Inspection on 11/03/08 for Chase House

This inspection was carried out on 11th March 2008.

CSCI found this care home to be providing an Adequate 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

Chase House 12/02/07

Chase House 01/03/06

Chase House 01/09/05

Chase House 09/03/05

Chase House 22/09/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Chase House 95 Chase Road Brownhills Walsall West Midlands WS8 6JE Lead Inspector Sue Woods & Rebecca Harrison Unannounced Inspection 11th March 2008 10:15 Chase House DS0000020846.V359734.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 Chase House DS0000020846.V359734.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. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chase House Address 95 Chase Road Brownhills Walsall West Midlands WS8 6JE 01543 252063 01543 300399 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 Angela Lane Mr Peter David French Mrs Denise Joan Suffolk Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th February 2007 Brief Description of the Service: Chase House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of four adults with autism. The home is part of a group of small residential services located in Walsall. Mrs Angela Lane and Mr Peter French are the registered providers and Ms Denise Suffolk is the registered manager of the service. The Mission Statement is ‘To provide a caring and peaceful home environment where adults with autism and allied conditions can feel happy and secure, and where they have access to continued specialist support, help and education throughout their life’. The property is set back from the main road on the outskirts of Brownhills and opened in 1998. All bedrooms are single, each service user having been involved in choosing the decor and furniture. The garden area is small, with a patio and lawned area. Shared space includes a lounge/diner, domestic style kitchen and a conservatory. There is a drive to the front of the property with limited parking. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged were not available in the Service User Guide as required however fees are assessed depending on the individual needs of each person therefore the reader may wish to obtain this information direct from the service provider. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was unannounced and took place on 11th March 2008 by two inspectors over 7 hours. A range of evidence was used to make judgements about this service to include discussions with staff, the manager and the provider, a tour of the home and observation of care experienced by people using the service. We also looked at a number of records to include care records for two people receiving a service, complaints, staff training, quality assurance processes, recruitment, Fire Authority reports, Environmental Health Officer reports and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to Chase House for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The manager completed this and some comments have been included within this inspection report. The purpose of the inspection was to assess ‘Key’ National Minimum Standards for Younger Adults and to review all 9 requirements that were made as a result of the previous inspection undertaken on 12th February 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The home has a committed team of staff who try hard to meet the needs of the people they support and function well as a team. Feedback received from two staff on duty was positive with staff reporting morale as ‘good’ and ‘quite high’. Staff reported that the team functions well. People are provided with a homely place to live. Bedrooms are personalised and the home is domestic in appearance. The manager appears committed to providing a good service to the people living at the home. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 6 People living at Chase House are given good opportunities to develop their interests, learn life skills and partake in the local community. The provider has opened a new Community and Learning Centre where people can access a range of activities in addition to facilities provided by the local leisure centre. Individual’s health needs are well-monitored and appropriate referrals to healthcare professionals made where necessary. What has improved since the last inspection? What they could do better: Discussions held with the manager evidence her commitment to improve the service provided and the overall outcomes for the people living at Chase House. We found some serious areas of concern in relation to restrictive practices. The manager was advised to seek professional input on the development of behaviour management guidelines and to review some current practices used within the home, which can be seen as restrictive and not in the best interests of individuals. The manager had not recognised some poor practice issues however the owner committed to reviewing all restrictive practices within the home and to implement new appropriate guidelines for the manager and staff to adhere to. Therefore quality rating scored in outcome groups to include complaints and protection and conduct and management of the home reflects that the owner has committed to address such shortfalls. Staffing levels to support community activities should be reviewed to ensure the staffing structure is based around delivering outcomes for all individuals using the service and is not led by staff requirements. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 7 The self assessment (AQAA) completed by the manager identifies areas for improvement to include possible provision of en-suite facilities for people using the service and improve quality assurance processes. The manager should ensure all staff receive training in safe working practices at the required frequency and develop a staff training and development plan to assist future planning based around the needs of the individuals accommodated. The manager has yet to develop an annual development plan, which reflects aims and outcomes for service users. 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. Chase House DS0000020846.V359734.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 Chase House DS0000020846.V359734.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 and 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Chase House has appropriate procedures in place that would enable the successful admission of a new service user to the home. EVIDENCE: Information about the service is readily available in the Statement of Purpose, Service User Guide, Brochure and Newsletter. These documents provide people with information to help them understand the services that Chase House provides and has been reviewed and updated to reflect the change in registered manager and staffing. The manager reported that she intends to develop the Guide in a more ‘user friendly’ format for people currently living at the home and any potential service users in the future. There have been no new admissions to the service since 1999 however the admissions procedure is clearly stated in the Statement of Purpose and Service User Guide. The self assessment (AQAA) completed by the manager states ‘The service user is fully assessed to ensure that our service is able to deliver the type of care they require’. