Inspection on 16/02/07 for Champion House - Leonard Cheshire Disability

This inspection was carried out on 16th February 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Champion House - Leonard... 07/03/06

Champion House - Leonard... 06/10/05

Champion House - Leonard... 03/02/05

Champion House - Leonard... 27/07/04

Champion House - Leonard... 26/02/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOME ADULTS 18-65 Champion House Clara Drive Calverley Yorkshire LS28 5PQ Lead Inspector Dawn Navesey Key Unannounced Inspection 16th February 2007 09:00 Champion House DS0000001329.V325561.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 Champion House DS0000001329.V325561.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. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Champion House Address Clara Drive Calverley Yorkshire LS28 5PQ 01274 612459 01274 619221 mary.harrison@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Mary Louise Harrison Care Home 26 Category(ies) of Physical disability (26) registration, with number of places Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Champion House, a converted, extended stone built property, provides care for residents with physical disabilities. Care is provided on two floors in singly occupied rooms, some of which are very spacious. The third floor of the home is used as a training area for staff. Each resident has their own private room decorated to their own personal taste, and is provided with all necessary aids and adaptations to suit their individual requirements. Every room is fitted with a nurse call facility. It is situated in a rural area of Leeds. Entry to the home is down a long driveway, therefore providing privacy for the residents. It is close to both Bradford Town Centre, and Leeds City Centre. There are many shops, a Post Office and supermarkets close by, and a large retail park is only a short drive away. There are extensive gardens and a large car park. There are three lounge areas provided, one of which is dedicated to those residents who smoke. The home has a mini bus and a people carrier, which are used to take residents out on arranged visits, activities and shopping trips. Meals are taken in the large dining area, which also has as an activities area and a newly built kitchen that residents can access. The scale of charges at the home range from £563 to £963 per week. Additional charges are made for transport, hairdressing, newspapers, magazines, holidays, TV licences, reflexology, aromatherapy and horse riding. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector between 9-00am and 5-30pm carried out this unannounced inspection. The purpose of this key inspection was to make sure the home provided a good standard of care for the people living there. The methods used at this inspection included a tour of the home, looking at care records, observing working practices and talking to residents, visitors, volunteers and staff. Information gained from a pre inspection questionnaire and the home’s service history records were also used. Surveys were sent to residents, their relatives and visiting professionals to the home, asking for their views about the home. Three of these have been returned. This information has also been used in the preparation of this report. Feedback was given to the deputy home manager at the end of the day. The manager was not on duty on the day of the visit but did however call in to meet the inspector. Requirements and recommendations made during this visit can be found at the end of the report. Thank you to everyone for the pre-inspection information and for the hospitality and assistance on the day of the visit. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager has continued with her efforts on staff recruitment and reduced the amount of agency staff the home uses. The dining area has been re-furbished and re-decorated to a high standard. The residents now have a small, adapted kitchen they can use for making their own drinks and snacks. More volunteers have been recruited. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 7 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. Champion House DS0000001329.V325561.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 Champion House DS0000001329.V325561.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their carers can be sure that the home will meet their needs following assessment for admission. Written and verbal information available to prospective residents is comprehensive. EVIDENCE: The Statement Of Purpose and Service User Guide are kept on display in the entrance hall of the home where families and visitors can have access to them. These are documents that give information on the home and what services it can provide. Residents have a contract with the organisation. The contracts have the costs for the place at the home listed in them. Residents’ needs have been assessed to make sure the home could meet their needs. Residents’ assessments give a good summary of their current needs. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 10 Many of the residents said they had chosen the home themselves after visiting this one and others. One resident said, “I was made really welcome and given plenty of information.” Another said, “I couldn’t wish for a better home, it’s the best I have ever been in.” The organisation must apply for a variation in the conditions of registration at the home for residents who are over 65. Champion House DS0000001329.V325561.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments, in the main, provide clear detailed instruction on how residents’ needs are to be met. Residents are involved in the day to day running of the home. EVIDENCE: Residents care plans are kept in their own rooms, so they can access them. Some of the care plans have detailed and specific instructions for staff, for example, the personal support plans. However, some care plans need more detail. A resident who needs some support with behavioural and emotional needs does not have a care plan showing staff how to do this. Also a resident whose needs have changed recently has not had their care plan fully updated. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 12 The deputy home manager is aware of this and is planning to do it once a new assessment has been completed. The staff spoken to, have a good awareness of residents’ needs and can talk in detail about the support they give. Residents or their relatives have signed the care plans to show they are in agreement with them. One relative said she had been involved in drawing up the care plans and that staff had added to them when she had given them any new information about her son. A resident said she would not sign a care plan if she didn’t agree with it. Care plans are reviewed every three months or as needs change. Risk assessments have been completed for residents as part of the care planning process. These are up to date and reviewed. Some of the instructions for staff are, however, vague. An assessment regarding a risk of choking is not detailed enough. It does not give clear instruction on how to prevent the resident from choking. A resident who is at risk from epilepsy does not have a detailed management plan in place. The plan says to “ensure safety”. It does not tell staff how to do this. Despite these occasional gaps in the written documentation, staff are aware of what to do in both these events. When talking about the care plans, a resident said, “We are very well looked after.” There is some good person centred information within the care plans such as, life history work, a lifestyle assessment and a skills and interest assessment. This is good practice. Residents’ meetings are held on a monthly basis. Residents are asked if they are happy with the menus and the food in the home. Other topics for discussion are activities, forthcoming events, and holidays and staff recruitment. Many of the residents said they were involved in the meetings and said they have a residents’ committee. Residents make choices on a daily basis about what to do, what time to get up or go to bed and what to eat. Staff were seen to respect residents’ choices on activities and having a lie in on the day of the visit. Residents have requested that staff do not wear uniforms in the home. This has also been respected. The home has recently employed a member of staff to work as a communication support worker. This person will work mainly with residents who do not use speech, trying to find out how they best communicate their wishes. The deputy manager said this would also involve working with speech and language therapists who may already be involved with residents. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers opportunities to residents for their personal development in addition to a wide range of leisure activities. A good, healthy and varied diet is offered to residents. EVIDENCE: Residents are involved in various activities each week. This ranges from college courses, day centres, going to the pub, meals out, shopping and the theatre. There is also an activities co-ordinator who arranges activity such as pottery, painting, use of computers and flower arranging in the home. During the visit, one resident went out for a pub lunch and a group of residents went to see a show at the theatre. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 14 The home has a newly re-furbished kitchen for residents to use to make their own drinks and snacks and to practice their independence skills. This kitchen area is designed and adapted for use by people who use wheelchairs. The home also employs a volunteer co-ordinator who has recruited a large number of volunteers for the home. Volunteers provide companionship, support residents on activities or drive the home’s vehicles. They play a big part in the leisure and activity events. Residents and staff spoke very highly of the support they get from volunteers. A number of residents receive communion at the home from a visiting priest. Another resident goes to a local church and is supported to do this by volunteers from the church. The residents enjoy holidays from the home. Destinations planned for this coming year include Spain and Lanzarote. The organisation also runs a scheme where residents can do exchange visits with other Leonard Cheshire homes around the country. This gives residents an affordable way of going somewhere new and meeting new people. A resident said, “They are very good the holidays and exchanges, I have been all over.” Another resident spoke of a friendship he had made through going on the exchange holidays. Residents are encouraged to keep in contact with their family and friends. Relatives are made to feel very welcome at the home. A number of relatives visit the home at least two or three times a week. One relative stays at the home for up to a week at a time when visiting. A room has been made available for relatives who wish to stay overnight. All relatives said they feel welcome and involved at the home. Residents are also encouraged to be part of their local community. They use the shops, churches and pubs in the local area. Some residents said they wished they could get out more, especially to the local pub. One resident said they would like to get out more without having to wait for it to be organised, for example, to just go shopping when you feel like it. Some of the residents who have complex needs and do not use verbal communication did not at times seem to have much interaction or occupation. They seemed to rely on the television or music during the visit. It was not clear at times if this was fulfilling their needs. The deputy manager said part of the role of the new communication support worker would be to look at activity and interests of these residents and to try and introduce more activity for them. She said they would consider sensory type activity and look at getting them out and about more. Some of these residents receive PEG (tube feeding direct into the stomach) feeding which makes it difficult to leave the home during these times. The manager and deputy manager said they would look into portable PEG feeding systems or look at changing the times of the feeding to give the residents a more flexible lifestyle. A relative who returned Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 15 a survey said they felt that residents who have high support needs do not get as much attention as those who can speak or move about independently. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure residents are as independent as possible. One staff member said, “It is important for residents’ wellbeing to feel they have a goal or a challenge.” Another said, “It is important to give people choices on how they want to live and be attended to.” Staff interacted well with residents. The atmosphere in the home is relaxed and happy. Menus seem to be well balanced and nutritious. A good variety of food is available and there is a good selection of fresh produce. Food choices are made on the day from a pre-planned menu. Residents who need a blended diet are presented with meals that look attractive and appetising. The lunchtime meal was relaxed and made into a social occasion for residents. The meal was a choice of steak, chips and vegetables or chicken, chips and vegetables. The pudding was a choice of rice pudding or yoghurt. The main meal of the day is taken at lunch- time. However a resident who preferred his meal in the evening was given the choice to do this. Staff responded to any requests from residents, such as to fill the salt pot or to get them a different choice of meal. Residents who need support at mealtimes were given this discreetly. Staff sat down at the table with these individuals and gave them the time they needed. Residents spoke highly of the food and the choices available. The home’s chef attends the residents’ meeting in order to get comments on the food and to find out likes and dislikes in order to prepare the menu. Champion House DS0000001329.V325561.