community life and offer choices, which are often taken up. Staff provide information on the local community and encourage independence in all things. Some service users attend college or centre activities, but most like to take a walk and visit the shops on Newland Avenue or Beverley Road. Service users were asked about their experiences of living in the home, the respect they receive and how well their rights to make decisions for themselves are upheld. They made only positive comments: “I have been fine at Ash Lodge, people are still getting to know me,” and “We get on well with each other, and if not we make compromises. We are all very polite to each other.” Service users were observed coming and going freely, unless their care plan stated restrictions on freedom because of high risk to their safety. Service users were also observed making choices about daily life and decisions. Those service users spoken to are quite satisfied with the levels of privacy and dignity they experience, are complimentary of the support they receive from the Manager and staff, and are generally quite happy with the environment they live in and the company they keep. Where there are elements of risk to the activities and pastimes service users indulge in, then risk assessment documents are compiled, discussions are held and decisions are made about setting up ‘safety nets’ or contingencies in order to enable the activity to still go ahead. There is a procedure to follow in the event of a service user going missing and staff would use this promptly should there be a need. There has been no requirement to complete the record for missing persons recently. Service users are able to make their own decisions on coming and going, with the exception of two at the moment. They are understanding of the safety implications. DS0000065410.V314639.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) 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, 17 (adults 18-65), 10, 12, 13 and 15 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home offers good opportunities for service users to engage in activities and pastimes, to maintain contact with family and friends and to eat healthily, so service DS0000065410.V314639.R01.S.doc Version 5.2 Page 13 users enjoy satisfying lifestyles of their choosing, with support from staff where necessary. EVIDENCE: Of the service users spoken to the most important issue is for them to be able to get out and do something of their own choosing. No one is actually employed, but several service users take part in college, centre or local community activities and pastimes. Places attended include Hull College of Further Education and MIND and Waterloo Street centres, and pastimes taken up include swimming, bowling, visiting the local park, bingo hall and library, and going shopping. Some service users were discussing the need to make arrangements for transport to take them to Hull Fair. For one service user interviewed, a simple spell out in a wheelchair and a look at what is happening in the area is something to look forward to. In-house activities include themed nights for darts, dominoes, videos, bingo, arts and crafts, music and special sporting occasions. Something occurs every night if possible. Some service users have their own televisions, music centres, games consults, etc., but these are limited due to limited personal allowance and the spending of it on such as cigarettes. One service user, wearing a rugby league shirt was asked if he would be going to the match that evening. He said, “oh I don’t support them, _____ buys the shirts and he gave me this one. Anyway, even if I wanted to go it’s too expensive.” Staff assist service users to explore new pastimes if they make such suggestions and where possible funding is sought through the appropriate channels. Holidays are arranged each year where possible, again according to funds, and several service users had been to Skegness this summer. One service user interviewed said, “I’d have liked to have gone, but it wasn’t a good place for me with my poor mobility. _____ is going to look for something for me and some of the others to do next year.” There are no restrictions on receiving visitors to the home, although the Manager and staff prefer that mealtimes be avoided. Some service users have family members that visit regularly and assist them to go out or to spend time with them at home. A relative took one service user out after lunch on one of the days of the site visit. She was able to provide the Inspector with an impromptu interview and provided good insight into the quality of care on offer. The relative was highly satisfied with the service of care being given to the service user. Some comments included, “The staff have taken time to find out all about mum. She is not totally happy living in a home, but she is more DS0000065410.V314639.R01.S.doc Version 5.2 Page 14 settled now. She goes out when she likes and staff are interested in her when she returns. Her health and safety are being fully considered.” Service users are satisfied with the arrangements for receiving visitors and for going out. Risk assessments are in place for anyone considered to be at risk on leaving the home, and staff are well aware of the requirements to maintain service user safety. Individual situations apply and these are well understood, risk assessed and individually encouraged to happen. Service users are able to keep their rooms locked and either hold a key or ask staff to open the room for them when they require it. These arrangements depend upon the risks involved for service users holding a key of their own. Generally staff do not enter service users’ rooms without their permission or their presence and use time spent with them assisting to keep rooms clean and tidy as opportunities to get to know them. Service users are asked to maintain their rooms in a tidy state and receive assistance whenever necessary. Rules on smoking and consuming alcohol are clearly made known to service users on admission, are listed in the terms and conditions of residence and the contract and everyone respects and upholds them. Service users were observed smoking only in the designated smoking lounge. No service user made any adverse comment about rules of the home or indicated any dissatisfaction with arrangements for having their cigarettes etc. held in the office for safety. A rotating four weekly menu is compiled by the home Manager after consulting service users in meetings or as part of the quality assurance activities. Menus offer a choice alternative and a choice of specified dessert or yoghurt or ice cream at the main meal of the day, early evening. There is also the facility to request a vegetarian meal, and any specific health diets are also catered for. Lunchtimes see service users taking a light meal of sandwiches or such as beans on toast. No one made any adverse comments about the meal provision. Service users are satisfied with the food they are offered. DS0000065410.V314639.