Inspection on 09/05/07 for Chapel Hill Hostel

This inspection was carried out on 9th May 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chapel Hill Hostel 05/12/05

Chapel Hill Hostel 31/05/05

Chapel Hill Hostel 09/11/04

Chapel Hill Hostel 18/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Chapel Hill Hostel 44 - 55 Chapel Hill Crayford Kent DA1 4BY Lead Inspector Maria Kinson Unannounced Inspection 9th May 2007 10:45 Chapel Hill Hostel DS0000006812.V334915.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 Chapel Hill Hostel DS0000006812.V334915.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. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chapel Hill Hostel Address 44 - 55 Chapel Hill Crayford Kent DA1 4BY 01322 553 201 01322 527 786 chapelhill@together-uk.org www.together-uk.org Together Working for Wellbeing 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) Mrs Diane Flower Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 4 places for people aged 65 years and over. Date of last inspection 5th December 2005 Brief Description of the Service: Chapel Hill Hostel is owned by Bexley Council, which leases the property to Together Working for Wellbeing. The service is registered to provide rehabilitation and support for 23 people with a mental disorder. The home consists of the following: a three-bedroom flat for independent living; a one-bedroom bed-sit; a eight-bedroom house (House B); a sevenbedroom house (House C); and a four bedroom unit Hill Top View for people requiring respite or in crisis. All bedrooms are single occupancy and four rooms have en suite facilities. The property is within walking distance of shops and public transport services and there is limited off-road parking. The Primary Care Trust funds some of the people living in the home. The fees charged by the home range from £502 - £750 per week. This does not include additional charges such as newspapers, magazines, toiletries, activities, hairdressing and personal clothing. This information was supplied to the commission on 26.04.07. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 9th and 11th May 2007 and was unannounced. The inspector examined a variety of records, observed staff interactions, undertook a partial tour of the home and spoke with seven service users and three members of staff. The commission obtained written feedback about the service from nine people that lived in the home, three relatives and one health care professional. Since the last inspection the home had reduced the number of registered beds from 24 to 23 and had varied its registration to include up to four people over the age of 65 years of age. What the service does well: This home meets or exceeds all but one of the National Minimum Standards for Young Adults. The arrangements for admitting new people into the home were satisfactory. People were encouraged to visit and spend time in the home prior to making a decision to move in. Adequate information was obtained about peoples needs and staff developed an individual support plan to help the person become more independent and meet their personal goals. Staff planned how they would minimise potential risks before and after the person was admitted to the home. Feedback from the people using the service, other professionals and relatives was mostly good. One relative said that her family member felt “safe” in the home and always received “encouragement and support from staff”. The people living in the home said staff were “kind”, usually listened to what they had to say and acted on the information if necessary. The food provided in the home was good and all of the people spoken with on the day of the inspection said they enjoyed it. The management of medication was good. Accurate records were maintained for medication received and administered in the home. The home provides a flexible self- medication programme that enabled people to take on more responsibility for managing their medication as they became more confident. The people living in the home were encouraged to register with a local GP and were supported to attend appointments if necessary. People were supported to attend local colleges, specialist services for people with mental ill health and to take part in social activities in the home and community. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 6 The people living in the home received support from staff that were familiar with their needs and preferences. Although there were some basic “rules” about respecting other peoples privacy people said they were able to choose how and where they spent their time and make decisions for themselves. Staff encouraged people to contribute to the running of the home by helping to keep the communal areas clean and tidy, assisting with shopping and undertaking other tasks in and around the home. The building was maintained to a satisfactory standard. All areas were comfortable and tidy. Fire safety equipment was serviced regularly and health and safety issues were addressed promptly. The provision of training for staff was excellent. The manager could access a variety of different training courses to meet individual needs and requirements. There were good systems in place to support junior staff and all staff received regular supervision. The manager had a good awareness of national and local issues that affected the service and took action where necessary to make staff and service users aware of changes and developments. The people living in the home knew who to speak to if they had any concerns. Complaints were recorded and were addressed promptly by the manager or area manager. There were good systems in place to monitor the quality of care provided and to obtain feedback from the people using the service. What has improved since the last inspection? What they could do better: Compliance with the National Minimum Standards and Care Homes Regulations was good. One requirement was set as a result of this inspection. Some relatives felt that they were not kept informed about their family members progress. It was not clear whether this was the service users choice or if staff thought the person would undertake this task themselves. