Inspection on 07/10/08 for Charles Davies House

This inspection was carried out on 7th October 2008.

CSCI found this care home to be providing an Excellent service.

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

Charles Davies House 13/12/06

Charles Davies House 09/01/06

Charles Davies House 05/07/05

Charles Davies House 17/02/05

Charles Davies House 25/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Charles Davies House 388 Lodge Road Hockley Birmingham West Midlands B18 5PW     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Brenda ONeill     Date: 0 7 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Charles Davies House 388 Lodge Road Hockley Birmingham West Midlands B18 5PW 01215238880 F/P01215238880 cherylyardley@mind-birmingham.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Cheryl Marie Yardley Type of registration: Number of places registered: Mind in Birmingham care home 13 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 13 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD) 13 Date of last inspection Brief description of the care home Charles Davies house consists of three units that can accommodate up to 13 younger adults with enduring mental health issues. Focus Housing Association owns the building and MIND in Birmingham provides the care and support. The home is located within a residential area of Birminghams inner city, approximately two miles from the city centre. The home is close to shops, bus services, a post office and a medical centre. Two of the houses provide single rooms and a communal lounge and dining area for up Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 13 Brief description of the care home to nine people. The other unit consists of four bed-sits, including a kitchenette and bathroom. The aim of Charles Davies House is to provide support and training to the the people living in the home in order that they can progress onto either independent living or supported living. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was carried out by one inspector over one day in October 2008. During the course of the inspection the support offered to two of the people living in the home was tracked which included sampling their personal files and medication records and speaking to them. Other documentation that was sampled included staff training records, staff rotas and health and safety records. A tour of the communal areas of the home was undertaken and we were shown one bedroom and one of the bed sits by the people living in the home. We spoke with five of the people living in the home, the manager and one staff member. The home had their last key inspection on December 13th 2006. In December 2007 an annual service review (ASR) was undertaken. This involves all the information received Care Homes for Adults (18-65 years) Page 6 of 31 since the last key inspection and information requested from the manager at the time being reviewed. The people living in the home were also sent satisfaction surveys to complete. After reviewing this evidence the home was judged as continuing to provide a good service. Prior to this key inspection the manager of the home had completed and returned an annual quality assurance assessment (AQAA) which provided some additional information about the home. Satisfaction surveys were sent out to the people living in the home and all of these were returned and were generally positive. No complaints or adult protection issues had been lodged with us since the last key inspection. Three relatively minor complaints had been logged at the home. All the complaints had been raised by the people living in the home. One was in relation to the excessive noise being made by people outside the home and two were in relation to disagreements between two of the people living in the home. A record had been made showing how the issues had been resolved to the complainants satisfaction. What the care home does well: The home has consistently demonstrated that it offers a very good service to the people living there. The assessment procedure showed that an extensive assessment of peoples needs was undertaken prior to admission and that they were fully involved in the process. The completed surveys returned to us indicated that people were able to visit the home prior to admission. One person stated I came and look around first. I did like it so I came and lived here. The people living in the home were fully involved in drawing up their care plans and they were written from their perspective. They made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. Numerous risk assessments had been undertaken for the people living in the home with corresponding management plans in place where necessary. The emphasis at the home was on supporting and encouraging the people living there to maintain and develop their skills to enable them to move to more independent living. Clearly people were at various stages in this process and no pressure was put on people to hurry this process. The personal and health care needs of the people living in the home were being met and they were supported and encouraged to take responsibility for these areas of their lives. Very good relationships between the staff and the people living in the home were evident throughout the course of the inspection. They spoke to us about staff being very helpful and always there to remind them of things. One of the completed surveys commented All the staff who I have worked with or who have taken care of me have been wonderful. I think that they all do an absolutely fantastic job between them looking after us. Individuals were comfortable approaching and speaking to staff which would give them the confidence to raise any issues. Comments received from the people living in the home included: The carers are always willing to listen to what I have to say. Staff who are always caring and have an ear and try and listen. Staff had undertaken a range of training to ensure they could