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Effective care plans provide staff with the information they need to meet the needs of people who live at the home however people are vulnerable if certain care practices are restrictive and inappropriate. People enjoy community activities after assessments have been made to ensure they are safe to do so. EVIDENCE: People who live at Chase House have care plans that identify how their individual needs should be met. The plans are regularly looked at by the manager and updated as necessary. Likes and dislikes are recorded and daily routines are clearly written to enable staff to support people how they prefer and follow the routines that are so important to them. Staff were seen to communicate well with the people living at Chase House using signs and speech. The manager gave examples of how staff have learnt Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 11 to understand individual signs and gestures and as a result the people living at the home are happier and more relaxed. Life books have now been introduced for every one. These books provide information about people’s lives needs and wishes using photos and symbols making them interesting and personal to the people they belong to. Key workers have helped people to complete their books. Identified behaviours are supported by management guidelines that have been developed by the manager. The plans identified how support should be offered while maintaining people’s privacy and dignity however the content of some of these guidelines were inappropriate. Issues identified were discussed with the manager and the owner of the home. The owner said that he would immediately review practice and that any inappropriate ‘restrictive’ practices would be stopped immediately. Given that the manager had not recognised poor practice in this area it is strongly recommended that all management guidelines to support identified behaviours are developed by people who are qualified to do so. Risk assessments provide clear guidance to staff in order to support people safely especially while out in the community. Risk assessments are also reviewed regularly. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 12 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. People who live at Chase House enjoy a variety of leisure opportunities and are able to learn new and exciting skills. People also benefit from staying in touch with their families and enjoying meals that reflect their individual tastes and meet their dietary and cultural needs. EVIDENCE: People living at Chase House enjoy a very structured daily and weekly routine. People have the chance to learn new skills and develop existing ones. For example people are soon to try rock climbing at the local recreation centre and already enjoy horse riding, swimming and canoeing. When at home people are supported to share the cleaning tasks and the cooking as well as doing group activities like watching movies. People also do arts and crafts in the conservatory. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 13 On the day of the inspection everyone went out with two members of staff for lunch and then to do personal shopping. Records reflected that the majority of community based activities were group events although it was evident that one person who did not wish to attend one planned activity was able to stay at home. The manager and the staff gave examples of how family support is encouraged by the home and people stay in touch with regular visits, letters and emails. One person sends photos to her family of recent activities that she has enjoyed. Staff support one person to ensure that he is able to practice his religious beliefs and customs in his every day life and acknowledged that a male support worker would enable better opportunities for support. (A male support worker has just been appointed). The menu shows a variety of foods on offer to reflect individual needs and tastes. Cultural needs are catered for and people are encouraged to try new dishes as well as enjoy ‘take-aways’ and meals out. It was reported that both the manager and deputy manager have completed a course in Nutrition since the last inspection. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 14 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. The personal and health care needs of the people who live at Chase House are met enabling them to have a good quality of life. People are safeguarded by the home’s system for handling, storing and administering medication although written guidelines to support the administration of medication taken as and when required will offer better protection. EVIDENCE: Care and support plans are very detailed and clearly show how people prefer their needs to be met. This is important because people living at Chase House have communication difficulties. The self assessment (AQAA) completed by the manager states ‘Our service users are well supported by medical services…’ Health plans and ‘baseline’ assessments were seen on both files reviewed and there was evidence that they are regularly updated. Records also showed that Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 15 people have regular health care appointments and on the day of the inspection one person had been supported to attend a detail appointment, which had proved very successful. Annual well person appointments are also attended and an optician visits the home. The home has referred one person for a medication review and an appointment with a Specialist after noticing a change in her behaviour. Medication arrangements within the home were seen to be satisfactory. People had their own cabinets to store medication in and records seen were accurate and up to date. Staff seen administering medication at the time of the inspection followed the correct procedure as identified by the manager. The manager ensures that staff giving medication are competent to do so. She carries out assessments and acts upon the outcomes to ensure that if required staff receive additional support until ‘competent’. There were no written guidelines available to support staff to make the decision as to when medication prescribed ‘as and when required’ should be given and the manager said that she would produce one immediately. Staff receive training to support the administration of medication and the home also receives regular checks from the local pharmacist. Medication assessments, completed by the manager, show that people are encouraged to take their own medication as far as they are able to do so safely. