Inspection on 03/05/06 for Asher

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Asher 03/12/07

Asher 14/12/05

Asher 13/07/05

Asher 24/02/05

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Asher 33 Wilbury Gardens Hove East Sussex BN3 6HQ Lead Inspector Jane Jewell Key Unannounced Inspection 3rd May 2006 11:00 Asher DS0000062718.V290329.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 Asher DS0000062718.V290329.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. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Asher Address 33 Wilbury Gardens Hove East Sussex BN3 6HQ 01273 823310 01273 749810 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) Parkview Care Homes Limited Mr Julian Hopkins Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is seventeen (17). Only adults with Mental Health needs who have been assessed as requiring nursing care to be accommodated 14th December 2005 Date of last inspection Brief Description of the Service: Asher is a privately owned nursing home for up to seventeen adults who have a mental health illness. The home was registered with the Commission for Social Care inspection in January 2005. Prior to this the home was an independent hospital. The home was originally established as a nursing home when purchased by its current providers in January 1999. The providers also own a further three registered care establishments and supported accommodation within the Brighton and Hove area. Asher is a detached corner property situated on the main A270 into Brighton and close to local amenities and bus routes. The home is on three levels with a shaft lift providing access to all floors. Resident’s accommodation consists of seventeen single bedrooms with all but one room providing bathing/shower ensuite facilities. Communal space consists of a combined lounge dining room, meeting room and conservatory. There is a small rear patio area connected to a car parking area. The home provides both short and long term placements. The homes literatures states that it aims to provide a safe homely environment in which residents have as much control over their lives as possible, enabling them to achieve the maximum degree of independence whilst retaining their dignity. The daily charges are £118.03. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced site visit undertaken on 03/05/06 between 11am to 7pm and information gathered about the home since the previous inspection. This includes survey questionnaires, discussion with stakeholders involved in resident’s care and records relating to providers visits and notification of accidents and incidents. The site visit was undertaken with Julian Hopkins (registered manager) and Azhar Juri (deputy manager) and there were sixteen residents living at the home. The site visit involved a tour of the premises, examination of the homes records, discussion with staff on duty and residents. The focus of the inspection was to look at the experiences of life at the home for people living there. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: Residents live in a homely and clean environment with their private accommodation equipped to provide comfort and privacy, and the feedback from residents in this regard has been positive. Remaining central to the ethos of the home is respecting resident’s privacy and individual lifestyles. There is historically little staff turnover at the home, with some staff having worked there for many years. This stability clearly benefits residents through the continuity of the support being provided. The home continues to achieve its aims of enabling short-term residents to move onto independent living and long-term residents with a stable and secure environment and balances well the needs of both groups. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There are few areas that do not meet the national minimum standards. Those areas which do not are: The need for clearer medication policies and the risks faced and posed by residents must be more regularly reviewed to ensure that residents remain safe. It is suggested that a plan of redecoration be developed to ensure that redecoration and repair issues are identified in advance and are able to be budgeted for. In response to the draft inspection report, the provided returned to the CSCI an action plan of how they intend to meet the requirements and recommendations made from this inspection. 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. Asher DS0000062718.V290329.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 Asher DS0000062718.V290329.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, 3 and 4 Quality in this outcome area good. This judgment has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about whether to live at the home. Residents are only accommodated if the home is satisfied that they can meet their needs. The home continues to balance well the needs of those undertaking short-term care and those who require long term nursing care. EVIDENCE: There is a range of literature about the home and the services and facilities it provides. This includes a statement of purpose and service user guide, which was reported to be routinely given out to prospective residents and interested parties. They are also displayed within the home. Records inspected for a recent admission to the home showed that a copy of a care management assessment from the placing authority had been obtained prior to their admission. The home also conducted its own comprehensive assessment of needs. This ensured that a comprehensive picture had been established of the residents in order to decide whether the home would be able to meet their needs and ensured that staff were aware of the residents needs upon admission. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 9 The home provides six long-term and eleven short-term placements funded by a health care trust. Therefore there are a large number of admissions and discharges. Over the last twelve months with many residents having moved onto more independent living environments. Most residents consulted said that the home was meeting their needs. For some short-term residents it was often difficult for them to cope with some of the long-term residents acute symptoms. Staff were mindful of this and strategies were in place to help cope and defuse this. A relative felt that although their relative “can be a handful” the home have never given up on them and that they managed his behaviour really well as their relative always seemed happy and well cared for. Residents said the following about their experiences at the home: “very nice no complaints the best bit is having some freedom back” “lovely friendly home” and “I don’t know where I would have ended up if I couldn’t have come here” . The short stay nature of the majority of placements means that there is not a fixed settling in period. This is instead determined by the needs of residents. Placement authorities usually visit within the first six weeks to check out with the residents whether their needs are being met. Asher DS0000062718.V290329.