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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, 20 (adults 18-65), 8, 9 and 10 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a good level of support and protection with their health care and personal care, and with administration of their medicines. EVIDENCE: There are very few instances within the home where service users require assistance with personal care. These would only be if mental health deterioration impacted on service users’ ability to function and at these times service users would only require prompting to attend to their own personal care. Service users spoken to are happy with the levels of assistance given to them when it proves necessary, and everyone recognises there may well be times DS0000065410.V314639.R01.S.doc Version 5.2 Page 16 when any service user feels they need assistance. Staff are sensitive to individuals’ diverse needs around religion and faith, sexual orientation and cultural preferences, and to ensuring they protect the dignity and privacy of service users and expressed this in interviews. This was also observed when staff gave service users some assistance or made suggestions or offers to provide support. The home maintains good relationships with the local GPs, clinics and CPNs for providing additional specialist support to service users when necessary. The Manager mentioned there have been situations when service users required her or the staff to be their advocate, in order to obtain the required services to ensure their continuing or improving good health. One service user related their experience of having been in hospital in the last few months and spoke of the support and encouragement given by the homes staff, in helping to overcome a strong reluctance to seek in-patient treatment. All service users have a written health care plan element within their general care plans, which is met with the aid of staff support to access professional health care assistance: physical and mental. Diary notes and records of health care appointments or visits show evidence of how these needs are met. Changes in health care needs are recorded in these documents and evidence is available in the form of reviews of care and health plans, which take place every six months or as service user needs change. Service users have allocated key workers from the staff group, confirmed by both staff and service users in conversation, and have some choice in who that may be. Any obviously difficult relationships are changed at the request of service user or sometimes staff. Relationships that develop between service users or their acquaintances are sensitively handled and staff offer advice and support where necessary to meet diverse needs. Medication administration is always the responsibility of trained, and deemed competent, designated staff. The home has a medication administration policy and procedure, which both state the requirements of staff to hold in safekeeping and give out medicines of any sort. Staff and the Manager confirmed these arrangements and certificates of competence displayed on the home’s corridor evidenced the staff training. The ability of service users to self-medicate would have to be fully risk assessed and very carefully monitored, before full agreement to self-medicate was given. There are no service users self-medicating in the home at the moment. Storage, auditing, administering and disposing of drugs is currently satisfactory and according to the requirements of the Medicines Act 1968 and any accompanying guidelines. Medication administration record sheets show a DS0000065410.V314639.R01.S.doc Version 5.2 Page 17 clear audit trail, have receipt and start dates, staff signatures, show a stock control and any information relevant to the taking of individual medicines. DS0000065410.V314639.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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, 23 (adults 18-65), 16, 17, 18 and 35 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users, and their relatives, have access to robust complaint and protection systems within the home, have used them and so they are confident their concerns will be dealt with appropriately and that they will be protected from harm or neglect. EVIDENCE: The home has robust complaint and protection policies and procedures in place, known to and confirmed in interview with service users, relatives and the staff. Interviews revealed that the complaint, whistle blowing and grievance procedures have been tested and complainants have had their concerns satisfactorily dealt with. Records, letters and documents also confirmed this. There have only been two complaints in the home in the last twelve months, which were appropriately handled, substantiated and satisfied. There have been no referrals to the vulnerable adults team in the last twelve months. The home has an open-door policy and the Manager’s approach to concerns, worries, complaints or compliments is a very healthy one, in which discussions take place, action is taken, and problems are solved wherever possible. DS0000065410.V314639.R01.S.doc Version 5.2 Page 19 Everyone freely expressed their openness in making and handling such issues and service users clearly feel they are able to speak up without any recriminations. The necessary help is sought from the right source if the Manager is unable to resolve issues. Staff are trained in handling complaints and in vulnerable adult awareness, they are confident when speaking about procedures and their responsibilities to act in situations, and training records and certificates evidenced the work they have done to gain that confidence. Service user, staff, professional and relative questionnaires and comment cards indicated good handling of complaints and protection issues at the beginning of the inspection process and interviews with the Manager, staff, service users and a relative, and documentation held confirmed this. DS0000065410.V314639.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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, 30 (adults 18-65), 19 and 26 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a good level of cleanliness and hygiene within the home and the fabric of the building is well maintained. EVIDENCE: Service users spoken to are very satisfied with the accommodation they have, either single or shared. Permission to view bedrooms was given by those service users spoken to, and they proved to be personalised, very clean and DS0000065410.V314639.R01.S.doc Version 5.2 Page 21 comfortable, and a place where service users could enjoy their privacy. One room required redecoration and the service user confirmed a wish for this to happen also adding he would like some shelves fitting to the walls by the bed. The Manager confirmed this room would be the next on the homes redecoration programme. Communal areas seen are also comfortable and the designated smoke room is respected as such by all service users. The dining room is probably the most pleasant room and acts as a hub at particular times of the day: meals, drinks and evening activities. There is a very distinctive lack of office/meeting space and the non-smoking lounge often has to be utilised for private meetings for larger groups. This is an inconvenience to those service users who regularly sit there. The administrator has a small office by the main entrance and the Manager has only a cupboard-sized facility to work in or consult service users and visitors. Neither