Inspection on 31/10/07 for Chalk Hill

This inspection was carried out on 31st October 2007.

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

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

Other inspections for this house

Chalk Hill 31/08/06

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Chalk Hill Chalk Hill Waterhouse Lane Kingswood Surrey KT20 6DT Lead Inspector Elaine Green Unannounced Inspection 15 November 2007 12:00 th DS0000066903.V349580.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 DS0000066903.V349580.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. DS0000066903.V349580.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chalk Hill Address Chalk Hill Waterhouse Lane Kingswood Surrey KT20 6DT 01626 899930 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) www.moduscare.com Modus Care Limited Ms Nicola Patricia Miller Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000066903.V349580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: Chalk Hill is a detached property located in Kingswood, Surrey. It is a fivebedroom property which benefits from a large garden to the rear of the property with off road parking to the front. The home currently accommodates three service users with learning disabilities. The home comprises of large communal areas including a lounge and dining room. Each person who lives in the home has his or her own private bedroom, two of which are en suite. The home is situated close to the village stores and benefits from a public transport network with easy access to London and the local countryside. Fees are assessed on an individual basis and range from £2,200 to £3,500 per week and include a supported annual holiday, further information in respect of fees can be obtained from the home. The following are not included in the fees: hairdressing, chiropody, newspapers, dry cleaning, alcohol, entertainment, personal stationery and confectionary. A copy of the service and the homes Statement of Purpose, Service User Guide and the moist recent Inspection Report are kept in the office at the home and are available on request. DS0000066903.V349580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The National Minimum Standards refer to individuals who reside in Care Homes as “Service Users”. In this report individuals who reside at Chalk Hill will be referred to as ‘the people who live at the home’. As part of the unannounced Key Inspection of Chalk Hill, a site visit took place to the home on the 15th November 2007. Issues relating to the day-to-day running of the home were discussed with the Registered Manager, a senior member of staff and a relatively new member of staff. Discussions also took place with two of the people who live at the home, one of which gave a guided tour of the building. A range of documents were examined including three care plans, two recruitment files, a selection of the homes’ policies and procedures and some of the homes daily records. In addition to this the Registered Manager completed an Annual Quality Assurance Assessment. This document provides the Commission for Social Care Inspection (CSCI) with statistical information relating to the home. Two of the three people who live at Chalk Hill completed surveys feedback from which will be included in this report. What the service does well: People considering moving into Chalk Hill have their needs assessed prior to moving into the home and are given all the relevant information they require in order to make an informed decision about whether or not to reside there. People are provided with the opportunity to participate in stimulating and enjoyable activities in the home and by accessing the facilities on offer within the local community. They are able to make choices about the way they spend their time and about the way they decorate and furnish their rooms. People who live at the home are also supported to express themselves through their appearance and are given the opportunity to have a supported annual holiday. Peoples’ care plans are highly individualised and provide staff with the specific guidance they require to support individuals appropriately and to live the lifestyle of their choice. The people who live at the home have a plan that details their likes, dislikes and preferences. This helps to ensure that all their diverse needs are met. The people who live at the home are involved in setting the menu, buying provisions and in making the arrangements for the provision of food at meal times. The food provided is nutritious and wholesome and mealtimes are relaxed and informal. The support that people receive at mealtimes is appropriate and ensures that dignity and choice are promoted. The home is domestic in character and are furnished and decorated in a modern style to a good standard. The bedrooms of the people who live at the home are individualised and reflect their personal tastes and interests. DS0000066903.V349580.R01.S.doc Version 5.2 Page 6 The medication policies and procedures adopted by the home are safe and peoples’ health care needs are met. Referrals are made to the relevant health care professionals when required and adult protection alerting procedures are followed when required. Recruitment practices are safe. The staff team are open and enthusiastic to new ways of working. They receive appropriate training and are supervised on a regular basis. Informative handovers take place at the beginning of each shift ensuring that all relevant information is passed onto the staff coming on duty. The management of the home are open and transparent and there are systems in place to ensure the home is run in the best interest of the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000066903.V349580.