CARE HOME ADULTS 18-65
Boniville House 17 Melrose Avenue London NW2 4LH Lead Inspector
Tony Brennan Key Unannounced Inspection 28th June 2007 11:00 DS0000017469.V343643.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 DS0000017469.V343643.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. DS0000017469.V343643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Boniville House Address 17 Melrose Avenue London NW2 4LH 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) 020 8450 1755 0208 830 6984 Mrs Mabel Dingiswayo Mrs Mabel Dingiswayo Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places DS0000017469.V343643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Boniville House is a care home and accommodates a maximum of 5 residents with mental health problems. The home is located in a residential part of Willesden and is close to local shops and transport links. Parking is restricted in the street outside the property during the daytime, Monday to Saturday. There is off street parking for 2 cars. The property consists of a ground, first and second floor. There are 5 single bedrooms, one of which has en-suite facilities. There are two bathrooms, each containing a toilet. The office is situated on the ground floor. There is a small garden at the rear of the premises. Information regarding the level of fees may be obtained, on request, from the manager of the home. DS0000017469.V343643.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken as part of the annual inspection programme. I sought to confirm that the ten areas for improvement identified at the last inspection had been addressed. The inspection took place over one day. I was assisted with the inspection by Catherine Chishiri, senior worker and Mabel Dingiswayo, the registered Manager. I spoke with the three people who live at Boniville House, and two members of staff. I observed care practice and interaction between staff and people living at the home. I toured the building and examined a number of records relating to the care, health and safety and management of the home. I would like to thank the staff that assisted me by answering questions about the running of the home. I would also like to thank the three people who live at the home who discussed their views of the service they receive. What the service does well:
The statement of purpose positively promoted the rights of people living at the home to express their diversity. A person spoken to explained that she is a Muslim. She thought that staff understood and respected her. I case tracked two people who live at the home and found that there were assessments from the home and care management. Initial assessments identified the mental health needs of people living at the home. This included a history of their mental health needs and any resulting behavioural management issues. People felt that staff understood their views and wishes regarding how they wanted to live in the home. Care plans generally identified the cultural, religious and disability issues facing people living at home. One person case tracked explained that the home had supported her to access Mind’s befriending service. She told me that this had helped her to explain her needs to staff. Details of behaviour that might challenge the service of people were identified in their risk assessments and care plans. Actions to address and manage these behaviours are outlined in detail. Where appropriate staff discussed and recorded the views of those people living at the home whose behaviour might be challenging.
DS0000017469.V343643.R01.S.doc Version 5.2 Page 6 People spoken to said that they could choose from a range of activities. Daily notes and care plans confirmed that service users were regularly involved in activities both in and outside of the home. People spoken to told me that they had been consulted about the activities that are being provided. One person said, “ I like to go out to the coffee bar. I just have to ask staff and I can go”. People spoken to confirmed that they were involved in the cleaning of their bedrooms and cooking. People are able to make hot drinks whenever they wish to. I observed that people went to the shops when they wanted to. Daily records showed that people were supported to maintain contacts with family and friends. People living at home were able to develop contacts in the local community. Staff and the registered manager explained how they have been working with one person to find a Muslim group that meets her needs. The registered manager explained how the persons family had been consulted. I spoke with a person and she explained that she was happy with the home and how it had supported her. The menu is prepared at a weekly meeting of people living at home. I saw minutes of these meetings these confirmed that people suggestions for meals were recorded. People spoken to confirmed that they had been involved in preparing the menu. The menu is varied and reflected the cultural and dietary needs of individuals. One person living at home is a vegetarian. His preferences were reflected in the menu. The person told me, “ I get my vegetarian food that I like”. Staff provides support people with their personal hygiene through prompting. Male and female carers are employed in the home to ensure that those people who prefer same gender care can be supported sensitively. Two people case tracked confirmed that they had received regular support from community mental health professionals. One person spoken to told me that she had been consulted and involved when her community psychiatric nurse had changed. Daily notes confirmed that the General Practitioner had been consulted when the people were unwell. I spoke with people living at the home who told me that staff supports them to follow a healthy diet. One person case tracked was identified as being at risk due to having a poor diet. This was identified in her care plan and appropriate actions had been identified to address this issue. People confirmed that they had been supported by staff to attend hospital appointments. One person spoken to said, “ staff will advise me, it is my choice if I attend medical appointments”. Multi-disciplinary reviews had been held to ensure that any changes to the mental health needs of people living at home were thoroughly addressed. One person spoken to told me, “ if you are feeling unwell you can talk to staff and they will get you the help that you need from your psychiatrist”.