support the people living in the home appropriately. The home offered the people living there a safe, generally well maintained and comfortable environment in which to live. The health and safety of the people living in the home and the staff were well managed. The home was very well managed and run in the best interests of the people living there. Care Homes for Adults (18-65 years) Page 8 of 31 What has improved since the last inspection? What they could do better: No requirements were made following this inspection however there were some recommendations. It was recommended that staff undertake refresher training for adult protection issues. This will ensure they have all the current information required to enable them to recognise and report any issues. The grouting in the shower room should be renewed. This will ensure good hygiene is maintained. The furniture in the smoking lounge is showing signs of wear and tear and should be replaced. This will ensure standards are kept to an acceptable standard for the people living in the home. All opened foods that are stored in the fridges should be dated on opening. The drawer fronts on the kitchen units that were wearing should be replaced. This will ensure good food hygiene can be maintained in the kitchen. Care Homes for Adults (18-65 years) Page 9 of 31 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wanting to move into the home were fully involved in the pre admission assessment process that ensured their needs could be met by the home. Evidence: There was a service user guide for the home which was issued to the people moving into the home. This included details of the fees charged at the home. No new people had been admitted to the home since the last key inspection. However at the time of the that inspection the assessment procedure showed that an extensive assessment of peoples needs was undertaken prior to admission and that they were fully involved in the process. A new referral had been made to the home and the manager was in the process of arranging for an assessment to be undertaken. During the course of this inspection she was heard discussing the assessment process with a family member and giving the option of the individual concerned either going to the home or staff visiting him in his own home. The completed surveys returned to us indicated that people were able to visit the home prior to admission. One person Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: stated I came and look around first. I did like it so I came and lived here. Care Homes for Adults (18-65 years) Page 13 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were fully involved in drawing up their care plans and risk assessments. They made decisions about their lives on an ongoing basis and were aware of the risks involved. Evidence: The care plans for the people living in the home were entitled Essential Lifestyle Plans (ELPS). The format for these had been changed since the last inspection. Two were sampled and were found to be very comprehensive. It was clear when looking at the ELPs that the people living in the home were fully involved in drawing them up and they were written from their perspective. The ELPs included quite detailed information on what was important and essential to the individuals, their likes, dislikes and preferences, daily routines and what others needed to know to support them. Included in the information was what the individuals wanted to achieve in the future. An action plan was then drawn up with them for the next six months detailing what their aims were and how staff were to support them to achieve the action points. Progress on the Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: action plans was monitored in monthly evaluations undertaken by key workers with the people living in the home. These had improved since the last inspection and it could be seen from these what people had achieved during that month and any significant events that had taken place. The evaluations also included a review of areas such as mental health, physical health, interpersonal skills and domestic skills. Staff recorded their comments during the evaluations and then the people living in the home were asked to record their own comments on the documents. There was also evidence that full care reviews were being held every six months. This meant there were in depth discussions with the people living in the home about all areas of their lives in the home, progress made towards their goals and what else they wanted to achieve. Social workers were present at these reviews where applicable. The two files sampled included numerous risk assessments and management plans for any identified risks. These detailed included returning late to the home, self harm, exploitation, aggression and violence and every day issues such as the risk of fire due to smoking in bedrooms. Where applicable the triggers and early warning signs were detailed with the actions to be taken by staff. Both files included very detailed relapse management plans in respect of the individuals mental health. All the risk assessments had been drawn up with the full involvement of the people living in the home and were signed by them. The people living in the home made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. They were fully involved in drawing up their ELPs and deciding what they wanted to do and how staff would need to support them. They were fully involved and aware of the risk assessments in place for them for their protection. They made decisions on a daily basis, within the bounds of any risk assessments that were in place, about what and when they ate,when to clean their rooms and do their laundry, how they spent their leisure time, whether they wrote their daily records and so on. Care Homes for Adults (18-65 years) Page 15 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were supported to have an independent lifestyle which the home encouraged and supported them to achieve without undue pressure. Their rights and responsibilities were recognised in their every days lives. Evidence: The emphasis at the home was on supporting and encouraging the people living there to maintain and develop their skills to enable them to move to more independent living. Clearly people were at various stages in this process and no pressure was put on people to hurry this process. The people living in the home at the time of the inspection lived very different lifestyles, for example, some were out and about all the time and enjoyed socialising when in the home, others went out less and did not really enjoy socialising too much. Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: The people living in the home spoke to us about keeping their own rooms clean and tidy, doing their own laundry and cooking for themselves. They also told us there were always staff around to support them when necessary. Records seen indicated that people attended a variety of colleges, training centres and day centres. People spoke to us about doing training courses in topics such as IT, maths, English, cooking and assertiveness. One person was taking a retail course as he was hoping to work in retail. The people living in the home could also take part in some of the training that staff undertook if they wished. Some of them were involved in the recruitment and selection of staff and had undertaken training for this. They also went to other homes within the organisation to help with staff recruitment. The people living in the home used many of the local facilities including health care facilities, post offices, shops and pubs. The majority of them were able to use public transport independently. Staff escorted people when necessary depending on the distance they were travelling or if it was a new venue. Some of the people living in the home made regular visits to their families, friends and partners in the local community. Staff encouraged people to maintain links with their families where this was what they wanted. Evidence was seen of staff helping one of the people living in the home trace a family member they had not seen for a long time. Some of the people living in the home had taken an annual holiday in Torquay and told us how much they enjoyed this and what a nice hotel they stayed in. Others preferred day trips and this was arranged either by them or with the help of staff. The rights and responsibilities of the people living in the home were recognised on a daily basis. Those spoken with confirmed they had keys to their bedrooms and the front door and that staff did not enter their rooms without their permission.They had been informed about their responsibilities in relation to the security of the home at a meeting with them. The people living in the home spoke to us about taking responsibility for cleaning their own rooms and doing their own laundry but if they needed help from staff they asked and it was given. All the people living in the home managed their own money but again systems were in place to help with budgeting where necessary. At the time of the inspection six of the people living in the home were fully self catering. They were given a budget to enable them to do this and did their own shopping. They drew up their own menus with support from staff where necessary to encourage healthy eating and discourage too many take away meals. The menus seen were varied, included fresh vegetables and indicated people were having culturally appropriate foods. One of the people living in the home who was self catering spoke of how staff continued to support him by reminding him to do his vegetables and so on at the appropriate times. The other people living in the home drew up a weekly menu Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: between them and helped staff with shopping, food preparation and cooking depending on their abilities. As people progressed in this area they would cook one or two meals until they were confident enough to fully self cater. All the people living in the home ate together at weekends. At these times they did the cooking between them with staff support. If the people who were self catering did not want to join in with this it was not an issue and they could cook their own food. Care Homes for Adults (18-65 years) Page 18 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and health care needs of the people living in the home were being met and they were supported and encouraged to take responsibility for these areas of their lives. Evidence: As at the last inspection none of the people living in the home required direct assistance with personal care needs. It was mainly prompting by staff to ensure their personal hygiene was to an acceptable standard. Medical appointments were generally made by the people living in the home and they attended on their own in most instances. One of the people living in the home spoke about having an operation recently to help with his mobility and of his attendance at follow up appointments. The majority of the people living in the home were able to attend clinics for such things as blood tests on their own. All the people spoken with confirmed that they were registered with a local G.P. Although there were not always specific records of appointments attended on the sheets specifically for this purpose these were all recorded in the daily records and on the monthly evaluation sheets. Any Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: health care issues that had been identified during the month were also recorded during the monthly evaluations with indications of any progress or monitoring needed. One of the people living in the home spoke to us of attending a stop smoking clinic and how much better he felt since stopping smoking. The manager indicated that the teams of mental health workers involved with the people living in the home had changed. After the change the manager did have some concerns because of different ways of