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 DS0000066903.V349580.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3&4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can have a trial period at the home and are supplied with the information required enabling them to make an informed decision about whether to reside there. EVIDENCE: The manager explained that prospective residents are assessed prior to them moving into the home. A pre admission assessment was examined and was found to be in order. There is a trial period enabling prospective residents to assess the home for suitability. Feedback from the people who live in the home confirmed that they had received the information they needed about the home before they moved in. The homes statement of purpose and service user guides were examined and found to be satisfactory. The manager has given assurances that all residents in the home are provided with copies of these documents. The people who live in the home confirmed that they felt that the home was able to meet their needs. DS0000066903.V349580.R01.S.doc Version 5.2 Page 9 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): 6,7,8&9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in the home know their assessed and changing needs are reflected in their plans of care. People are supported to safely live the lifestyle of their choice. EVIDENCE: The care plans of the three people who live at the home were examined. They are based on comprehensive assessments and provide all the guidance required by staff to support people effectively and appropriately. Care plans are individualised, person centred, include personal history that reflect their chosen lifestyles. They include a ‘Day in the Life’ profile for the individual. All the associated records that were examined had been completed as required. Care plans are signed by the person it relates to when appropriate. The personal goals of the people who live in the home are specified and progress made towards meeting these goals is reviewed on a regular basis. All DS0000066903.V349580.R01.S.doc Version 5.2 Page 10 care plans contain information illustrating the activities participated in including the preferred activities for evenings and weekends. Scheduled and recorded one to one sessions with the people who live in the home and their respective key workers’ are used to help assess and record peoples preferences in relation to the activities they would like to participate and the decisions made in respect of the goal setting at reviews. This is considered to be good practice. One person stated that they decide themselves what they want to do and have very clear plans for their life in the future. They said that the staff support them to achieve their goals and that they have become more independent since they moved into the home. Care plans provide guidance for staff to follow when supporting people to manage behaviours that may be difficult or challenging and also detail guidance on proactive ways of working with people, thus promoting their independence. People who live in the home are encouraged to make decisions for themselves. Comprehensive risk assessments undertaken for each person in respect of all the activities they participate in. The home has a robust system in place for ensuring care plans and the associated documentation are reviewed and updated on a regular basis. Staff read and sign all care plans. There is a daily cleaning schedule in place which both the staff and the people who live in the home take an active part in. On a daily basis people will choose what house chore they would like to complete for the day and will tick it off when the chore is completed. This ensures that the home is clean and is a pleasant environment to live in. Everyone is encouraged to look after their own room and are asked to clean their bedrooms and bathrooms on a weekly basis. People are also involved in the buying of privisions and the preparation of meals. House meetings are held on a regular basis where the people that live in the home can make suggestions about the way the home is run and feedback to the team what they feel is working etc. DS0000066903.V349580.R01.S.doc Version 5.2 Page 11 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): 11,12,13,14,15,16&17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The support provided to the people who live at the home ensures that they can access the community and participate in meaningful and appropriate activities. People are provided with a healthy diet and enjoy their meals. EVIDENCE: People who live in the home are given the opportunity to choose for themselves what they would like to do rather than everything in their lives being structured and pre-planned. At each shift handover staff are allocated people to work with and the tasks and activities they are to support them with. Care plans specify family relationships and peer group relationships pertinent to the individual. Staff stated that peoples’ visitors are welcomed into the home. DS0000066903.V349580.R01.S.doc Version 5.2 Page 12 On the day of the first site visit the people who live in the home had arranged to go out into the local town to do some personal shopping after they had had their lunch. Before lunch all the people who lived in the house were engaged in activities in respect of the running of the home, e.g. preparing food, doing laundry etc. Each person was given a choice of what to eat for their midday meal and where he or she would like to eat it. Two people chose to eat together and help prepare the food and one person chose to eat on their own. Independence, dignity and choice were promoted throughout lunchtime and people were supported appropriately. Staff demonstrated an in