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 16 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 adequate This judgement has been made using available evidence including a visit to this service. The home has is a complaints procedure in place and people using the service are provided with pictures and symbols if they wish to express their concerns. Procedures are in place to safeguard people using the service from potential abuse however people would be better protected if the manager would seek professional input in producing guidelines to support people’s behaviours that can challenge the service. EVIDENCE: People who live at the home and their representatives have access to a complaints procedure in an appropriate format. We have not received any concerns or complaints in relation to this service since the last inspection. No complaints were found recorded in the complaints log and the manager confirmed that no complaints have been received by the home since the last inspection. A referral under safeguarding adult procedures was made after staff reported concerns about a colleagues practice using the homes ‘whistle blowing’ procedures. The manager stated that the home was requested to investigate the allegations and as a result dismissed the staff member concerned. The home has a copy of local multi-agency adult protection policy and procedure. Staff spoken with confirmed that they had received training in adult protection Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 17 and records indicate that of the eight support staff employed all but one member of staff has received training in adult protection. The home has a policy in place for the management of service users finances however the manager was advised to review this in relation to the holding bank cards and personal identity numbers (PIN) on behalf of people as this as an area of potential vulnerability. It was reported that people have their own bank accounts and records of all transactions were detailed and appeared satisfactory at the time of inspection. The manager stated that she and the senior manager regularly audit records held. Financial procedures were discussed with a member of staff who considered these to be robust and safeguard both people using the service and staff. The manager must seek professional input in relation to the development of individual behaviour management guidelines as her lack of understanding in relation to restrictive practices may place people at risk. The owner who attended the feedback at the end of the inspection fully acknowledged shortfalls found as identified under the Individual Needs and Choices section and Management outcome groups and committed to addressing matters immediately. The quality rating in this outcome area reflects that the owner committed to reviewing all restrictive practices within the home a to implement new appropriate guidelines for the manager and staff to adhere to. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 18 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. People who live at Chase House are provided with a clean and well-maintained place to live. There are good infection control procedures in place to protect the people who live there. EVIDENCE: During a tour of the building it was seen that all areas of the home were clean and well maintained. People who live at Chase House are supported to do housework and the kitchen was well organised with infection control guidelines displayed. The manager said that the home had recently received an Environmental Health inspection and had scored very well. The new conservatory is being well used as an activity room and the garden is well laid out and private. The manager said that people enjoy the garden and all helped out when it was landscaped last year. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 19 Locks on bedroom doors were available but are not used following individual risk assessments identified they were not needed. Locks that are used in communal areas were not supported by risk assessments and the manager began to complete one at the time of the inspection to ensure the safety of one person living at the home while ensuring that they did not restrict the movement of others. Training records indicate that half of the staff team have undertaken training in infection control procedures. An Infection Control Nurse has recently undertaken an infection Control audit and the home achieved a score of 83 . The manager reported that that the few recommendations made have since been met. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 20 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 adequate This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a trained, committed staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Staff were seen to interact with service users in a positive manner throughout the inspection and observations made clearly evidence that staff have developed positive working relationships with the people they support. Three of the service users use Makaton as a form of communication and the manager provides this training to all new staff. Of the eight support workers employed it was reported that four have obtained a care qualification known as NVQ at level 2 and above and the remainder of the staff are working towards this qualification. The team consists of a registered manager, a deputy manager and seven support workers. The home currently has one full time support worker vacancy however an offer has been made to a successful applicant. The current staffing ratio is a minimum of two staff to support the four people using the service Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 21 throughout the day with one waking night staff member on duty during the night, which was an accurate reflection of the staff rota seen. Feedback received from two staff on duty was positive with staff reporting morale as ‘good’ and ‘quite high’. Staff on duty reported that the team functions well. One staff member stated, “We have a good team, it’s fantastic and we get on well, which is good for the service users”. Records held on behalf of one person evidence that when all four people are accessing activities in the community together that the behaviour of one person can impact on the other service users and therefore a review of staffing levels should be undertaken to ensure the staffing structure is based around delivering outcomes for people using the service and is not led by staff requirements. Two staff files were randomly selected and examined and the majority of the documentation required by Regulation was available. Neither file contained a photograph of the staff member as required however photographs were available on other files held for other staff employed. Only one of the files contained an original Criminal Records Bureau Disclosure. A CRB Disclosure number was available on the other file examined however this does not meet current guidance as Disclosures should be kept and not destroyed until after we have inspected the service. All staff are provided with a copy of the General Social Care Council Code of Conduct and these were