working. These had been resolved at the time of the inspection and the manager was finding the workers supportive and responsive. The system for medication administration was very well managed. The people living in the home were asked to go the office and ask for their medication at the appropriate times to encourage them to take some responsibility for their medication. They were all working towards being able to self administer their own medication. Medication was delivered to the home in weekly nomad packs. All medication was acknowledged when received and copies of prescriptions were available to cross reference to. The people living in the home asked for their medication from staff, the nomad was given to them they then took the medication due at that time whilst being supervised by staff. Individuals then signed their own MAR (medication administration sheets) charts and staff then also signed to indicate the medication had been taken. There were some boxed medicines in the home, some of these were audited and all balances were correct. There were protocols in place for the administration of PRN (as and when necessary) medication for staff to follow. No controlled medication was being administered in the home at the time of the inspection. The minor issues raised at the last inspection had been addressed. Care Homes for Adults (18-65 years) Page 20 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were confident that any issues they raised would be addressed. The people living in the home were safe guarded by the policies and procedures in the home and the training staff had received. Evidence: The people living in the home received a copy of the complaints procedure in the service users guide. The surveys returned to us before the inspection indicated that the people living in the home knew how to make a complaint and staff listened to what they said. The individuals spoken with said they would go to staff if they had any issues they needed to raise. Throughout the inspection it was evident there were good relationships between the people living in the home and the staff. Individuals were comfortable approaching and speaking to staff which would give them the confidence to raise any issues. Comments received from the people living in the home included: The carers are always willing to listen to what I have to say. Staff who are always caring and have an ear and try and listen. No complaints had been lodged with us since the last inspection. Three relatively minor complaints had been logged at the home. All the complaints had been raised by the people living in the home. One was in relation to the excessive noise being made by people outside the home and two were in relation to disagreements between two of the people living in the home. A record had been made about how the issues had been resolved to the complainants satisfaction. The completed surveys indicated that, with the exception of one, the Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: people living in the home knew how to make a complaint. It is known from previous inspections that the home have appropriate policies and procedures on site for adult protection. The training matrix for the home indicated that all staff had received training in protection from abuse however this had taken place a considerable time ago. It was strongly recommended that the staff had some refresher training in this topic. No adult protection issues had been raised with us about the home since the last inspection. Care Homes for Adults (18-65 years) Page 22 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained, safe and comfortable and offered the people living there a good standard of accommodation. Evidence: During the course of the inspection the communal areas of the home were toured, one bed sit and two bedrooms, one of which was vacant, were also seen. The AQAA received prior to the inspection indicated that there had been some improvements to the home since the last inspection including new beds, improvements to the gardens and decoration to some bed rooms, bed-sits and hallway. The occupied bedroom and bed sit that were seen were adequately furnished and decorated. The bed sit consisted of a combined sleeping and sitting room, bathroom and kitchen. The person occupying the bedsit was very happy with the accommodation and stated I love it. He was very happy that he did not have any stairs to negotiate due to a mobility difficulty. The bed sits enabled people to be very independent but to have staff support when needed and the company of other people if they wished. The person occupying the bedroom that was seen was also very satisfied with her room and had clearly personalised it to her choosing. All the people living in the home had Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: keys to their rooms. The two units that housed the single bedrooms had a lounge, dining room and a kitchen. One of the lounges was designated smoking area. The furniture in this room was beginning to wear and in need of replacing. The manager was aware of this and was to replace when finances allowed. The dining rooms were adequately decorated and furnished. Both the kitchens were quite large. One looked quite new and was very modern. The units in the other one were beginning to show signs of wear and tear particularly in relation to the drawer fronts. The garden for use of the people living in the home was very well laid out and maintained and had seating and a patio heater. There were adequate numbers of toilets bathrooms and showers throughout the home to meet the needs of the people living there. It was noted that the grouting between the tiles in one of the shower rooms was looking grubby and needed to be renewed. The home was clean and hygienic on the day of the inspection. However it was noted that there were some opened foods in one of the fridges that had not been dated on opening. The surveys returned to us indicated that the home is always clean and