depth knowledge and understanding of the needs of the people who live in the home throughout the mealtime. Menus were examined confirming that the food provided is balanced, varied and nutritious. Staff explained that the people who live in the home are fully involved in setting the weeks’ menu, buying the provisions. One of the people who live in the home explained that they had recently decided that they were going to start preparing meals from scratch and not to use sauces from jars and packets. They said that they were really enjoying doing this because they were learning new skills and that the food tasted better. After lunch one person changed their mind about going out on the shopping trip and so the staff rearranged plans to ensure that this person was able to undertake his chosen activity. This person explained that they often access the community on their own to pursue their hobby. They stated that they have a mobile phone that they take with them and that before they go out they let staff know where they are going and what time they will be back. They also sign in and out of the house and staff keep a record of what people are wearing when they leave. Another person explained that they are able to catch the local bus to get to the college they attend and that they hope to get a qualification in order for them to gain employment in the future. DS0000066903.V349580.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health care needs of the people who live at the home are well met and personal support is provided appropriately. The homes’ medication policies and procedures are robust, protecting the health and safety of the people who live in the home. EVIDENCE: Observations of practice on the day of the site visit, an examination of records and discussions with the people who live in the home and staff confirms that peoples’ health care needs are met. Referrals are made for input from health care professionals when required and people who live in the home receive support and treatment in the privacy of their own rooms. Clear guidance is in place for when ‘as and when’ or medication can be administered. No member of staff can make the decision to administer this medication independently. DS0000066903.V349580.R01.S.doc Version 5.2 Page 14 All medication is administered and signed for by two members of staff. When staff are working on their own they must ring the organisations own health care professional to discuss why they feel it is necessary to administer ‘as and when’ medication the discussion and decision is then documented. The health care professionals have with them copies of all the medication that the people who live in the home have been prescribed along with their medical histories. This system is in place 24 hours a day. When two members of staff are on duty and a decision about ‘as and when’ medication has to be made one of the must them a manager or a senior member of staff. The manager explained that even then they often ring for advice prior to administering. Medication records were examined and found to be in order. The manager explained the robust system the home has in place to ensure that the risk of errors being made are minimised and that if errors are made they are identified as soon as possible and the appropriate training provided for the staff member who has made the error. The training provided for staff in relation to the administration of medication is robust and provided on a continual basis. There are in depth clear and specific guidelines in place for how staff should support the people who live in the home with their emotional health care needs. The guidelines examined had been updated recently and the manager stated that this is an ongoing process. She also explained that the staff team strive to have a consistent approach to the support they provide and to ensure that this happens any changes in guidelines are discussed with the staff team and they must read them and sign to say they have read them. One of the people who live in the home explained that they had recently had a medication review and was able to discuss what medication they were on and what it was for. The three people who live in the home each have a key worker. Times for getting up, going to bed, having meals etc are flexible. People who live at the home are given the freedom to express themselves through their choice of clothing, hairstyles and make up and are supported to do so by the staff team. DS0000066903.V349580.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the people living at the home are listened to. The homes’ adult protection policies and procedures protect the people who live in the home from abuse and harm. EVIDENCE: All staff are trained in the protection of vulnerable adults, there is a policy in place and the procedure is kept in the office. When new staff join the company they are asked to read through the policies and procedures and are made aware of the complaints procedure and the whistle blowing policy. A copy of the signature list shows that staff have read and understood the complaints procedure. There is evidence that appropriate investigations have been carried out when necessary. Some people who live in the home can display a level of behaviour that may be challenging. Guidelines for staff to follow in relation to managing this behaviour is included on their care plans thus minimising the risk of raised anxiety levels and potential harm. Staff have received training in relation to the protection of vulnerable adults and a programme for staff to receive this training is in place. An ‘in house’ induction adopted by the home ensuring that all new staff receive information, guidance and ‘in house’ training on how to work with specific