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 good. This judgement has been made using available evidence including a visit to this service. Personal and health care support is provided in a way that meets residents’ needs. Residents are, in the main, protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff support residents with their personal care needs in private and with dignity. Staff have good knowledge of their likes, dislikes and preferences. For example, what time residents like to get up or if they prefer a shower or bath. A visiting professional who returned a survey said, “The care in this home is very good and the staff are very caring and competent.” The care plans had details of any health professionals that residents see. These included, GP, dentist, specialist nurse, psychologist, optician and Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 17 chiropodist. The home employs its own physiotherapist and assistants. There is a large room in the home that is used for physiotherapy. Records are kept of any health appointments and their outcome. A visiting professional who returned a survey said, “Communication is good.” Staff usually stay with residents when they are admitted to hospital if this is the support they need. The manager said she always tries to arrange for this type of support, especially for residents who have complex needs and no verbal communication. Some residents have specialist health needs such as epilepsy, diabetes and depression. Health support plans are not in place for these needs. For example, there is no plan in place for a resident who has seizures or for a resident who is at risk from hypo or hyperglycaemia. Nursing and care staff are however, able to describe what to do in the event of either of these emergencies happening. The deputy home manager said she would make sure more detailed health support plans are put in place. Staff have received training in the health needs of the residents. This includes PEG feeding, wound care, epilepsy and diabetes. The home uses a monitored dosage pre-packed system for medicines. Nursing staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked. One resident’s MAR sheet showed a medication that did not have clear instructions for staff as to whether it was still to be given. On discussion with the deputy manager, she began to investigate this. Also handwritten entries on the MAR sheets had not been checked and countersigned. This could lead to errors in medication administration. The home uses controlled drugs and this is well managed. Champion House DS0000001329.V325561.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. Residents and their relatives have their views listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure displayed in the entrance to the home. Any complaints the home has received have been dealt with properly. The manager spoke of a recent complaint received from a resident and how she is dealing with it. The minutes of the residents’ meeting showed that residents are not afraid of speaking up and voicing their opinions on the home. All residents spoken to said they knew how to complain. One resident said, “Any little niggles are always dealt with.” Another resident described a complaint he had made and the action taken to resolve it. Staff have received training on the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse and the whistle-blowing procedure. The organisation has a detailed policy on the protection of vulnerable adults. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 19 The organisation is currently carrying out an investigation into a possible adult protection issue. The CSCI must be advised of the outcome of this. Records are kept of residents’ finances and their monies are kept safe. The home’s administrator deals with most of the transactions, receipts and record keeping. A float of petty cash is left with the nurse in charge of the home when the administrator is not on duty. This means that residents have access to their money at all times. The administrator and the manager check receipts and records regularly. Champion House DS0000001329.V325561.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, 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 environment in the home is clean, safe and hygienic. Staff’s practices control the spread of infection. EVIDENCE: A tour of the home was carried out, accompanied by a staff member. The home is spacious and well laid out, providing sufficient room for all residents. Residents’ bedrooms have been decorated and furnished to suit them as individuals. The styles of the rooms show their interests and personality. One resident said, “I love my room.” The home is clean, fresh smelling and warm throughout. Fixtures and fittings are of good quality. The dining area has recently been decorated and refurbished. And, as previously mentioned a small kitchen has been added to Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 21 the dining room area where residents can make their own drinks and snacks. There are three lounges; one of these is a smoking area for residents. The other lounge downstairs is a large room and would benefit from a larger television, especially for those who sit at the back of the room in their own specialist seating. The home has large, well-kept grounds which residents make good use of, especially in the summer months. There are a variety of bathrooms and toilets, which have specialist baths, showers and moving and handling equipment. This gives residents a good choice and makes sure all residents’ needs can be catered for. Clinical waste is properly managed and staff wear protective clothing when attending to residents’ personal care needs. Staff have received training in infection control and are able to say what infection control measures are in place. The laundry area is arranged to make sure there is no cross infection from dirty to clean linen. Liquid soap and paper towels are available at all sinks to make sure of good hand hygiene. Champion House DS0000001329.V325561.