DS0000017469.V343643.R01.S.doc Version 5.2 Page 7 The medication policy contained all the required information. I found that records for the administration of medication were complete. Records of medication received and returned were also complete. Daily notes showed that community mental health professionals had been consulted to ensure that people were receiving the medicines they required. People told me that they understood how to make a complaint. Copies of the complaints policy were available around the home for people to consult when necessary. People who live at the home told me that they could challenge and raise concerns about the way they were treated. Bedrooms were personalised with items of furniture and pictures belonging to people who live at the home. People living at the home had chosen how they wanted their bedrooms decorated. People living at home told me that there are enough staff to provide them with the care they need. Training records confirmed that all staff were up to date with, and had all the statutory required training. 50 of staff have achieved the National Vocational Qualification in care. Staff have the skill to care for the people living at the home safely. The home has a stable management and the registered manager has experience and understanding people with mental health needs. Staff and people spoken to confirmed that they felt that the registered manager was supportive and approachable. The registered person ensures that the safety risks to people living at the home and staff are identified. What has improved since the last inspection?
The registered a manager has reviewed care plans of all the people living at home. Care plans were found to contain detailed information on the support provided to meet the needs of people. Risk assessments have been reviewed and provide detailed risk management strategies for people. Risk assessments had been reviewed to ensure changes to the level of risk were addressed. The risk assessments had been agreed with the people or their representatives. Risk assessments were found to cover all areas that affected the peoples’ daily lives. All staff have now completed a training course on Mental Health awareness. Staff spoken to told me that this training had given them a better understanding of the mental health needs of the people they were working with. The registered manager explained that she would be arranging further
DS0000017469.V343643.R01.S.doc Version 5.2 Page 8 training on mental health issues. This will assist staff to develop their understanding of specific issues affecting people with mental health needs. The registered manager has commenced the Registered Managers Award. I was able to see confirmation that she had obtained a place on the course. This will make sure that she has all the skills to manage the service in the best interests people. A system has been put in place to monitor the quality of the service provided by the home. The registered manager explained that she carries out quality monitoring on a monthly basis. A different area of the service is covered each month. I saw examples of the surveys. People living at home, relatives and professionals had completed these. The registered manager explained that an action plan is developed to address any areas for improvement that are identified. I was able to see these action plans and confirmed that the issues raised had been addressed. People are consulted about how the home is run. COSHH guidance now in place and is kept in the COSHH cupboard so that staff always have access to it. The carpet in the second-floor bedroom has been cleaned. Peoples’ safety is maintained. What they could do better:
Three areas for improvement were identified at this inspection. Although care plans are generally detailed providing sufficient information on the needs of people, they are based on activities of daily living model. This was discussed with the registered manager who agreed to organise the care plans in a manner that focus on the specific needs which had been already identified in them. There are two areas where the carpet is not properly secured. I observed that the carpet had been held down with masking tape. This is a potential trip for people living at home. These areas were pointed out to the registered manager who agreed to ensure that the carpet is secured safely. The registered manager explained that since the last inspection she has started to complete a training plan for the home. However, work on this has only just started. A training plan still needs to be put in place to ensure that staff have all the relevant skills to support people living at the home. DS0000017469.V343643.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000017469.V343643.R01.S.doc Version 5.2 Page 10 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 DS0000017469.V343643.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support required. EVIDENCE: The statement of purpose clearly sets out the philosophy and objectives of the home. I found that the needs of the people case tracked were within the range of those specified in the statement of purpose. The statement of purpose also identified the skills and staffing resources that are to be available to meet the needs of people living at home. The statement of purpose positively promoted the rights of people living at the home to express their diversity. A person spoken to explained that she is a Muslim. She thought that staff understood and respected her. The registered manager confirmed that the needs arising from the peoples’ adversity would be respected and met by the home. People living in the home have a range of mental health needs. Care plans and assessments showed that these needs were identified and supported to ensure positive outcomes for people.