individuals with difficult or challenging behaviours. DS0000066903.V349580.R01.S.doc Version 5.2 Page 16 The manager is aware of the need for referrals to be made to the local social service department when required in line with local guidance. The home has worked closely with relevant health care professionals and other professional bodies in order to achieve the best outcome for the people who live at the home by promoting their independence and health and safety. People who live in the home are able to make complaints and there are a number of ways they can do this. Two people said that they would speak to their key worker and felt able to do so they also were aware of the complaints procedure. People are offered the opportunity to discuss their preferences, likes and dislikes with staff on a one to one basis every week ensuring that their views are listened to. DS0000066903.V349580.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26&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 clean and comfortable, peoples’ own rooms promote their independence and the home is suitable for its’ purpose. EVIDENCE: Chalkhill is a large and spacious home that provides accomodation for three people, each have their own bedroom and bathroom facilities. Peoples’ own rooms have got suitable furniture to meet their individual needs and wishes. People who live in the home have been able to choose the decoration of their room and the possessions they have in it. All bedrooms and bathrooms are lockable. Chalkhill benefits from a large, secure garden to the rear of the property. On the ground floor there is a variety of communal areas including a dining room, a large and small lounge area in hwhich ther is a computer for the use of the people who live there. The staff office is located downstairs next to the main kitchen. There is a separate utility room and a second small DS0000066903.V349580.R01.S.doc Version 5.2 Page 18 kitchen. There is access to the local community by both public transport and the use of a company vehicle. Effective maintenance systems are in place so that damage is repaired quickly and new furniture can be purchased where necessary. Regular fire and environmental risk assessments are carried out, as well as inspections of fire equipement, ie extingushers and alarm by professional personnel. The home operates a no smoking policy and has a designate smoking area in line with current legislation. Policies are in place regarding infection control and staff are trained in infection control procedures, and appropriate personal protective equipment is always avaliable. On the day of the site visit we were shown around the home by one of the people who lives in the home. The home was found to be both clean and hygienic, and decorated and furnished in a modern style to a good standard. All rooms are domestic in character, have a homely and comfortable feel to them and are fully accessible. All three bedrooms are on the first floor. Residents’ own rooms are decorated and furnished to their own tastes and personalised with their belongings. All bedrooms meet the needs of the residents they accommodate. The windows are not restricted (based on a risk assesment) so the home is well ventilated. DS0000066903.V349580.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35&36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are good and consistently followed. All staff receive regular documented supervision and appropriate training. People who live in the home are supported by an experienced and effective staff team. EVIDENCE: Staff recruitment and induction files were examined. The recruitment procedures adopted by the home are safe and all the required security and identity checks are undertaken prior to staff being deployed to work in the home. All staff are supplied with a copy of their job description and the General Social Care Council (GSCC) code of conduct handbook for reference. Staff undergo a period of shadowing at the beginning of the appointment. This means they work with an experienced member or staff in order to familarise themselves with the people who live in the home and the running of the home. DS0000066903.V349580.R01.S.doc Version 5.2 Page 20 During this period staff complete a competency pack which includes basic cooking skills, the use of electrical appliance and basic cleaning skills and completing company paperwork. Supervisions and reviews are carried out on a six weekly basis and at the beginning of the staff members empolyment this is weekly. An examination of the supervision records confirmd this. The homes’ ‘in house’ induction package that all new staff must complete was examined and was found to be comprehensive, covering all aspects of the running of the home, including; the main points of care in relation to the people who live in the home, a health and safety induction, introduction to medication administration and assessment, time to read care plans, information relating to the Protection of Vulnerable Adults and details of the fire evacuation procedures. The training the staff receive is an on going process within the home, mandatory training courses include Health & safety, Food hygiene, Postive Behavioural Management, Autism & Aspergers training, Manual Handling, Infection Control and First Aid. All staff within in the home are working towards obtaining a Nastional Vcational Qulification (NVQ) in Care at level 2, some staff who have completed this award have started working towards NVQ Level 3. Further staff training needs are identified through supervision and additional courses are sourced according to the changing needs of the people who live in the home. On each shift there is a shift coordinator who is the senior member of staff on