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 7 The times of fire drills should be varied. This will help the manager to assess how all staff, including the night staff would respond if there were a fire in the home. All staff should attend fire safety training updates at regular intervals. Although recruitment practices were mostly satisfactory it was not clear from the records if proof of identification was obtained and if staff had checked that the references were genuine. 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. Chapel Hill Hostel DS0000006812.V334915.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 Chapel Hill Hostel DS0000006812.V334915.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 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People received information about the service and were given an opportunity to spend time in the home prior to making a decision to move in. EVIDENCE: The homes Statement of Purpose provides information about the aims and objectives of the service and the facilities. The Statement of Purpose had been updated since the last inspection to provide additional information about the crisis and respite unit and staff changes. The needs of many of the people referred to the home were presented and discussed at joint assessment panel meetings. A senior member of staff from the home attended these meetings. The meetings provided additional information for staff about prospective service users background and support needs. Staff also obtained a copy of the service users assessment, care plan and risk assessment before inviting the person to visit the home and confirming in writing that they would be able to meet their needs. Most of the people living in the home said they received adequate information about the service before they moved in. People that were considering moving Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 10 into the home were encouraged to view the facilities to meet some of the staff and the other people living in the home. Chapel Hill Hostel DS0000006812.V334915.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. Staff worked in partnership with the people living in the home to develop individual support plans that reflected their personal goals and chosen lifestyle. People were supported to make decisions and choices for themselves and to contribute to the running of the home. EVIDENCE: New people were asked to complete a self- assessment form. The form outlined the support that they felt they required and any issues that were important to them. The form also provided information about the signs that staff would notice if they were becoming unwell and who they wanted staff to consult if they were not able to make decisions for themselves. The key worker provided support to complete this paperwork if necessary. Although the people living in the home had a care programme support plan staff developed a more detailed plan with the service user. The plans seen included small achievable goals that would help the person to work towards their Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 12 ultimate goal. For many of the people living in the home their ultimate goal was to live independently in the community. Staff completed a monthly summary sheet which listed significant events and issues such as appointments, medication changes and changes to the support plan. Less information was obtained for people that spent short periods in the home for respite. A copy of the service users assessment was obtained and the person was asked to provide information about their needs and how they liked to spend their time. This information was then discussed with the service user or their carer on subsequent admissions and any changes or new information added. Because most of the people living in the home were there to learn new skills and to become more independent there was an expectation that they would establish a regular pattern of activities. Staff allowed time for people to settle in and supported them to take on new challenges and activities when they felt ready. The people living in the home said they were always or usually able to make decisions about what they did during the day, evening and of a weekend. There were regular meetings in each of the houses to discuss issues and concerns. Since the last inspection one of the people living in the home had agreed to take the minutes and another person had agreed to chair the meeting. In this house the meetings were arranged and led by the people living in the home. The people living in the home helped staff to keep the communal areas clean and tidy. A rota had been developed in each house to identify who was responsible for specific tasks such as cleaning the bathroom, hovering and dusting the lounge. Some people assisted staff to purchase the food shopping and to prepare and serve meals. The registered company works hard to ensure that the organisation is representative of the group of people it serves. The company has a director, business manager and several administration staff that are service users. Training is made available to the people living in the home if they wish to become involved in staff recruitment and service users are encouraged to attend company meetings and events. Information about potential risks was obtained before the person moved into the home and a risk assessment checklist was completed by staff on admission. Staff developed strategies to reduce the risk of harm where possible but did not impose unnecessary restrictions that could affect people’s quality of life or independence. Staff must ensure that risk assessments are signed and dated. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 13 Staff responded appropriately when people did not return to the home as expected or went missing. A door alarm had been fitted in one of the houses to alert the night staff about people leaving the home. Chapel Hill Hostel DS0000006812.V334915.