Inspection on 19/07/07 for Budge Lane (21)

This inspection was carried out on 19th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Budge Lane (21) 05/01/07

Budge Lane (21) 07/12/05

Budge Lane (21) 07/07/05

Budge Lane (21) 26/11/04

Budge Lane (21) 05/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Budge Lane (21) 21 Budge Lane Mitcham Surrey CR4 4AN Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 19th July 2007 09:30 Budge Lane (21) DS0000007155.V345339.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 Budge Lane (21) DS0000007155.V345339.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. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Budge Lane (21) Address 21 Budge Lane Mitcham Surrey CR4 4AN 020 8640 5169 020 8640 5169 budgelane21@walsingham.com 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) Walsingham Manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2007 Brief Description of the Service: 21 Budge Lane is a residential care home that was first registered in January 1997 to provide care for up to six adults with learning disabilities. The home specialises in providing a service to people who have a learning disability and who may also have a secondary physical disabilities. The accommodation compromises to six single bedrooms. There is a communal lounge towards the rear of the building overlooking the back garden, and a secondary lounge towards the front of the premises. Other facilities include a dining room, kitchen, laundry, garage, staff sleeping in room and staff office The home itself is located on a new estate, which has a mixture of housing association and private properties. The nearest shops are some 15 minutes walking distance away; it is not the most convenient place for some forms of public transport, however the home does have its own transport. The home is owned and run by Walsingham, which is a registered charity that has a Christian ethos. The current costs of the placement were not available for the year 2007/08, therefore the figures referred to are for the previous year, they range from £1,214 to £1,379 dependent upon need. Placing authorities are advised to contact the home directly for more detailed information. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2007/08. It was an unannounced inspection that started at 9.30 am. The inspection took approximately six hours. The inspection took the form of discussions with the majority of people who use the service, staff on duty and observations of staff interaction. In addition, there was a tour of the building and looking through documentation, which related to people who use the service to make sure that they were relevant, accurate and up to date. This case tracking ensured that all documentation relating to two people was checked thoroughly. The inspector also checked documentation coming into the Commission, so that this report reflects the home over the year, rather than a snap-shot of findings on the day of inspection The home has a new manager who has been in post since March 2007 on a part-time basis. The manager made herself available during the inspection process; the deputy manager was not available, as she had been seconded to another home. The inspector would like to thank the people who use the service and staff for their time and co-operation during the inspection process. What the service does well: People who use the service, when asked ‘are you happy here’, relied ‘yes, I’m happy’ and ‘they look after you’. There is no doubting that the people who use the service are assisted in living an ordinary, fulfilling and meaningful life. Walsingham are committed to ensuring that their workforce has a solid foundation during their induction period; and that staff then undertake regular training in order to improve their knowledge and skills. This was evident as staff were all able to communicate effectively with people who use the service even though they had very different communication patterns. The staff at the home and Walsingham consider the views of people who use the service to be vital to the running of the home and the organisation. There are many examples of good practice, which can be highlighted as evidence of this. These range from day to day choices, such as what to wear and when to Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 6 eat, through to service users being on an interview panel for managers and senior staff within the organisation. What has improved since the last inspection? What they could do better: The homes last key inspection was in January 2007, when eleven requirements were made. It is to the credit of the manager and staff team that these requirements have been reduced from eleven to four, in five months. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 7 However, within this home there has been an ongoing issues regarding medication. Staff when administering medication, often do not record whether it has or has not been administered. This is something that the home needs to get to grips with. In addition, there was an incident when an incorrect dose of medication was given to someone. The home must ensure that all staff are aware of the policies and procedures regarding the storage, handling and recording of medication, and that they adhere to the practice. 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. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 8 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 Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 9 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): 1,2,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has gathered information from a variety of sources and then completed their own thorough assessment for all new people. This process would be completed in conjunction with the new person themselves and their family, friends and advocates. The aim would therefore be that people who use the service would not just be fitted into a vacancy; but that people themselves would make an active choice about the accommodation that they wanted to live in. To aid in this process, a new service users guide has been written. EVIDENCE: Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 10 The home has been open since 1997; all people who use the service arrived at that time came with an assessment. These documents were checked at the previous inspections and were of variable quality. The home has subsequently devised a care assessment for each of the people who use the service. This document contained general information, which was gathered from the original assessment plan, and from the homes own assessment process. Walsingham have their own ‘assessment of needs’ for all new people. This document was extensive and comprehensive with areas for likes, dislikes, significant friends and family, sexuality and level of disability. The home has recently