DS0000017469.V343643.R01.S.doc Version 5.2 Page 12 I case tracked two people who live at the home and found that there were assessments from the home and care management. Initial assessments identified the mental health needs of people living at the home. This included a history of their mental health needs and any resulting behavioural management issues. These identified the needs of people prior to admission to the home. There have been no new admissions since the last key inspection. I found that the needs of the people case tracked had been reviewed both by the home and by social workers. People told me they had been consulted and received feedback from the review. Changes in needs had been addressed to ensure that people receive a consistent level of care to meet their needs. DS0000017469.V343643.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 679 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provided detailed information on the needs of people living at home. People are supported to make decisions about their lives. Risks to service users are assessed to ensure their safety. EVIDENCE: Since the last random inspection the registered a manager has reviewed care plans of all the people living at home. Care plans were found to provide detailed information on the support provided to meet the needs of people. I found that care plans had been developed with the involvement of people living at home. Care plans explained the mental health needs of people and how staff needed to respond to support them. People spoken to confirmed they had been involved in reviews of their care plans. DS0000017469.V343643.R01.S.doc Version 5.2 Page 14 People felt that staff understood their views and wishes regarding how they wanted to live in the home. Care plans generally identified the cultural, religious and disability issues facing people living at home. One person case tracked explained that the home had supported her to access Mind’s befriending service. She told me that this had helped her to explain needs to staff. Although care plans are generally detailed providing sufficient information on the needs of people they are based on activities of daily living model. This was discussed with the registered manager who agreed to organise the care plans in a manner that focuses on the specific needs which have already been identified in them. Details of behaviour that might challenge the service of people were identified in their risk assessments and care plans. Actions to address and manage these behaviours are outlined in detail. Where appropriate staff and discussed and recorded the views of those people living at the home whose behaviour might be challenging. Staff spoken to understood both the general principles, and specific needs of people living at the home with regards to managing challenging behaviour. Since the last random inspection risk assessments have been reviewed and provide detailed risk management strategies for people. Risk assessments had been reviewed to ensure changes to the level of risk were addressed. The risk assessments had been agreed with people or their representatives. Risk assessments were found to cover all areas that affected the peoples’ daily lives. Risk assessments identify the specific risks facing people and these are reflected in care plans. Staff were able to describe how they prevented risks to ensure that service users were safe and were supported to exercise control over how they live. Risks relating to behavioural issues were identified and actions to prevent or lessen the level of risk were discussed in team meetings. I observed that staff engaged with people living at home in an appropriately adult way. DS0000017469.V343643.R01.S.doc Version 5.2 Page 15 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to engage in a range of activities that meet their needs. People have community contacts and are supported to maintain personal relationships. People are supported to maintain a nutritious diet that reflects their personal choice. EVIDENCE: People spoken to said that they could choose from a range of activities. People spoken to gave examples of activities these consisted of playing cards, going to local community groups and listening to music. Daily notes and care plans confirmed that service users were regularly involved in activities both in and outside of the home. People spoken to told me that they had been consulted DS0000017469.V343643.R01.S.doc Version 5.2 Page 16 about the activities that are being provided. One person said, “ I like to go out to the coffee bar. I just have to ask staff and I can go”. People spoken to confirmed that they were involved in the cleaning of their bedrooms and cooking. People are able to make hot drinks whenever they wish to. I observed that people went to the shops when they wanted to. Daily records showed that people were supported to maintain contacts with family and friends. People living at home were able to develop contacts in the local community. Staff and the registered manager explained how they have been working on one person to find a Muslim group that meets her needs. The registered manager explained how the persons family had been consulted. I spoke with a person and she explained that she was happy with the home and how it had supported her. The menu is prepared at a weekly meeting of people living at home. I saw minutes of these meetings which confirmed that peoples’ suggestions for meals were recorded. People spoken to confirmed that they had been involved in preparing the menu. The menu is varied and reflected the cultural and dietary needs of individuals. One person living at home is a vegetarian. His preferences were reflected in the menu. The person told me, “ I get my vegetarian food that I like”. I observed that there were fresh vegetables and fruit available. One person explained that they had been involved in doing the weekly shopping. I saw that meals were well presented and were provided in a relaxed and supportive environment. DS0000017469.V343643.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People are supported with their personal care needs to maintain their independence. People are able to access the medical care they need. People are protected by safe procedures for handling medication. EVIDENCE: Care plans outlined the support people require and how they could be supported to maintain their independence in doing their personal care. I spoke with people who explained that staff provided support and encouragement to maintain their personal hygiene. People living at the home are self caring. Staff provide support for the maintenance of personal hygiene through prompting. Male and female carers are employed in the home to ensure that those people who prefer same gender care can be supported sensitively.