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): 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. The people living in the home were supported to learn new skills and to work towards achieving greater independence. The choice and quality of food provided in the home was good. EVIDENCE: The people living in the home were supported to establish a regular routine based on their personal interests and goals. For some of the people living in the home this included undertaking studies leading to formal qualifications at a local college, learning new skills that might help them to find paid work, attending classes to improve their daily living skills or to help them relax or manage stress and work experience such as secretarial duties, house clearance and decorating. During their free time people said they liked to visit their family, go shopping, study, watch television and relax. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 15 People were supported if necessary to do their own laundry, keep their room clean and tidy and to assist staff to keep the communal areas clean. Some of the people living in the home did their own shopping and cooking. Staff supported service users to pursue personal interests and hobbies and to become more independent over time. One person was completing a cycling proficiency course and was provided with advice and support from staff to purchase a suitable cycling helmet, another person was supported to plan a long journey to visit relatives and one person was now responsible for maintaining part of the garden. People were given a key for the front door and their bedroom. Staff only entered people’s bedrooms with their permission or if they had concerns about their welfare. Group activities were arranged during house meetings. In recent months some of the people living in the home had attended social events such as a video / DVD night, bingo, local walks, karaoke, garden games and watching large sporting events. People said they were able to maintain contact with their friends and family if they wished. One relative said she spoke to her family member on their mobile phone regularly and when this was not working she used the payphone. Some relatives visited the home and some of the people living in the home spent weekends with their family. Two relatives indicated that they were not always kept up to date with important issues affecting their relative. As most of the people living in the home were able to make decisions for themselves it was difficult to establish if this was because the person did not want or felt it was not necessary for staff to share information with their relatives. See recommendation 1. Some relatives said they attended review meetings if their family member wanted them to be present. The cook used feedback about previous dishes and suggestions from the people living in the home to develop new menus. Some of the people living in the home were ‘self-catering’ and were responsible for purchasing and cooking all of their own food. The remaining people chose their own breakfast and lunch and were supported by staff to prepare some of their own food. The cook prepared a hot meal four days a week and staff were responsible for cooking on the other days. The two menus seen included a variety of different foods and a list of alternative dishes such as salad or an omelette that could be prepared on request. All of the people spoken with confirmed that they were able to request alternative dishes if they did not like the food listed on the menu and said the food provided was “excellent”, “good”, “lovely”, “fantastic”. Chapel Hill Hostel DS0000006812.V334915.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. Staff worked in partnership with other professionals to promote people’s health, safety and wellbeing. EVIDENCE: Most of the people living in the home did not require support with personal hygiene or mobility. If assistance was required with personal care the service was arranged through a local domiciliary care agency. All of the people spoken with said they had a designated key worker that they had regular contact with. Staff had established good working relationships with other health and social care professionals. One health care professional said that staff were “very professional”, always communicated effectively and usually had the right skills and experience to meet people’s needs. The respondent said that the home was particularly good at providing a “relaxed, pleasant environment”, supporting people to manage their finances, medication and work and encouraged people to take things at “a steady pace forward”. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 17 The home had recently changed to a new pharmacy supplier. Training was provided about the new system and paperwork but the local medication procedure still referred to the previous supplier. Two medication records were checked to ensure that staff had recorded the amount of medication received in the home, administered to service users and sent for disposal. Good records were maintained. The medication record for one person that was managing his or her own medication was examined. There was written agreement from the person stating that they would store their medication securely and confirming that they were aware that staff might check if they were taking their medication properly. The assessment was reviewed by staff regularly and was signed by the service user. Since the last inspection the home had notified the commission about one medication error. As a result of this incident the deputy manager had introduced some new paperwork to remind staff about peoples regular medication and to alert staff to medication changes. Chapel Hill Hostel DS0000006812.V334915.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. The home had good systems in place to respond to concerns, complaints and allegations of abuse. EVIDENCE: The home had received two complaints since the last inspection. One complaint was about room sizes and one was about communication. One of the complainants had also raised some additional concerns when responding to other correspondence. Both complaints were responded to in a timely manner. Most people were familiar with the homes complaints procedure and said they would approach their key worker, the manager or deputy manager if they had any concerns. Relatives were less confident about the procedure that they should follow if they wanted to make a formal complaint but said “staff were always there to speak to” and usually responded appropriately if they raised concerns. The home had good systems in place for safeguarding people’s personal money and valuables. Individual records were maintained about money held for the people living in the home and for any money or items returned to them. Two signatures were obtained for all transactions. The manager or deputy manager carried out regular checks to ensure that staff were following the correct procedure and to see if balance of money held in the home was correct. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 19 The people living in the home were encouraged to manage their own finances where possible. Twelve people were doing this at the time of this inspection. The home follows the local authority safeguarding adult’s multi agency procedure. This procedure was reviewed and updated in 2007. Since the last inspection the manager and deputy had attended safeguarding adults training for managers and most of the other staff had attended a training session led by the local authority adult protection coordinator. Staff had a good understanding of abuse and knew what they should do if they witnessed or were made aware of an allegation of abuse. Chapel Hill Hostel DS0000006812.V334915.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building was maintained to a satisfactory standard and work to improve the facilities and the amount of space provided the people living in the home was under consideration. EVIDENCE: The home was maintained to a satisfactory standard but some parts of the building particularly some of the bathrooms and toilets looked a little dated. One relative raised concerns about the amount of personal space provided for his relative, the quality of some of the furnishings and the lack of en suite facilities. Discussions were taking place with the owner of the site about possible changes to the building to provide more space and better facilities for the people living in the home. Since the last inspection some of the communal areas had been redecorated and laminate flooring had been fitted in some of the lounges. Staff had added Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 21 additional items such as prints and soft furnishings to make the rooms look homely. Most people said their rooms were comfortable but one person said they found their room rather small. The home was clean and tidy overall but some of the units in the bathrooms were dusty in parts. A new cleaner had recently been appointed and recruitment checks were in progress. This should resolve this issue. Some of the people living in the home showed the inspector the cleaning schedules and confirmed that they usually found the home to be fresh and clean. Hand washing facilities were good and most staff had completed infection control training. The home was awarded a silver clean food award by the local environmental health department in 2006. Refrigerator and freezer temperatures were monitored regularly. Staff were advised that the refrigerator in house C required adjusting or defrosting to lower the temperature slightly. Chapel Hill Hostel DS0000006812.V334915.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, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff team were supported to attain the necessary skills and knowledge to meet people’s needs. Recruitment procedures were mostly satisfactory but some of the required documentation could not be located in staff files. This information will provide additional safeguards for the people using the service. EVIDENCE: The inspector examined the staffing roster. The roster indicated that there were at least three care staff on duty throughout the day and one carer and a sleep in carer during the night. The manager works Monday to Friday and there was an on call manager available for advice outside office hours. The home had experienced some staffing difficulties in 2006 due to staff sickness and absence. During this period four staff resigned. Despite these challenges the home had not used any agency staff. This was achieved by the permanent staff undertaking additional shifts and by using regular bank staff that were familiar with the home. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 23 Eighty percent of care staff had attained a vocational qualification at level two or above and one support worker had just enrolled on this programme. This exceeds the standard set by the Department of Health. Three staff recruitment files were assessed. All of the files included an enhanced criminal record bureau disclosure and two written references but there was no proof of identification. One of the files did not include a recent photograph of the employee and it was not clear if one reference that was not on headed paper had been verified. See requirement 1. Applicants were asked the same questions at interview and were scored according to their responses. New members of staff worked alongside an experienced member of staff for the first two weeks. During this period the employee was not included in the staffing number and had an opportunity to observe staff, read policies and procedures and get to know the people living in the home. New staff were not expected to undertake complex tasks such as administration of medication and key working until they had completed any relevant training and felt they had adequate knowledge and understanding about their role. Individual training files were maintained for each member of staff and training needs were identified during supervision and appraisal meetings. Staff could access training from a number of sources. The company provides induction training to nationally recognised standards and a range of relevant courses for support staff and managers. The manager had a training budget and could arrange external training courses to meet staff needs where necessary. In addition to this staff could attend training arranged by the local Mental Health Trust or local authority and were encouraged to undertake government funded distance learning training packages. Since the last inspection some staff had attended managing stress, safeguarding adults, food hygiene, health and safety, fire safety, dual diagnosis, wellbeing and mental health and medication training sessions. Staff were satisfied with the range and quality of training provided. Staff had access to individual supervision sessions each month and could also attend weekly group supervision sessions if they wished. Staff said that they were encouraged to discuss concerns and practice issues and could request more supervision if they needed it. The arrangements for supporting staff exceed the national minimum standards. Chapel Hill Hostel DS0000006812.V334915.