developed a new service users guide, which comprises of photographs, drawings and some written text, which is in plain English. The document is specific to the home in that it includes photographs of the local area, amenities and the home itself. It also includes a photograph and a brief pen picture of the people that are currently living at 21, Budge Lane. A new contract has also been devised which focuses on the people who use the service and what they can expect from the home. Documentation was checked for two people who use the service, one person had an updated copy of the new agreement, and the other person did not. However, there was adequate information in their existing agreement, which was written, in a suitable format. The home is able to meet the needs of people who use the service either by the skills and experience of the staff team, or by the use of outside professional agencies. A physiotherapist and psychologist are available if necessary. A district nurse has been visiting on a regular basis because of the health needs of the people who use the service. All people who use the service within the home are able to communicate their needs either verbally or through gestures. The staff team all have the necessary skills and understanding of the varying forms of communication so that they can meet the needs of people who use the service. From observations it was evident that this was the case. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are generally given opportunities to make choices regarding daily activities; what they eat and when, through to senior staff appointments. The home is beginning to ascertain the aspiration, goals and needs of people who use the service and to put these into place so that people can have a meaningful and independent life. EVIDENCE: The home has a new manager, Ms. Mandy Barton who has been in post since March 2007. Ms. Barton has introduced many changes to the paperwork within the home, which is seen by the inspector as a vast improvement. However, it recognised that many of these changes are in the early stages of Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 12 introduction, and that they need time to ‘bed’ in with people who use the service and staff. The home is in the process of transition with regards to its documentation for people who use the service. All people who use the service do have a document entitled ‘my goals’, which was reviewed annually, written in plain English and in an accessible format. The home also initiated Person Centred Planning (PCP) for some individuals and then stopped the process and it was a paper exercise. PCP’s were put on hold, until sufficient staff were suitably qualified in the process. The manager informed the inspector that sufficient staff have now undergone training, and that one PCP has been initiated for an individual. All people who use the service have had an annual statutory review within the last year. Therefore a requirement made at the last key inspection that reviews must be carried out urgently is withdrawn. A daily activities log has been introduced in the home, whereby staff make an entry for each day stating what every individual has done. At previous inspections, the home could not evidence what activities had been undertaken; therefore this log is seen as a vast improvement. There still needs to be some clarification within the staff group, about the purpose and expectation of the daily log, as the inspector found a three day period with no entries for one person. A recommendation has therefore been made regarding this. At previous inspections the inadequacy of the risk assessments have been highlighted. The manager has therefore introduced ‘whole life’ risk assessment, which will be completed on every individual within the service. In addition, there will be specific risk assessments. This is an ongoing process, and although a requirement has been made regarding risk assessments, the inspector acknowledges the vast amount on work that has been undertaken already. Two of the homes service users have been on interview panels for staff for many years. They were given training in this area and undertook mock interviews. Subsequently, one of the service users has joined a regional interview panel which interviews managers and senior personal for posts. The questions asked were gathered from all the homes in the area. Two of the people who use the service attend regular meetings entitled ‘ Walsingham against Cotton Wool.’ Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 13 ‘Advocacy Partners’ are involved with one of the people who use the service, and has been for a number of years. People who use the service are able to come and go as they wish, although this is something that they often do not do. One person regularly takes himself off to a sister home, the front door is alarmed, purely to alert staff that someone has left the premises. The manager stated that the home is in the process of employing a part-time activities co-ordinator. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service within the home live ordinary and meaningful lives, and participate and contribute to the communities in which they live. There is an emphasis within the home of developing and maintaining personal and family relationships. This allows people who use the service to feel that they belong, and that there is someone external to the organisation that can consider their welfare. EVIDENCE: Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 15 People who use the service are encouraged to maintain friendships and family contact. Four of the service users do not have any family contact. The home has a representative from ‘Advocacy Partners’ involved with one person. Where there is contact with family, friends or advocates the home will try to maintain this. Everyone has a birthday party, if they chose; family are invited into the home at formal events such as Christmas and are welcome at other times. Three of the service users currently participate in spiritual activities and are encouraged to attend specific churches of their choice. One particular person is keen on jazz music. The home is able to access live jazz music in the community, which includes at pubs and music venues. This individual usually attends a jazz holiday every year. Over the summer period two people in the home will be going to Spain, one to Blackpool, one to a jazz festival and the other two have identified holidays of their choice but not yet booked them. People who use the service are encouraged to participate in community activities by the provision of a house car. In addition everyone has his or her own bus pass. One person has his own car, which is driven by staff; another has their own scooter. People who use the service now keep their own money in their bedrooms in a lockable drawer. People who use the service are able to choose what they want to eat; the house does this collectively on a Saturday when the menu for the week is decided upon. Menu’s were viewed for a number of weeks and showed that there are some favourites that appear regularly, these include, fish and chips, casseroles and macaroni cheese; in addition, on Saturday mornings there is the option of a cooked breakfast and on Sundays a roast dinner. Meals are taken in congenial setting that is relaxed and flexible. People who use the service are free to help themselves to snacks and drinks. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general it seems that the staff within the home are able to provide personal care that ensures privacy and dignity at all times. There is an awareness and understanding that people who use the service have the right to expect the same healthcare as others in the community, EVIDENCE: People who use the service are supported to manage their own healthcare needs, some are able to take themselves to their own GP and have a private consultation, and others need support to do this. The home has introduced a new medical form, which outlines all the appointments that have been kept, and when future appointments are needed. Two individual files were checked of people who use the service, they appeared to be up-to-date and accurate. Therefore a previous requirement relating to Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 17 the monitoring of health appointments and ensuring that people who use the service have access to health professionals is withdrawn. People who use the service within the home receive sensitive personal support, which maintains their privacy and dignity. This was confirmed via observations and discussions with staff. People who use the service are able to choose their own clothes and toiletries, and there are always a range of clean clothes available. No one within the home is currently able to self-administer medication, though the manager did confirm that they will be completing risk assessments for one individual. Medication is stored in a locked metal cabinet, which is sited in a locked cupboard. Medication arrives in the home in Dossette packs on a monthly basis. ‘Boots the Chemist’ audits the home on a regular basis, the last occasion being on the 6.7.07 when no action points were identified. All staff have undertaken a basic administration of medication course in November 2006. There is in addition, an internal course available to staff. A senior member of staff has also recently taken responsibility for overseeing mediation within the home. The Medication Administration Records (MAR) records were checked. There were a number of omissions found in the recording of administration. This has been an ongoing issue within the home, and at the previous inspection considered to be resolved. It is therefore disappointing that the issue has arisen once again. In addition, a medication error was made in February 2007, which was regarding the dosage that came into the house and subsequently administered to an individual. A requirement is therefore made that the home must focus on the procedures for the administration of medication to ensure that errors do not occur in the future and that all staff have received adequate levels of training. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general it appears that people who use the service feel listened to and confident that their views will be taken seriously. This acts as an added safeguard to ensure that their safety is paramount and that they are protected as far as possible from risk as vulnerable adults. EVIDENCE: The home has a general complaints policy which was dated August 2004, it contains information about the process, how long it should take and what to do if you are not satisfied with the response. Walsingham need to consider updating this document, as some of it is now out-of-date. The home does have a complaints log, which had no entries since the previous key inspection. The home has robust polices and procedures in place to make sure that service users are kept safe. There is Walsingham’s own vulnerable adults policy and in addition they have a copy of Sutton’s own procedural guidelines. The home has a whistle blowing policy. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 19 Two members of staff were asked a question regarding vulnerable adults as a way of testing their knowledge and understanding of the policies and procedures. It is positive to note, that both members of staff were able to give a reasoned and correct answer to the scenario. In addition, both had a working knowledge of the whistle blowing policy and its effects. The home has recently developed a complaints form for the people who use the service. It is in a format that is suitable for the people who currently live in the home with photographs and plain English. Budge Lane (21) DS0000007155.V345339.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): 24,26,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is supplied with specialist aids and adaptations required for daily living so that people who use the service can be as independent as possible. A number of changes to the fabric of the building have been made or are in the process of being made, thereby ensuring that people who use the service live in a homely, comfortable environment. There is a respect for service users privacy, enabling them to come and go as they wish, to receive guests in private and to have a key to their own bedrooms EVIDENCE: Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 21 The home’s accommodation is all on the ground floor and has been made wheelchair accessible by allowing sufficient width in all the doorways. The home is in keeping with its environment. The home has some moving and handling equipment, this includes overheadtracking hoists observed in the bedrooms, and a shower trolley. There were adaptations in the bathrooms and toilets, which included grab rails. Electrical sockets and light switches were in accessible places for wheelchairs users and there was evidence of a call alarm system throughout the building. The furniture and fittings of the home are generally of good quality and domestic in style. People who use the service have their own bedrooms, which are personalised according to their interests and tastes. People have their own keys to their bedrooms which some of them use, and in addition a lockable space in their bedrooms. A number of changes have been made to the fabric of the home. Most notably, the home is in the process of having a new kitchen installed. This has been an outstanding requirement since 2004, and it is therefore very positive that it is finally being installed. The home has managed this period of disruption, by moving the contents of the kitchen into the adjacent dining room; there has also been the use of local take-away restaurants. The manager reported that people who use the service have not found it to be too disruptive. On the day of inspection, work was being undertaken, with apparent minimal effect on the people within the home. Other material changes have included a new dining room table and chairs; new carpets and the small lounge has been completed redecorated. All this work has resulted in the home having a much more homely and comfortable feel for the people who use the service. The inspector conducted a tour of the building with one of the people who use the service, it was found to be clean and hygienic throughout, despite the work that was being undertaken. Budge Lane (21) DS0000007155.V345339.