DS0000017469.V343643.R01.S.doc Version 5.2 Page 18 Medical needs had been identified as part of the initial assessment and were referred to in care plans and risk assessments. Two people case tracked confirmed that they had received regular support from community mental health professionals. One person spoken to told me that she had been consulted and involved when her community psychiatric nurse had changed. Daily notes confirmed that the General Practitioner had been consulted when the people were unwell. I spoke with people living at the home who told me that the staff support them to follow a healthy diet. One person case tracked was identified as being at risk due to having a poor diet. This was identified in her care plan and appropriate actions had been put in place to address this issue. People are weighed monthly and this is recorded to ensure that may maintain a healthy weight. People confirmed that they had been supported by staff to attend hospital appointments. One person spoken to said, “ staff will advise me, it is my choice if I attend medical appointments”. Daily notes recorded that people had access to the opticians, dentists and chiropodists services. Multi-disciplinary reviews had been held to ensure that any changes to the mental health needs of people living at home were thoroughly addressed. Where necessary follow up action had been taken to provide the care and support that people need. One person spoken to told me, “ if you are feeling unwell you can talk to staff and they will get you the help that you need from your psychiatrist”. The medication policy contained all the required information. I found that records for the administration of medication were complete. Records of medication received and returned were also complete. All medication was held securely. People’s medication had been reviewed regularly to ensure their continued well-being. Daily notes showed that community mental health professionals had been consulted to ensure that people were receiving the medicines they required. Training records and discussions with staff confirmed that they had received training on the safe administration of medicines. Advice was available for staff on the side effects of medication. DS0000017469.V343643.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People can be confident that their complaints are listened to and acted upon. Adult protection procedures protect people from abuse. EVIDENCE: People told me that they understood how to make a complaint. The complaints policy explained how to make a complaint and how it would be dealt with. Copies of the complaints policy were available around the home for people to consult when necessary. Staff explained that people are encouraged to discuss their views of the service in weekly meetings. People who live at the home told me that they could challenge and raise concerns about the way they were treated. The inspector observed staff approach people and this was done appropriately and sensitively. There were policies on handling abuse and adult protection. Training records showed that staff had received training in adult protection. I spoke with staff and they demonstrated their understanding of adult protection issues. DS0000017469.V343643.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: I walked round the home and found that since the last inspection the carpet in the second-floor bedroom has been cleaned. The home was clean throughout. There were separate dining and sitting rooms. People were able to choose where they wished to sit or spend time in their bedrooms. Maintenances records showed there were no outstanding repairs. There are two areas where the carpet is not properly secured. I observed that the carpet had been held down with masking tape. This is a potential trip for people living at home. These areas were pointed out to the registered manager who agreed to ensure that the carpet is secured safely.