space is large enough to occupy two people working alongside each other, nor do they provide acceptable working conditions under health and safety at work legislation. The rear of the property has a paved area for two cars and the side street offers extra parking. The laundry is domestic in style and equipment, and meets the Water Supply (Water Fittings) Regulations 1999. The kitchen is also domestic and would benefit some modernisation, but in general it is clean and functional. Storage areas are satisfactory. Staff have completed infection control training and practice in maintaining cleanliness and preventing spread of infection is good. Training records, copy certificates and observation evidenced this. Personal protective equipment was seen in use and staff follow good food hygiene procedures and policies. The home follows fire safety legislation, has a regularly reviewed fire risk assessment and carries out equipment checks and fire drills as required. Some service uses, being heavy smokers and presenting high risks, have their cigarettes and lighters held in safekeeping all of the time and some do so only at night. DS0000065410.V314639.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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 (adults 18-65), 27, 28, 29 and 30 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from good recruitment and selection of care staff, and from a well-trained staff group in respect of mandatory training and qualifications, so they are confident their individual and collective needs will be met. EVIDENCE: There is a recruitment and selection policy and procedure in place, and staff files showed information required under schedule 2 is held. Staff recalled their recruitment experiences and the Manager confirmed the process. An induction process in line with current General Social Care Council guidelines is followed for new staff and recorded, though these were not inspected. DS0000065410.V314639.R01.S.doc Version 5.2 Page 23 The information obtained from the pre-inspection questionnaire, viewing certificate copies in staff files and discussion with the Manager and staff showed there are some staff with the necessary qualifications at NVQ level 2, numbering six from fifteen (plus nine on-going) and giving 40 of the care staff with the qualification and another 60 doing it. Staffing hours are appropriate for service users’ levels of dependency, the Residential Forum hours having been calculated. There is always three staff in the home during the day, and two waking and one on call at night. The Manager sometimes works supernumerary and sometimes as the third staff on duty. Staffing levels are good, although some comments from staff on questionnaires suggested there could be more cleaning staff employed to enable the care staff to spend more time with older service users and those more vulnerable due to their mental health needs. There is sufficient evidence to conclude that staff do complete regular statutory training and do keep up with current trends and developments, within training records and certificates displayed around the home, and interviews with staff and the Manager. There is sufficient evidence to conclude that staff do complete regular statutory training and do keep up with current trends and developments, within training records and certificates displayed around the home, and interviews with staff and the Manager. DS0000065410.V314639.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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, 42 (adults 18-65), 31, 33, 35 and 38 (older people). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from having a registered Manager in the home that maintains consistency of the service. They have use of a quality assurance system so that they are assured a good service. They enjoy protection from harm under DS0000065410.V314639.R01.S.doc Version 5.2 Page 25 the home’s health and safety measures in place and the practices carried out to maintain service users’ and staff health, safety and welfare. EVIDENCE: The current Manager has been in post for many years, has almost completed the NVQ Level 4 Registered Manager’s Award, and fully understands the needs of the service users. She maintains an open and honest approach to managing the home and firmly puts the needs and rights of the service users to the forefront of all activities. She is extremely pro-active in advocating for their rights and responsibilities. The Registered Provider and Registered Manager comply with the Care Standards Act and Regulations. There is a quality assurance system in place, which involves consulting service users through a new survey, daily conversations, care plan reviews and during occasional service user meetings, surveying relatives and visitors to the home, conducting an annual health and safety audit, and completing individual “lifestyle choices and preferences” documents. All of the information gathered informs the homes’ business plan, which is produced annually. Policies, procedures and practice are regularly reviewed and documented. Service users are not entirely aware of the details of quality assuring the service, but they are able to confirm in conversation, that opportunities are given to them to make suggestions, lodge complaints, and make known their personal and group preferences. There were no adverse comments about the levels of their involvement in the running of the home. Staff spoken to are fully aware of the system for assessing the quality of the service and sometimes assist with such as the health and safety audit. Areas listed in standard 42 that were spot-checked included fire safety, hot water temperatures, food hygiene and maintenance of a safe environment including kitchen equipment and laundry machinery, outdoor steps and pathways and gardens. The home follows fire safety legislation, has a regularly reviewed fire risk assessment and carries out equipment checks and fire drills as required. Hot water temperatures are regulated by thermostatic control valves and are checked weekly and recorded. DS0000065410.V314639.R01.S.doc Version 5.2 Page 26 Staff that prepare food undertake basic food hygiene training and update this as necessary. Certificates are displayed in the home. The house is generally well maintained and certificates of maintenance and safety checks are held within the office. The Administrator coordinates all such requirements. Staff were observed working responsibly and safely. Records and documents, and conversations with staff and the Manager and Administrator confirmed all of this. DS0000065410.V314639.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 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 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 3 3 X 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 DS0000065410.V314639.R01.S.doc Version 5.2 Page 28 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The Registered Manager should complete the NVQ 4 Registered Manager’s Award (or equivalent qualification) by the end of December 2006. DS0000065410.V314639.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. DS0000065410.V314639.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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