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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service is well managed. The home provides a stable environment where people are listened to, they feel safe and their views are respected. EVIDENCE: The manager was appointed in 2003 and was assessed and registered by the commission in June 2004. The managers holds an NVQ 5 in operational management, the registered managers award, an NVQ 4 in management, an NVQ 3 in promoting independence and an NVQ 3 in community mental health care. She is also a NVQ assessor, verifier and external moderator. The manager was able to provide evidence of ongoing professional training and development. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 25 The management arrangements were stable. Staff were satisfied with the support that they received from the management team and said they had an “open door policy” and were “approachable and helpful.” The people living in the home said that the manager or deputy manager were “excellent” and were “always around” if they had any concerns. One person said he thought the home was very well run. During the course of the inspection a person that had moved out of the home the previous day returned to the home to speak with the manager. It was apparent from the conversation that the person trusted the manager and did not want to lose contact with staff and his friends in the home. The home had good systems in place for monitoring the quality of care provided in the home. This included a monthly quality report covering different topics. Staff had to complete a report about how the home was meeting various standards. The information recorded by staff was checked and verified by the area manager. If the home did not meet the required standard an action plan was developed and a timescale for addressing the issue was set. The area manager carried out regular unannounced visits to monitor the conduct of the home and to obtain feedback about the service from the people living and working in the home. Each year there was an annual review of the service. During the review questionnaires were sent to the people living in the home, their relatives, staff and other health care professionals that were in regular contact with the home. The area manager then met the people living in the home and staff to discuss the results from the surveys. In previous years a report was prepared about the findings from the review to advise the reader about any action the manager and staff were taking to address the issues raised. A report was not completed in 2006. This made it difficult to establish how the information obtained during the review was used. The manager had identified that that it was difficult to obtain feedback from people that stayed in the respite unit as they were only in the home for a short period and were often reluctant to return to the home once they had left. The deputy manager and a person that used the service were looking at ways of addressing this issue. There was an up to date fire risk assessment and the fire alarm system and fire safety equipment was serviced at regular intervals. The fire alarm was tested once a week and fire drills were taking place regularly. The times of drills should be varied to ensure that staff that work night duty shifts are included. Staff attended fire safety training during induction and the training department provides a fire safety training update every three years. The manager should ensure that all staff attend these sessions. See recommendation 2. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 26 Health and safety records for the portable electrical items and gas appliances were examined. All of the records seen were well maintained and up to date. Window restrictors were not checked regularly but the manager agreed to add this to the room checks that staff complete. Staff carried an alarm, which was used to request help from staff in other parts of the building. The alarm was tested each week to ensure that it was working properly. The manager had held a meeting to discuss the new smoking legislation with the people living in the home and staff. It was apparent during discussions with the people living in the home that they were well informed about the reasons for the changes and knew what changes were planned. Appropriate signs had been purchased and extractor fans had been fitted in the designated smoking room. The manager and deputy manager had applied to attend training to support people that wanted to give up smoking. Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 27 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 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 3 X 4 X 3 X X 3 X Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 28 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 YA34 Regulation 19 Requirement The Registered Person must ensure that all of the documents listed in paragraph 1 to 9 of Schedule 2 are obtained prior to allowing new staff to commence work in the home. Timescale for action 02/07/07 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 YA15 Good Practice Recommendations The Registered Manager should establish and record on admission to the home what information, if any service users want staff to share with their relatives. If service users are happy for staff to provide regular updates for relatives a system for doing this should be developed. The Registered Person should ensure that staff attend regular fire safety training updates and that the times of fire drills are varied to include the night staff. 2. YA42 Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Chapel Hill Hostel DS0000006812.V334915.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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