shift. On call (telephone) support is available in emergencies, as well as response on call. Staff rotas are based on the needs of the people who live in the home and activities for the particular day and time of the week. Attempts are made when planning the rota to ensure a diverse staff mix with regards to gender, age and drivers etc. All staffing records are kept up to date and records of sickness, lateness, disciplinary action and similar issues. Staff team meetings are held every month and an examination of records confirmed this. Staff within the home are given extra responsibility when appropriate such as a key worker role or ensuring the house tasks are completed, e.g. fire safety, stationary, first aid checks or petty cash. The Inspector observed information being passed between staff and the planning of the next shift. Issues discussed included comprehensive detailed information relating to the activities that the people who live in the home had participated in that day, a summary of their general health and emotional well being, the tasks that had been undertaken, other events of the day and information relating to activities planned for the evening and tasks that required to be completed. The staff that were coming on duty were given specific people to work with and specific tasks to complete linking in with peoples’ personal plan for the day. This is considered good practice and provides continuity and consistency in the way that support is delivered in the home. DS0000066903.V349580.R01.S.doc Version 5.2 Page 21 DS0000066903.V349580.R01.S.doc Version 5.2 Page 22 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): 37,38,39,40,41&42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is appropriately qualified and experienced and the management and administration systems are good. This service is run in the best interest of the people who live in the home. EVIDENCE: The Registered Manager has worked for Modus Care for eight years. She has a National Vocational Qualification (NVQ) in Care at Level 2 and 4, Registered Managers Award NVQ Level 4, an NVQ Assessors Award and is currently working towards an NVQ Internal Verifiers Awards and NVQ level 5. She has also has obtained a degree in psychology and Diploma in the psychology of the challenging behaviour. The manager stated that she participates in all the DS0000066903.V349580.R01.S.doc Version 5.2 Page 23 company training courses such as manual handling and first aid and ensures she keeps up to date with current legislation. Quality assurance takes place both internally and externally. The manager, the staff team and the people who live in the home carry out internal monitoring. The Responsible Individual and the company’s compliance officer undertake external monitoring. Unannounced monthly visits to the home are made to monitor the homes’ performance and the information gathered from this process is then used to identify the homes shortfalls and ways in which the home can improve the service they provide. The information supplied in these reports is detailed, informative, open and transparent. Clear guidance is contained within these reports in respect of the shortfalls identified, any action that is required. On a six monthly basis quality assurance questionnaires are given to the people who live in the home, their parents and their care managers. This is to ensure a high quality of service and to provide feedback on any improvements that the home needs to make. Regular meetings are held with the staff team and the people who live at the home at house meetings. The manager monitor staffs’ understanding of the homes’ policies and procedures and ensures that they follow them at all times. Polices and procedures are regularly reviewed and accessible for all to read. All records within the home are held securely in line with data protection requirements, the people who live in the home or parents (when appropriate) may access records if they so desire. All the relevant maintenance tasks and checks are completed and kept up to date. The Legionella testing, fire alarm and emergency lighting systems are tested on a six monthly basis and the fire extinguishers and all electrical appliances are tested once a year. Within the home there is a system implemented for the Control Of Substances Hazardous to Health regulation. All relevant risk assessments, i.e. fire and environment are in place, all staff are aware of them and these are reviewed regularly kept up to date. The homes record keeping is of a high standard. The records examined were all up to date and accurate and many of them were comprehensive and detailed to that above the standards required. A range of documentation and certificates in relation to residents’ health and safety were examined and found to be in order. The temperature of the hot food that is prepared in home is routinely recorded as required. All staff receive training in respect of food handling and preparation. Visitors to the home are provided with information about the home in respect of health and safety. This document includes information relating to Risk of injury, some guidelines about things a visitor may need to be aware of and information the arrangements in place in case of risk fire. Visitors are asked to read and sign this document however it is not a disclaimer. DS0000066903.V349580.R01.S.doc Version 5.2 Page 24 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 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 X X 3 3 3 3 3 3 DS0000066903.V349580.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000066903.V349580.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000066903.V349580.R01.S.doc Version 5.2 Page 27 - 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!