also readily available in the office. Both staff spoken with reported that they are provided with good training opportunities to include service specific training such as autism and makaton in addition to training in safe working practices to include first aid, fire safety, food hygiene and moving and handling. All members of staff are provided with an individual training and development profile, which details all training undertaken. It was reported that the senior manager holds the overall training budget for all of the providers registered services however the manager reported that sourcing training has been problematic therefore not all of the staff have yet received specialist LDAF (Learning Disability Awareness Foundation) training. Since the last inspection the manager has developed a training matrix and examination of this indicates that training in safe working practices is much improved although a small number still require this, which was fully acknowledged by the manager. An overall team training and development plan has yet to be developed as required by the previous inspection however the manager committed to develop this at the earliest opportunity which will assist with identifying the teams training needs focused on improving Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 22 outcomes for people using the service. It was reported that all new staff undertake structured induction training to Common Induction Standards specification as confirmed in discussions with a new member of staff however completed records were unavailable for inspection. Staff have either received training in equal opportunities or booked to attend shortly as required by the previous inspection. Staff on duty confirmed that they are in receipt of formal supervision as evidenced with records seen on the staff files examined. Minutes of staff meetings were also available. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 23 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): 37,39,40 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager has an understanding of the areas in which the service needs to improve in the best interests of service users. Quality assurance requires further development to assess performance and evaluate outcomes for people using the service. Overall the premises are managed and maintained in a manner, which ensures the safety of service users and staff. EVIDENCE: Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 24 Ms Denise Suffolk is the manager of the home and her application for registration was approved in April 2007. Records seen and discussions held with the manager evidence that the she has attended a number of training courses relevant to her role since the last inspection and has completed NVQ level 4 in Health and Social Care and is currently working towards gaining the Registered Managers Award. Staff spoken with stated that the manager is approachable and supportive. It is evident that the manager has made a number of positive changes since the last inspection to include detailed care plans, risk assessments and staff training to include medication, infection control, adult protection and equal opportunities. An information file has also been developed which is very well presented and contains documents to include the National Minimum Standards, Regulations, Adult Protection, No Secrets etc which is a valuable source for staff working at the home. Numerous other leaflets about the work of CSCI were readily available in addition to inspection reports. Discussions held with the manager evidence that she is committed to further developing the service. The Annual Quality Assurance Assessment (AQAA) forwarded to CSCI was detailed and reflects both the strengths and areas of improvement for the service. The manager stated that satisfaction surveys to gain the views of people using the service, their relatives, staff and stakeholders have recently been distributed and to date only three completed surveys have been returned. The manager agreed to develop a report based on the overall findings when surveys are all returned. As part of the managers application for registration the providers agreed to conduct audits under Regulation 26 initially on a more frequent basis than required in the Care Homes Regulations, however records seen on file suggest that visits have not been undertaken at the required frequency and that such visits have been announced which does not comply with the Regulation. It was a requirement of the previous inspection that the home must produce an annual development plan, which reflects aims and outcomes for service users however this has yet to be undertaken but a Business Plan covering all the providers registered care homes is available. Risk assessments for the management and safe working practices in the home are in place. Records seen and discussions held evidence the that the manager has a limited understanding around safe working practices in relation to managing behaviours that challenge and we have reported our findings and concerns under other outcome groups of this report. The owner committed to ensuring that a number of the homes policies and practices be addressed immediately. Since the last inspection both the Fire officer and Environmental Health Officer have visited the home and the manager confirmed that she has complied with the requirements made and that the home’s Fire Risk Assessment has been updated as required in order to safeguard people. The water has been tested for legionella as identified at the previous inspection. Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 25 Certificates for the servicing of equipment are maintained and safety checks are undertaken at the required frequency. As stated under the Staffing section of this report training in safe working practices is much improved however outstanding training for some staff must be given priority. Chase House DS0000020846.V359734.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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 2 x 3 x Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Behavioural support guidelines should be developed by people who are qualified to do so. This will ensure that people are treated appropriately and safely when they need additional support to manage their behaviour. The manager should ensure all staff receive training in safe working practices at the required frequency and develop a staff training and development plan to assist future planning based around the needs of the individuals accommodated. The homes quality assurance processes require further development in order to regularly review the quality of care provided to people using the service. The homes policies and procedures should be reviewed in conjunction with the manager to ensure they comply with current legislation and good practice. 2. YA35 3. 4. YA39 YA40 Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Chase House DS0000020846.V359734.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!