Inspection on 31/05/06 for Cherre Residential Care Home

This inspection was carried out on 31st May 2006.

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 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

Cherre Residential Care Home 23/08/07

Cherre Residential Care Home 15/02/06

Cherre Residential Care Home 16/05/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Cherre Residential Care Home 2 Daneshill Road Leicester Leicestershire LE3 6AL Lead Inspector Keith Charlton Unannounced Inspection 31st May 2006 02:00 DS0000063188.V296622.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 DS0000063188.V296622.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 Older People and 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. DS0000063188.V296622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherre Residential Care Home Address 2 Daneshill Road Leicester Leicestershire LE3 6AL 0116 2517567 0116 2517567 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) Cherre Residential Care Ltd Miss Hema Malini Patel Care Home 14 Category(ies) of Learning disability (14) registration, with number of places DS0000063188.V296622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Cherre Residential Care is registered to provide care for fourteen adults with learning disabilities. The home is situated close to Leicester city centre within easy reach of a range of local amenities. Service users are accommodated in eight single and three double bedrooms. In addition to their rooms, service users have access to two lounges and a dining area. There is a large paved area to the side of the property. Fees typically range from £ 326 to a higher figure for a service user who needs the attention of two staff with him at all times – this information was provided on the day of the inspection. There are costs for extras – hairdressing, toiletries, holidays, transport etc. DS0000063188.V296622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. There are only a small number of service users that can communicate their views. This was an unannounced Inspection. The Registered Manager was on duty to assist with the inspection process. Five other staff were also on duty. Planning for the Inspection included looking at the last Inspection Report, looking at the issues contained in complaints made about the service since the last inspection and assessing any notifications of significant events sent to the Commission for Social Care Inspection by the Registered Manager. There have been two complaints received regarding the home since the last inspection, both taken up by the Social Service Department. Neither complaint was upheld. The Inspection took place between 15.00 and 19.00 on day one and was completed the following day, and included a selected tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with six residents, four members of staff and the Registered Manager. What the service does well: Service users needs are seen as a priority - the service offers continues to offer individualised care to service users, the details of which are clearly documented in service users’ plans. Staffing levels allow for service users to receive one to one input and attention. Staff receive clear direction as to their duties and responsibilities, through training, regular supervision, staff meetings and handovers between shifts. Staff have assisted service users to compile their own excellent service user guide setting out what prospective service users can expect from the service. The Registered Manager through ongoing training ensures that she and the staff team are up to date with current best practice in supporting people with DS0000063188.V296622.R01.S.doc Version 5.2 Page 6 learning disabilities – through e.g. the Person Centred Planning system, which identifies service users individual needs. Service users are regularly consulted as to their views and opinions and these are taken into account in the running of the home – e.g. - the Registered Manager stated that service users take part in staff interviews. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. DS0000063188.V296622.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000063188.V296622.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) DS0000063188.V296622.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs and aspirations are fully assessed therefore their care needs can be met once they move into the home. EVIDENCE: Staff have assisted service users to compile their own service user guide setting out what prospective service users can expect from the service – this is a user friendly document and service users/staff deserve commendation for their efforts in producing this document. The Statement of Purpose was also viewed – this is a detailed document outlining the services of the home. The Registered Manager is to review this DS0000063188.V296622.R01.S.doc Version 5.2 Page 10 information to make it more user friendly with photographs/symbols so that all service users can more easily understand it. Three service users files were viewed and all had an assessment completed by staff. Following Person Centred Planning training (a system which identifies service users individual needs) the Registered Manager said assessments would in future contain more detail as to personal histories and interests/hobbies. DS0000063188.V296622.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are well met, as reflected in detailed Care Plans. EVIDENCE: Service users said that they are asked what they would like to do and did not think there were any rules they had to follow. Three service users’ plans were examined and details of the plan were verified through discussion with staff members and observation of practice. Plans were detailed and covered all aspects of daily living and there was documentary DS0000063188.V296622.R01.S.doc Version 5.2 Page 12 evidence of regular review. Some service users have mental health needs. Care plans and risk assessments again demonstrated good management and care of these needs and they have a regular review under the Care Programme Approach. Staff were observed to communicate regularly with service users throughout the inspection offering choices with regards to activities, personal care and food. Service users hold meetings on a monthly basis and were fully consulted about the re-decoration of their bedrooms. The Registered Manager stated that service users have the opportunity to participate in staff interviews. Service users are also asked their views in the regular Residents Meeting held monthly and this is reflected in the minutes. Service users said that they could use the kitchen to cook and one service user said he had baked a cake that morning. If service users are assessed to be capable they can go out on their own and two service users said they were able to do this. No service user is seen as safe to fully self medicate though one service user applies her own prescribed cream. Service users and staff said it was service users choice as to when they got up and went to bed. DS0000063188.V296622.