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 area is good. This judgment has been made using available evidence including a visit to this service. Care plans provide the necessary information needed to guide staff on the needs of residents and the support needed to help residents achieve their individual goals. Residents are enabled to participate in the daily life of the home, and to exercise personal choice, and are supported to take risks as part of an independent liftestyle. The current arrangement, for the review of individual residents’ risk assessments, is inadequate. EVIDENCE: Much improvement has been made to the care planning process with the implementation of clearer care planning recording, staff training and closer monitoring of standards by the management team. The main emphasis of the care planning process is the development of individual goals and targets for each resident. The care plans inspected identified the actions to be taken, in support of residents attaining their agreed goals. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 11 In line with previous requirements care plans are now being reviewed regularly, to ensure that changes in needs and preferences are identified promptly. Several residents consulted said that they had seen their care plan or had been involved in its development or review. Several residents were adamant that they did not wish to be involved in any aspect of their care plan, in these circumstances this had been recorded. Staff consulted demonstrated a good understanding of residents needs and the contents of individual care plans. Following previous concerns regarding the quality and accuracy of the daily recording, care staff now write directly onto the daily notes, of the events and activities they have been involved in. This has provided a more accurate picture of daily occurrences. The nurse in charge counter sings the notes to ensure they are aware of their content. The style of recording was noted in the main to be respectful and non-judgmental. There remains a wide variation between those residents who wish to participate in the running of the home, and those who express little desire to be involved. There are many mechanisms in place for residents to participate and influence the daily running of the home. These include residents’ meetings and quality audit groups. Some residents help to set the tables and help with light cleaning. A staff member was observed offering encouragement and impartial guidance to a resident who was particularly anxious about deciding whether they should visit a family member or not. Two residents have advocates to help in their decision making. Core and specialist risk assessments are undertaken on the risks faced and posed by residents. These include such areas as: challenging behaviour, selfharm, domestic safety, fire and bathing and include the actions needed to manage or reduce risks. Not all of the sampled risk assessment had been regularly reviewed, and it is essential that this be addressed, to ensure residents’ continuing safety. Asher DS0000062718.V290329.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): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Daily routines are largely determined by the needs and individual lifestyles of residents. The home continues to facilitate and ensure that suitable arrangements are made for occupation and activities depending upon resident’s individual preferences. Residents maintain contact with family and friends and with the local community as they wish. The food provided offers both choice and variety. EVIDENCE: Opportunities for residents to access formal education, drop in and day care centres are made available. These are currently accessed by very few residents. Staff continue to support residents to spend their time usefully and in accordance with their assessed needs, but balance this with the understanding that residents have the choice to become involved or not as they wish. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 13 Most residents make their own arrangements for occupation and stimulation as part of maintaining an independent lifestyle. For some residents the main focus of staff support is to motivate them to develop and undertake basic daily living tasks. As a result of a quality audit at the home an activities programme has recently been implemented. Residents spoke of being involved in film nights, art therapy and board games. During the inspection a small group of residents and a staff member were arranging to go out shopping and for coffee. Many residents spoke of how much they enjoyed visiting a local market at weekends. The home has access to a mini bus in order to access wider leisure facilities. A relative said that they visited the home at various times throughout the day and were always made to feel welcome and had been invited to stay for meals in the past. Staff were knowledgeable of the potential vulnerability for some residents when having contact with their visitors and clear guidelines had been established in order to help safeguard them. One resident uses the homes computer to email friends. Many residents have mobile phones in order to stay in close contact. There is a pay phone for communal use. One resident requested a booth around the telephone in order to aid privacy, this was fedback to the manager. Residents stated that there is flexibility in daily routines regarding meal times, going to bed, rising and bathing. For some residents there are set routines which are part of an assessed need, for example time for arising or cleaning and laundry day. Two chefs are employed to cook all meals. Menus are developed by the head chef and were reported to be based on the likes of residents. The head chef reported that they have recently completed a course on nutrition to aid in the development of menus. Residents said they are asked each day to choose their main meal from the days menu. In addition alternatives to the main menu are always available. Resident’s individual preferences were observed being respected as many different meal options were being prepared. One resident, by their own admission, was particularly fussy about meals and the chef continues to be innovative in ensuring that a balanced diet is offered to them. The inspector had lunch with residents and the food provided was of an exceptionally good standard, with all residents speaking positively about the food. A resident said that the chef was “best cook in Brighton” with another resident saying “very good choice, excellent”. Asher DS0000062718.V290329.