DS0000017469.V343643.R01.S.doc Version 5.2 Page 21 Bedrooms were personalised with items of furniture and pictures belonging to people who live at the home. People living at home and chosen how they wanted their bedrooms decorated. People spoken to were pleased with their bedrooms and told me they had chosen items to bring with them when coming to live at the home. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. Staff have received training on infection control measures. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. DS0000017469.V343643.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Sufficient staff with the necessary skills are available to meet the needs of people. A training plan needs to be put in place to identify all areas of training needed to meet the needs of people living at home. People are protected by the home’s recruitment procedures. EVIDENCE: I found that the rota showed that a consistent staffing level was maintained. The rota also showed that staff were on duty to provide escorts to appointments and support with activities when this was necessary. Staff spoken to confirmed that sufficient staff were available at all times. People living at home told me that there is enough staff to provide them with the support and care they need. Training records confirmed that all staff were up to date with, and had all the statutory required training. All staff have now completed a training course on
DS0000017469.V343643.R01.S.doc Version 5.2 Page 23 Mental Health awareness. Staff spoken to told me that this training had given them a better understanding of the mental health needs of the people they were now working with. The registered manager explained that she would be arranging further training on mental health issues. This will assist staff to develop their understanding of specific issues affecting people with mental health needs. Staff commented that the registered manager positively encouraged them to go on training to develop their skills and understanding of the needs of people. Training records showed that 50 of staff has either level 2 or 3 in the National Vocational Qualification in care. The registered manager explained that since the last inspection she has started to complete a training plan for the home. However, work on this has only just started. A training plan still needs to be put in place to ensure that staff have all the relevant skills to support people living at the home. Staff files had been examined at the last key inspection and were found to contain all the necessary documentation relating to the recruitment and appointment of staff. No new staff have been appointed since the last key inspection Staff go through an interview process and there were notes to confirm this. People can be confident that they are protected by the home’s recruitment procedures. DS0000017469.V343643.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The registered manager has the skills and understanding to manage the service in the best interests of people. People’s views of the service are sought and used as the basis for improvement. People who live at the home and the staff health and safety is always promoted and safeguarded. EVIDENCE: The home has a stable management and the registered manager has experience and understanding of the requirements of people with mental health needs. Staff and people spoken to confirmed that they felt that the registered manager was supportive and approachable. Since the last random inspection the registered manager has commenced the registered managers
DS0000017469.V343643.R01.S.doc Version 5.2 Page 25 award. I was able to see confirmation that she had obtained a place on the course. Since the last random inspection a system has been put in place to monitor the quality of the service provided by the home. The registered manager explained that she carries out quality monitoring on a monthly basis. A different area of the service is covered each month. I saw examples of the surveys. People living at home, relatives and professionals had completed these. The registered manager explained that an action plan is developed to address any areas for improvement that are identified. I was able to see these action plans and confirmed that issues had been raised were addressed. Ideas for improvement are sought. People are consulted about how the home is run. Minutes were seen of meetings held with people who live at the home to discuss the quality of the service provided. Action to improve the service had been agreed with people who live at the home. The registered person ensures that the safety risks to people living at the home and staff are identified. Measures are put in place to provide a safe living and working environment. Records showed that fire equipment was tested regularly and maintained. Drills were taking place. The fire risk assessment provides details of potential risks of fire. All health and safety policies were available. Certificates for gas and electrical testing were in date. COSHH guidance now in place and chemicals were stored safely. Training on health and safety topics was complete. People living at home have been involved in identifying safety issues. DS0000017469.V343643.R01.S.doc Version 5.2 Page 26 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 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 3 X DS0000017469.V343643.R01.S.doc Version 5.2 Page 27 YES 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 YA35 Regulation 18.1 Requirement The registered persons must ensure that a training plan is developed. People to live at the home must be supported by staff that have all the relevant skills to meet their needs. (Previous timescale of the 1st September 2006 and 1st April 2007 not met). Timescale for action 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The registered persons should review the use of activities of daily living as the basis for constructing care plans. Care plans should focus on the specific needs of people living at the home particularly with regard to their mental health and well being. The registered persons should ensure that the potential trip hazards identified to the registered manager are made safe. This is a potential trip for people living at home.
DS0000017469.V343643.R01.S.doc Version 5.2 Page 28 2 YA24 DS0000017469.V343643.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000017469.V343643.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