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users living at the home have the opportunity to have a fulfilling lifestyle. DS0000063188.V296622.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users said they attend day centres, colleges and employment. One resident proudly told the inspector about the work he does. Staff were observed to be engaged with residents in a variety of activities, such as board games, drawing and talking to them in a friendly manner. Some service users said they had been on holiday to Florida and Spain and they had really enjoyed these activities. There was a photo in the service users guide of their holiday in Spain where they appeared to be having a very good time. One resident told the inspector that he wanted to live independently in the future though he was enjoying living in the home at the moment but he thought help would be given by staff to do this. Records show that staff teach service users independent living skills such as cooking and cleaning. Staff were observed to be interacting with service uses positively and with respect and friendliness. Service users said that they could have visitors in to see them in the home. One staff was observed to say to a service user that she would help her write to her family. Another service user said she went home at weekends and enjoyed this. A mealtime was observed. Taste and presentation were good and service users said they liked the meals. Two fresh vegetables are offered and service users are offered a choice of two main courses and two sweets as seen by the menus. The mealtime was relaxed and informal. Residents had fruit for their dessert and there was a large amount of fruit available in the kitchen. A discussion was held with the Registered Manager, as a number of service users appeared to have weight issues, which could result in health problems. The Registered Manager stated that healthy eating is brought to the attention of service users (this was seen in Care Plans) but it is the service users who decide what they want to eat. DS0000063188.V296622.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive good personal support with their physical and emotional health needs being generally well met. EVIDENCE: There is a very comprehensive record on Care Plans which detail all medical appointments and check ups on an individual basis - from nurses, GPs, dentist, chiropodist, etc. Through observation, discussion and records, it was demonstrated that service user receive support in the way they prefer and require it. Care Plans indicate DS0000063188.V296622.R01.S.doc Version 5.2 Page 16 all aspects of service users health care needs are covered – e.g. management of diabetes, personal care, optical and dental checks etc. Staff indicated that they have to restrain a service user who needs the supervision of two staff at all times. The Registered Manager said that the policy is not to restrain but use low level supervision techniques. She said this would be followed up and the Commission for Social Care Inspection informed if restraint has been used, as the Commission needs to monitor the use of restraint and whether such techniques are acceptable practice. Accident records showed service users having falls but no contact with the GP surgery to ask for advice on the course of action to follow if a head injury had been sustained. The Registered Manager recognised this and said that the medical alert procedure would be amended so that staff alert medical authorities in these situations. Staff were considerate in their dealings with service users needing personal support. A service user, who has one to one support, was seen to be constantly reassured by a staff member in a calm and relaxed voice. No service user is able to self medicate. The Registered Manager stated that the pharmacist has trained all staff that issue medication. Medication records were checked and found to be generally good with only a small number of gaps, which the Registered Manager was to follow up. The medication is kept locked securely. DS0000063188.V296622.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users welfare is generally well protected by procedures in place. Service users views are listened to and acted upon. EVIDENCE: Service users said that they would tell the Registered Manager or staff members if they were unhappy with anything and they said it would be sorted out. The complaints record indicated there is an ongoing investigation into an allegation made by a service user. This had not been reported in writing to the Commission for Social Care Inspection – the Registered Manager stated this would be carried out in the future. The Registered Manager said that she was working with a Social Service Department regarding this investigation and would then be assessing appropriate action to be taken and would inform the Commission for Social Care Inspection of this action. A staff member also informed the inspector of two instances of potential abuse that she had recently reported to the Management. The Registered Manager DS0000063188.V296622.R01.S.doc Version 5.2 Page 18 said this had been followed up with the staff member concerned. Again such instances need to be reported to the Commission for Social Care Inspection so they can be properly monitored. The complaints procedure is clearly displayed and contains information as to how to contact the Commission should a complainant be dissatisfied with the home’s response. The Registered Manager said she would make amendments to the procedure so that it would be a more user friendly document for service users. There are service users meetings held where all people are invited to attend and share their views about the home. Records of these meetings are available for staff and service users to refer to. Staff members on duty were asked about their understanding of whistle blowing procedures, and demonstrated a good understanding of the protection of service users from abuse. DS0000063188.V296622.