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): 32,33,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an emphasis at the initial stages that staff receive a full induction so that they have the skills in order to provide a good service to people within the home. In general staff receive the training and support to ensure a high quality of care EVIDENCE: All new staff at the home receives a six-week induction, followed by core skills training, which covers areas such as health and safety, food hygiene and manual handling. Walsingham emphasis the importance of the training for their staff group. Records checked indicated that staff have all had the required level of training, that is to say at least five days per year. Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 23 Currently the home has a staffing establishment of twelve people and the full time equivalent of three vacancies. Existing members of staff, bank or agency workers cover vacancies. The manager reported that the vacancies are being recruited to and should be filled in the near future. The home expects that on any one shift during the day, that there will be at least three members of staff on duty. The inspector sampled the duty rota at random, including over May bank holiday and the previous week. The rota confirmed the number of staff on duty, with any vacancies being covered by agency staff. At night the home has two members of staff on duty, one on waking night and the other on sleeping in. Within the service users group there are four men and two women all of whom are white/European. Within the staff group there are mainly women from a culturally diverse groups. Staff records for supervision were viewed for three members of staff; notes were available for these meetings, which were signed by both parties. However, the frequency of supervision was sporadic; a new member of staff last had supervision three months ago, whilst another member of staff was supervised in January and then June. A requirement is therefore being made, that supervision must take place at the required level, that is to say, at least six times a year at regular intervals. Particular consideration needs to be given to new members of staff. Recruitment files are not kept within the home, but centrally. This is with the agreement of the Commission. Recruitment files are instead checked by a senior officer from the Commission on a regular basis. Budge Lane (21) DS0000007155.V345339.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): 37,38,39,41 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Walsingham have policies and procedures in place to ensure the welfare and safety of people who use the service and staff. The calibre of the manager affects the quality of the care provided within the home, so people who use the service and staff feel valued and listened to EVIDENCE: The home has a new manager, Ms. Mandy Barton, who has been in post since March 2007. Ms. Barton has worked in the field of learning disability since 1996 and has been a manager for three and a half years. She has qualified Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 25 with a National Vocational Qualification Level 4 and has the registered managers award. Ms Barton has yet to be registered with the Commission for Social Care inspection as the manager for 21, Budge Lane, although she did inform the inspector that this process had been initiated. The intention of the Walsingham group is that Ms. Barton will become the manager for 21 and 31 Budge Lane. This effectively means that she will be part-time at both homes. In discussions with people who use the service and staff, there was a positive response to the new manager. People felt that she was inclusive and approachable; staff commented that she was clear about expectations. It was noted that a number of significant changes have been made within the home in recent months which can be attributed to the new manager. In particular, paperwork relating to people who use the service has improved significantly. There has been in overhaul so that much information has been archived, and that there is now a ‘live’ file for each person within the home. New forms for medical records, activities log and risk assessments have been introduced. In general, therefore the home now has a set of records that are secure, up to date and in good order. Walsingham takes seriously its responsibilities to ensure the safety and welfare of people who use the service and staff. The inspector checked various documentation in relation to this. Gas certificate was dated the 18.7.07; Legionella on the 11.8.06; fire equipment was checked on the 28.2.07 and fire alarm testes were weekly; PAT was completed on the 7.9.06 It was noted that the last fire drill had taken place on the 31.5.07. However, fire drills need to take place at all times throughout the day, this includes at night. A requirement has therefore been made that in this regard. Budge Lane (21) DS0000007155.V345339.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 3 4 X 5 3 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 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 3 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 2 X 3 3 3 X 3 2 X Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 27 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. 2. YA9 YA20 Standard Regulation 15(1)(b) 12(1)(a) Requirement All risk assessments must be reviewed in a timely fashion Staff must all be made aware of the policies and procedures for the handling and administration of medication, and abide by them Supervision of all staff must be completed at the required level Fire drills must take place throughout the day, including at night Timescale for action 19/10/07 19/07/07 3. 4. YA36 YA42 18(2) 23(4)(e) 19/08/07 19/08/07 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 YA7 Good Practice Recommendations The purpose of the daily activities log should be made clear to all staff Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Budge Lane (21) DS0000007155.V345339.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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