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 area is good. This judgment has been made using available evidence including a visit to this service. Respecting resident’s privacy remains central to the ethos of the home. Personal support is provided in a consistenty and appropriate manner, in accordance with residents assessed needs. Suitable arrangements are in place for meeting the health care needs of residents. Medication systems are well managed. EVIDENCE: Few residents require direct personal care. Staff prompt and encourage according to the residents individual’s goals, e.g. maintenance of personal appearance and personal hygiene. A resident in receipt of personal care said that their gender preference of the carer was always respected and that personal care was always undertaken in accordance with her preferences. Residents confirmed that their privacy is respected and confirmed that staff followed the homes policy of knocking on bedrooms doors and waiting to be invited in. The majority of residents choose to lock their doors when not in use. A newly admitted resident currently did not have a key to their room and requested one. This was fedback to the manager. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 15 The home operates a key worker system to promote the continuity of care. A new system has been introduced along with clear criteria for keyworker selection. It was reported that residents had been written to regarding the changes and many residents knew the name of their keyworker and were happy with the allocation. Staff consulted were very knowledgeable about their key clients and what the role of keyworker entailed. One to one time with staff is valued by residents with one resident stating that they were looking forward to going out for coffee with their keyworker. On a daily basis residents are allocated a named worker, who is responsible for providing support as needed, throughout the day. Residents take an active interest in who their daily name worker is and said that usually their individual preferences are taken into account but in the main the allocation is gender based. Many residents make their own medical appointments and attend all appointments by themselves. For others staff make the necessary appointments and only accompany residents into the consultations, at the invitation of the resident. All residents have regular access to a psychiatrist, the frequency of which varies according to individual needs. A resident said that when they have asked to see a GP staff have made an appointment promptly. Residents make their own arrangements to access opticians, dentists and chiropodist or are supported by staff to make appointments. Significant improvements have been made in the administration of medication, with current practices providing a clear audit trail of medication entering the home, being administered or being disposed of. Care and nursing staff have undergone further medication training, since the last inspection. Since the inspection, the CSCI Pharmacist has confirmed that in no circumstances should prescribed medications be borrowed from one resident for another. Asher DS0000062718.V290329.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 area is good. This judgment has been made using available evidence including a visit to this service. Residents are able to raise complaints easily and these are dealt with promptly and effectively. There are procedures and practices in place that support the protection of vulnerable adults. EVIDENCE: There is an accessible complaints procedure for residents, their representatives and staff to follow should they be unhappy with any aspect of the service. There have been no complaints recorded by the home since the last inspection or raised with CSCI. Residents have raised minor concerns during meetings or directly to the provider during their monthly-recorded visit to the home. Residents confirmed that these have been addressed promptly. Residents were observed being confident to raise minor areas of concern to staff, which was addressed immediately by staff. There are written policies covering adult protection and whistle blowing. These make clear the vulnerability of people in residential care, and the duty of staff to report any concerns they may have to a responsible authority for investigation. Staff undergo training in adult protection, and demonstrated a good understanding of their roles and responsibilities under adult protection guidelines. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 17 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, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents live in a homely environment with parts of it decorated and furnished to a good standard. The home ensures that resident’s private accommodation is equipped to provide comfort and privacy. EVIDENCE: The home is located near to local amenities and bus routes into Brighton and Hove. Many residents said the homes central location is important to them and was a key factor in choosing the home. Generally the home is decorated and maintained to a reasonable standard with domestic style furnishings and fittings. Since the previous inspection two bedrooms have been redecorated. There is currently no formal plan of redecoration and repair and it is recommended that this be developed in order that decoration/maintenance issues are identified and budgeted for. A new maintenance reporting procedure has recently been developed to aid in the prompt addressing of maintenance issues. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 18 Due to the levels of smoking amongst residents there are inevitable signs of wear and tear on both the home’s fabric and furnishings. A conservatory is used as the designated smoking area. This has improved significantly the standard of air quality in the communal lounge, with residents feeding back that they feel able to use the lounge more, now that is clasified as “nonsmoking”. There are sufficient number of toilets and bathrooms located around the building, this includes all but one bedroom having their own ensuite facilities. Residents’ bedrooms are personalised in accordance with their individuals taste and preferences. Bedrooms are fitted with locks, with the majority of residents choosing to have a key. A newly admitted resident was still awaiting the allocation of a key and this was relayed to staff. The lifestyles of some residents and the level of privacy afforded means that some bedrooms could not always be cleaned and kept odour free. Whilst respecting the privacy and choice of service users, the home recognises that a minimun standard of hygiene must be maintained at all times, to ensure the well being and comfort of all service users, staff and visitors. Standards of cleanliness in other areas remain satisfactory with domestic cover provided throughout the day. New infection control practices and procedures have recently been introduced which are in line with good practice guidelines. The home is not designated to offer services to people with physical disabilities and the access arrangements within the home would make it unsuitable for residents with a permanent restricted mobility. There is a shaft lift, which provides level access to all floors. The manager and staff are mindful of issues around the declining mobility of one long term resident. This resident has been provided with various aids to help independence but has declined to use them. Although the bathing needs of a newly admitted resident, who has some restricted mobility, has been well thought out, consideration should be given to providing suitable furniture within his own accommodation to aid ease of independent movement. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 19 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): 31, 32, 34, 35 and 36 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The staff group, which includes a core group who have worked at the home for some years, present as competent, motivated and committed to enabling residents pursue their individual goals and aspirations. Staff are well supervised and supported, and have access to comprehensive training. The procedures for the recruitment of staff are not sufficiently robust to ensure the accuracy of the information being obtained. EVIDENCE: The staffing structure is for four to five staff to be on duty throughout the waking day. Staff consider that this is sufficient, to allow them individual time with residents. The consensus of resident’s views was that staff had the time to address their needs in a timely manner. Following a review of the roles of nursing assistants, they are now more directly involved in the recording of the care and support providedundertaken. This has been in factor in improving moral and team effectiveness. During the visit staff were observed interacting with residents in an appropriate manner often using humour. Residents confirmed that this is the norm. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 20 All staff consulted spoke respectfully and professionally regarding residents. Residents described staff as “alright” and “lovely”. A relative said that all the staff appeared “well qualified” as they all very good. It was reported that all nursing assistants have completed an NVQ 2 training or above. This is to be commended. One of the key responsibilities of the new deputy manager has been the management of training. A comprehensive training and development plan has been developed, which has included core and specialist topics. Training has been undertaken from a variety of sources including internally, externally and distance learning. In line with previously made requirements, staff confirmed that they are receiving more formal supervision. All staff consulted felt well supported by the management team in order to undertake their roles. The manager reported that nursing staff were also now receiving clinical group supervision. There is historically little staff turnover at the home, with some staff having worked there for many years. This stability clearly benefits residents, through the continuity of the support being provided. A recruitment process is followed which includes the use of an application form, interviews, CRB checks and written references prior to employment commencing. However an example was noted whereby the information gathered had not been thoroughly checked and the inspector noted discrepancies. Once highlighted the manager reported prompt action being undertaken to redress the Inspector’s concerns. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home is managed by a competent manager who is suitably qualified and experienced. The home is committed to the self-monitoring and review of its own practices in order to help inform future service development and maintain current good practices. Appropriate arrangements have been made for providing a safe environment for residents. EVIDENCE: The manager is a Registered Mental Nurse and has many years experience in mental health services. He has been the manager of the home since 2001 and is currently undertaking additional training to NVQ level 4 standard. All persons consulted regarding the home spoke positively about the manager, with particular reference to his helpfulness and approachability. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 22 A deputy manager has recently been appointed, who has had a significant impact on improving standards of general administration at the home. The consensus of staff was that this appointment had freed up the manager to focus on clinical issues and practices in the home. There are a number of mechanisms in place for the home to monitor its own performance and assess the quality of the services it provides. This includes the monthly assessment of the homes performance by the provider, regular placement reviews and feedback questioners. In addition a system of “bench marking” has been introduced. This has involved a group of staff and residents reviewing particular practices at the home. Practices looked at so far have been activities and health and safety. As a result of this initiataive, improvements have been made in both of these areas. Most residents completed an inspection survey and felt at ease to speak openly to the inspector about their experiences at the home. The general atmosphere throughout the inspection was relaxed. Following an internal review of the home’s health and safety systems changes have been made to the way in which health and safety tasks are delegated and monitored. Improvements were noted in the standard of fire safety recording, infection control and the management of cleaning chemicals. A record of accidents is maintained, however it was noted that limited information was being recorded following an accident, and the frequency and nature of accidents was not being reviewed. Accidents are not being recorded in a format recommended by data protection guidelines. The manager stated that he had obtained a new accident book for this purpose, and that all accident, in future, would be recorded in this format. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 23 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 3 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 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 3 X 3 X X X 3 Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13(4)(c) Requirement That residents individual risk assessments are reviewed on an on-going basis, and recorded as having been reviewed. Timescale for action 30/06/06 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. 2 Refer to Standard YA9 YA24 Good Practice Recommendations That staff undergo training in risk assessments. That a programme of routine maintenance and renewal of the fabric and decoration of the home be developed which includes the timescales for works completion. Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Asher DS0000062718.V290329.R01.S.doc Version 5.2 Page 26 - 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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