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service uses live in a homely and comfortable environment, and standards of hygiene are satisfactory. EVIDENCE: DS0000063188.V296622.R01.S.doc Version 5.2 Page 20 Service users said that they liked their bedrooms. The bedrooms observed were seen to generally have a good deal of service users personal possessions in them. Staff said that rooms had been decorated in the colour chosen by service users. A Care Plan showed that a service user’s bedroom was to be decorated in a colour she had chosen from a hardware store. All areas of the home appeared clean and tidy. There were no unpleasant odours present. Maintenance had been carried out so facilities were in a generally good state of repair. There were some inside windows in bedrooms that need to be repainted as paintwork was cracked. There was a hole in the wall in the first floor corridor with a wire on show, which needed attention. A drawer was broken on a wardrobe. A sofa had been damaged and awaiting repair. The Registered Manager said these issues would be quickly attended to. A trailing flex cable from a television causing a tripping hazard in a bedroom stated in the last Inspection Report has now been dealt with. DS0000063188.V296622.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good staffing levels and staff training ensure service users’ individual needs are met. EVIDENCE: Service users said they thought the staff were good and one service user said they were his friends. There were five staff on duty for the afternoon shift on the day of the inspection including a senior carer, plus the Registered Manager. Duty rotas inspected showed five to six staff on daytime/evening shifts. Although there is DS0000063188.V296622.R01.S.doc Version 5.2 Page 22 a service user who needs the attention of two staff and another needing the attention of one staff at all times there appeared to be sufficient daytime staff on duty to respond to the individual requests and needs of service users. A discussion was held with the Registered Manager as to night time staffing – there are two awake night staff with the above service user needing two staff at times. The Registered Manager stated that currently needs are covered with the on call system though this issue is subject to review. When service users requested attention during the inspection they were given this within a reasonable time and always treated with friendliness and respect. A service user wanted to go out for a coffee and a staff member was available for this. There continues to be a good balance of male and female staff on duty reflecting the gender composition of the service user group. Staff records were inspected and generally found to have all the necessary statutory checks apart from a missing reference for one staff member. The Registered Manager said this would be followed up. Staff members were spoken to and had a good knowledge of service uses care needs and were again committed to providing a good service to residents. There are over fifty of staff with a National Vocational Qualification level 2 qualification, which meets the National Minimum Standard. More staff have signed up to do this training and one staff said she was aiming to start a National Vocational Qualification level 3 course. Staff have had training in a wide range of topics – the Person Centred Planning system which identifies service users individual needs, medication, health and safety, rectal diazepam, training in using low key interventions to deal with challenging behaviour etc. Training records are kept within individual staff files. There was a discussion as to looking at Learning Disability Award Framework training to see if this is more comprehensive to provide a better grounding of knowledge of service uses care needs for new staff. The Registered Manager said that she had developed a more comprehensive system. This was inspected and contained relevant issues. DS0000063188.V296622.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the proactive management of the home. EVIDENCE: DS0000063188.V296622.R01.S.doc Version 5.2 Page 24 Service users and staff said they thought the home was run well. Staff said they were supported, listened to and respected by the management of the home. The Registered Manager owns the home and has been a manager for twelve years. She holds the City and Guilds 325 qualification in managing care and is currently undertaking her Registered Managers Award. The Registered Manager places great emphasis on teamwork, as evidenced from the minutes of Staff Meetings, which are held on a monthly basis and recorded so that staff can reference them. There was a discussion as to indicating in the minutes that that staff are asked as to their ideas as to the running of the service. The Registered Manager said that minutes would reflect this in future. Service users are consulted on an ongoing basis through speaking to staff and they have their own key worker. Monthly Service User meetings are held and recorded. The Registered Manager said a formal questionnaire is circulated to all service users on an annual basis – this was seen though no completed ones were available to view. It was recommended that the views of other stakeholders such as relatives and visiting professionals are also sought on a formal basis and the results of such consultations included in the home’s information, available to all interested parties. Some service user monies records were viewed and found to be satisfactory. The Registered Manager was asked to produce evidence as to how service users are charged for using the home’s transport as this was raised by an anonymous source. There was evidence that policies and procedures are reviewed regularly and staff said that they were asked to read them, so as to provide consistent practice. There are Risk Assessments as to safe working practices. The Registered Manager said that currently there was only one service user who needed a window restrictor for safety reasons. There were no Risk Assessments for hot radiators. The Registered Manager said this would be carried out though she thought that this was not a problem in practice as all service users were able to recognise and avoid contact with hot radiators. As there are three service users with epilepsy who could be in danger of falling against radiators she will again review this issue. The hot water temperature was measured and found to comply with the National Minimum Standard of 43c to prevent scald injury. A staff member was asked as to the fire procedure and was aware of this. Fire records showed that regular testing of fire bells and emergency lighting was in place and there are regular fire drills – evidenced in fire records. DS0000063188.V296622.R01.S.doc Version 5.2 Page 25 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 4 38 X 39 3 40 X 41 3 42 3 43 X 4 3 3 X X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X DS0000063188.V296622.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000063188.V296622.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 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. 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