fresh. Comments received included: The home is usually very, very tidy and kept in good condition. Lovely and clean. Care Homes for Adults (18-65 years) Page 24 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were supported by a well trained, stable staff team that could meet their needs. Recruitment procedures were robust and safe guarded the people living in the home. Evidence: The rotas for the home indicated there were always two staff on duty throughout the waking day and one person sleeping in. On many days there was a third staff member on duty during the day and the managers hours were supernumery to the care rota. There were two staff vacancies at the home but the manager could not appoint to these as the organisation had a freeze on recruitment. The vacancies were being covered by staff working overtime or by the use of bank staff employed by the organisation. The manager stated she always tried to use the same bank staff so as to ensure some continuity for the people living in the home. Very good relationships between the staff and the people living in the home were evident throguhout the course of the inspection. They spoke to us about staff being very helpful and always there to remind them of things. One of the completed surveys commented All the staff who I have worked with or who have taken care of me have been wonderful. I think that they all do an absolutely fantastic job between Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: them looking after us. No new staff had been recruited at the home since the last inspection therefore recruitment records were not checked. However it was known from previous inspections that the recruitment procedures were robust and safeguarded the people living in the home. The training matrix for the home indicated staff have had a variety of training including food hygiene, first aid, manual handling, infection control and fire safety. The issues raised at the last inspection in relation to staff needing some of their training updated had been addressed. Staff had also undertaken a range of training in relation to mental health issues such as mental health awareness, voices, and self harm. The training matrix also indicated that five of the seven staff had NVQ 3, one had NVQ 2 and another was undertaking this. The AQAA indicated that there were also new training opportunities for staff including specialised support planning training and diversity training. Care Homes for Adults (18-65 years) Page 26 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was very well managed and run in the best interests of the people living there. The health safety and welfare of the people living in the home were promoted and protected. Evidence: The manager of the home had been in post for a considerable amount of time and was well qualified for her role. She demonstrated a very good knowledge of the needs of the people living in the home throughout the inspection. It was evident throughout the inspection that the relationships between the manager, the people living in the home and the staff were good. Since the last key inspection the home had implemented the Organisations quality monitoring system. The system involved assessing the service against the quality standards set by the organisation which are linked to the National Minimum Standards. The people living in the home and staff were being fully involved in the process and group meetings were being held. The manager has to produce evidence for senior Care Homes for Adults (18-65 years) Page 27 of 31 Evidence: managers that the service is meeting the set standards and if any short falls are found an action plan has to be put in place to address them. The people living in the home were being surveyed directly by the Organisation for their views on the service offered at the home. There were regular meetings for the people living in the home which they chaired and minuted themselves. The minutes for the meetings indicated that the quality system had been discussed and interest had been sought for a qaulity group workshop. It was evident throughout the course of the inspection that the people living in the home were very much involved in the day to day processes in the home, for example, writing their own daily notes and involvement in staff recruitment. Their views were listened to and taken into account and on an ongoing basis the manager was looking for ways to involve individuals further. The AQQA recieved prior to the inspection indicated that the equipment in the home was serviced as required. The in house checks on the fire system were sampled. These indicated that all the required checks were carried out, fire drills were undertaken which always involved the people living in the home and fire trainig was up to date. The home also had a very indepth fire risk assessment. The recording and reporting of accidents and incidents were appropriate. No requirments were made in relation to health and safety following this inspection. Health and safety in the home were very well managed. Care Homes for Adults (18-65 years) Page 28 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 23 It is recommended that staff undertake refresher training for adult protection issues. This will ensure they have all the current information required to enable them to recognise and report any issues. The grouting in the shower room should be renewed. This will ensure good hygiene is mainatined. The furniture in the smoking lounge is showing signs of wear and tear and should be replaced. This will ensure stanadrds are kept to an acceptable standard for the people living in the home. All opened foods that are stored in the fridges should be dated on opening to ensure good food hygiene. The drawer fronts on the kitchen units that wearing should be replaced. This will ensure good hygiene can be maintained in the kitchen. 2 3 27 28 4 5 30 30 Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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