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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent to meet the needs of residents; they are well supported and supervised. Residents are protected by the home’s recruitment procedures. EVIDENCE: There are staff on duty throughout the day and night. There are usually four or five care staff and one nurse on the morning shift and four care staff and a nurse on the afternoon shifts. In addition to this the home has a chef or cook on duty, domestic and laundry staff and kitchen assistants. At night there are two care staff and one nurse on duty. The manager and deputy manager work flexibly according to the needs of the home. They also provide on-call support to the home. The home also employs a full time administrator, a fulltime housekeeper, a volunteer co-ordinator and a maintenance officer. Staff said they felt there is always enough staff on duty Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 23 and they never feel too rushed in their work. Relatives spoken to during the visit said there is always enough staff around except in occasional circumstances where staff sickness may reduce the numbers. Most residents said there are enough staff in the home if there is no sickness. A resident who returned a survey said, “The staff are often busy when I go to bed. Sometimes staff are short-staffed or busy and often both.” Most residents said they get on well with the staff. One resident said they found some staff lazy on occasions but would always tell them if this was the case. Another resident said there were more staff shortages at weekends than at other times. In a returned survey a resident said, “The staff are very willing.” Recruitment records were checked. Recruitment is, in the main, properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Interview records have not been kept for some staff; therefore it is unclear if an interview has taken place. Some staff have only a black and white photocopy of their photograph on file. This would not be suitable for identification purposes in most cases. The manager said she would make sure all interview records are kept on file in the future and arrange for photographs to be taken of staff. Residents are involved in the recruitment of staff. This is good practice. Staff’s training is up to date. Good records are kept of staff’s training and when their updates are due. The manager assesses this regularly to make sure training doesn’t get missed. The organisation has a training co-ordinator who provides a comprehensive training plan to the home. Training topics include; food hygiene, infection control, moving and handling, first aid, keyworking role, care planning and risk assessment. Some staff are learning British Sign Language in order to communicate better with a resident who uses this. Staff spoke highly of their training and the support they get from the manager. One staff member said their induction had been good and prepared them well for the job. Many staff said they had enjoyed the training on the residents support plans and had found it really useful in knowing how to then use the plans or make suggestions to them. Almost 60 of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. Other staff are currently working on this qualification too. All staff said they felt they have a good team and that the management team are very supportive. Staff said they felt communication and teamwork within the home is good and that they have regular meetings. Staff said they receive supervision every two months. Records confirmed this. Champion House DS0000001329.V325561.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager who is a Registered Nurse and has the Registered Managers Award. She works alongside staff to make sure of good practice as well as completing her management role and tasks. A deputy, who is also doing the Registered Managers Award, supports her. Residents spoke highly of the manager. One said, “She is a very good manager and has made a lot of improvements here.” Staff also said the manager has made Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 25 improvements such as reducing the numbers of agency staff used in the home and working hard on recruiting and keeping staff. The area manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to residents and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation carries out a service review, as part of its quality assurance programme. This also includes residents, relatives and staff. The home then has an action plan developed from this. The maintenance officer carries out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and checks on the house vehicles. Maintenance records are kept. Environmental risk assessments are completed where necessary. Water temperatures are checked regularly and shower heads and trays are bleached regularly. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. There is also a system in place where accidents are analysed to see if there are patterns, trends or ways of avoiding future accidents. The home has a comprehensive range of policies and procedures in place to make sure health and safety is maintained. Champion House DS0000001329.V325561.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 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 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 RQN Regulation Care Standards Act 2000 Section 15 15 Requirement Timescale for action 15/05/07 2 YA6 3 YA9 13 4 YA20 13 The organisation must apply for a variation to the conditions of registration for the residents who are over 65. The manager must make sure 30/04/07 that each resident has a clear and detailed care plan, which identifies all their needs and how they will be met in a person centred way. The manager must make sure 30/04/07 that all identified risks for residents have a detailed action plan in place to minimise the risk. The manager must make sure 15/03/07 that handwritten entries on the medication administration records are signed, checked and countersigned as correct. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA14 YA34 Good Practice Recommendations The manager should make sure that the leisure needs of residents who have complex needs are fully considered and addressed. The manager should make sure that interview records are kept and that staff have a recognisable photograph on file. Champion House DS0000001329.V325561.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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