Inspection on 06/03/08 for Church Street

This inspection was carried out on 6th March 2008.

CSCI found this care home to be providing an Good 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

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 ADULTS 18-65 Church Street 19 - 23 Church Street Market Warsop Nottinghamshire NG20 0AU Lead Inspector Jayne Hilton Unannounced Inspection 6th March 2008 12:45 Church Street DS0000070766.V360657.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 Church Street DS0000070766.V360657.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. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Street Address 19 - 23 Church Street Market Warsop Nottinghamshire NG20 0AU 01623 840000 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) londonroad@tiscali.co.uk Milbury Care Services Ltd Mrs Daniella Rubio-Mayer Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons 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 are within the following category: Learning disability - Code LD. The maximum number of service users who can be accommodated is 10. N/A 2. Date of last inspection Brief Description of the Service: Church St is a purpose built detached house situated in the centre of Market Warsop, which provides care and support for people with learning disabilities and physical health needs. There are eight bedrooms in the main house all with en-suite facilities. There are also two self-contained ground floor flats. The home is owned by, Milbury Care Ltd. The home is accessible for people with mobility difficulties and a passenger lift provides access to the first floor. The home has extensive gardens that are well maintained and easily accessible. There is ample car parking available. The home has its own accessible mini bus with hydraulic ramp as well as a car to enable people to travel for appointments and outings. The manager stated on 6/3/08 that the homes current charges range from £1,645.00 to £1,748.00. Church Street DS0000070766.V360657.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 2 star. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people living in the home and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 4.5 daytime hours and was unannounced. The home was registered in September 2007 and this was the first inspection of the service. Prior to completing this visit the inspector assessed the homes service history including complaints and adult protection referrals, and the Annual Quality Assurance Assessment completed by the registered manager. No surveys were returned by people living in the home or by relatives prior to the inspection. The main method of inspection used was case tracking, this is to randomly select people who live in the home and read their care files, examine their private and communal accommodation along with any specialist equipment they require. Their care is tracked to ensure that their needs are being met and that staff, have the skills to deliver the care they need. One person’s care files was examined in detail and one other persons care file was randomly sampled for information. The people who were “case tracked” were not able to help by giving an opinion about the care provided as they were out for the majority of the inspection. Two people who could express an opinion were spoken with. Two members of staff and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to the people who live at the home. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 6 What the service does well: The key principle of the home is that people using the service are in control of their lives. Staff, are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service confirmed they make their own informed decisions and have the right to take risks in their daily lives. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, appropriate to their peer group, in both the home and the community, and to enjoy all the rights and responsibilities of citizenship. The staff team understands the importance of enabling younger adults to achieve their goals, follow their interests and be integrated into community life and leisure activities in a way that is directed by the person using the service. The service understands and actively promotes the importance of respecting the human rights of people using the service, with fairness, equality, dignity, respect and autonomy all being seen as central to the care and support being provided. The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who use the service who live there. The living environment is appropriate for the particular lifestyle and needs of the people living there and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. Individuals are encouraged to see the home as their own. It is a very well maintained, attractive home and has very good access to community facilities and services. It has a wider range of up to date specialist equipment and adaptations to meet the individual needs of people who use the service. Prospective new residents are assessed before coming to the home to make sure that the home is able to meet their needs. Where risk assessments identify risks faced by residents these are included in care plans to minimise the risk to residents. People living in the home have health action plans in place to ensure their health is monitored their needs met. Care is provided in a way that promotes the privacy and dignity of people living in the home. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 7 The home has a complaints procedure, which is easy for people to use. The home has policies and procedures for staff to follow if they suspect anyone is not being properly treated which makes sure that people living in the home are protected from any form of abuse. Most staff have either completed or are working towards National Vocational Qualification level 2 and regular training is provided, which means that people living in the home, are supported by staff who have a qualification in their work and are suitably trained. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. She works to continuously improve services and provides an increased quality of life for residents with a focus on equality and diversity issues and promoting human rights, especially in the areas of dignity, respect and fairness. There is also a focus on person centred thinking, with residents shaping service delivery. There is a strong ethos of being open and transparent in all areas of running of the home. The manager leads and supports a strong staff team who have been recruited and trained to a good standard. Comments from people living in the home said “ I like it here and can do what I want to here” “ We have a choice about things we like to do and I have agreed my care/support plan” “ The staff are very kind and helpful” “I have my own flat and please myself what I do” What has improved since the last inspection? What they could do better: Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 8 No requirements were made at this inspection, however seven good practice recommendations have been made further development of the service as follows: Ensure any limitations on facilities, choice or human rights to prevent self harm or self neglect or abuse or harm to others are made only in the persons best interests, consistent with the purpose of the service and the homes duties and responsibilities under the law. The service needs to ensure the individual understands and agrees any limitations imposed/used [such as use of lap belts, bedrails, use of monitor alarms etc]; and that they are fully documented and reviewed regularly. Further development of the menu in formats and which offer more than one option would improve this area of the service. Where prescriptions have to be handwritten on the medication administration record, two signatures should be in place to evidence appropriate checks have been undertaken to minimise risk of error. Provide staff with a clear policy and procedures for when they go shopping with or on behalf of people living in the home in respect of the use of store advantage/bonus cards. The manager and deputy manager should seek to undertake training in the referral process under The Nottinghamshire Safeguarding protocol. Provide a stock of protective gloves for use in the laundry room to promote infection control. Provide training for staff in Equality and Diversity and Bullying and Harassment. 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. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 9 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 Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,3,4,5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home have the information they need and have their needs comprehensively assessed prior to moving to the home and are assured these will be met. EVIDENCE: Significant time and effort is spent planning to make admission to the home personal and well managed. Prospective residents and their families are treated as individuals and with dignity and respect for the life-changing decisions they need to make. There is a high value on responding to individual needs for information, reassurance and support. The home has developed a comprehensive statement of purpose and service user’s guide, which is very specific to the resident group and considers the different styles of accommodation, support, treatment, philosophies and specialist services required to meet the needs of people who use the service. The information is in a format suitable for residents and their families’ needs, using, for example, appropriate language, pictures or Braille. All new residents receive a comprehensive needs assessment before admission. This is carried out by, staff with skill and sensitivity. The service is highly efficient in obtaining a summary of any assessment undertaken through Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 11 care management arrangements, and insists on receiving a copy of the care plan before admission. For individuals whom are self funding, the assessment is undertaken by a highly qualified member of staff. Individuals are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the individuals agreement, carer’s interests are taken into account. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnic and diversity needs of the individual. The six strands of diversity are: gender (including gender identity), age, sexual orientation, race, religion or belief, and disability. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and special attention to help them to feel comfortable in their surroundings and enable them to ask any questions about life in the home. All residents receive a contract to which they have agreed. It gives clear information about fees and extra charges, which is reviewed and kept up to date. This information is meaningful and is provided in appropriate languages and formats, such as large print, Braille or easy read. The documents are also explained to individuals, so they fully understand the information. The use of advocates to support people is encouraged. The contract is reviewed and amended with the person when their life and circumstances change. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their needs met and are involved in their support plans. Risk management is integral to their independence. EVIDENCE: The key principle of the home is that people using the service are in control of their lives and they direct the service. Staff, are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service make their own informed decisions and have the right to take risks in their daily lives. The care plan is developed with, and owned by the person using the service. It is based on a full and up to date holistic assessment. It includes reference to equality and diversity and clearly addresses any needs identified in the six strands of diversity, which are: gender (including gender identity), age, sexual orientation, race, religion or belief, and disability. The plan is person centred and focuses on the individual’s strengths and personal preferences. The plan is Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 13 written with the individual, or their representative, and includes a range of information that is important to them. This includes information such as who and what is important to them, how they keep safe, their goals and aspirations, their skills and abilities, and how they make choices in their life. It also includes information about their health; with a ‘health action plan’ incorporated. It celebrates the individual, their life experiences and sets out in detail how all their current requirements and aspirations are to be met through positive individualised support. Plans are all different and highly individualised and they include evidence that the service values improving outcomes for people using the service. Key workers actively provide one to one support, keep the care plan up to date and make sure that other staff always know the person’s current needs and wishes. The service identifies and records the preferred communication style of the individual, and uses innovative methods that enable the person to fully participate. The plan is an up to date working tool used by the individual and all involved staff. People who are not familiar with the individual can, easily use the care plan, to deliver a personalised and consistent person centred service. Plans are be reviewed regularly, and as the individual’s needs change. The care plan includes a comprehensive risk assessment, which is regularly reviewed. The service has a ‘can do’ attitude and risks are managed positively to help people using the service lead the life they want. Any limitations on freedom, choice or facilities are always in the person’s best interests. However the service needs to ensure the individual understands and agrees any limitations imposed/used [such as use of lap belts, bedrails, use of monitor alarms etc]; and that they are fully documented and reviewed regularly. People using the service told us that they know, and are able to see, the records the home holds about them. Individuals know their rights and advocacy services are encouraged to promote these. The service works creatively and actively with other services and organisations to ensure that the person’s whole life needs are met, and goals addressed. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their rights respected and are supported to lead fulfilling lifestyles in the community. Further development of the menu in pictorial formats and which offer more than one option would improve this area of the service. EVIDENCE: The service has a strong commitment to enabling residents to develop or maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. People who use the service have the opportunity to develop and maintain important personal and family relationships, and are able to access information and specialist guidance about issues such as intimate relationships. The staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 15 The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. People living in the home told us that they are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. One person told us he considers himself to be retired and that staff respect this and another said he attends a day care service. Where appropriate, education and occupational opportunities are encouraged, supported and promoted. People may be attending local colleges, supported employment schemes, and also paid employment. Other support may be offered in the service by a skilled and trained team. People living in the home told us they could access and enjoy the opportunities available in their local community, such as using public transport, library services, the local pub, and local leisure facilities. Where appropriate, people are involved in the domestic routines of the home. They take responsibility for their own room, menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like. The menu is varied but it devised by staff currently and offers one choice, however staff and the people living in the home, confirmed alternatives can be provided should anyone not want the menu dish. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. Further development of the menu in pictorial formats and which offer more than one option would improve this area of the service. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their healthcare and medication needs met and are involved in their support plans. Risk management is integral to their independence. EVIDENCE: People living in the home receive effective personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. The statement of purpose sets out the competencies and specialist services the home offers and delivers this effectively through a skilled, trained and knowledgeable staff group that work in a person centred way. . Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. These needs are recorded in a separate ‘health action plan’. Practices in the home reflect residents’ needs under the six strands of diversity: gender (including gender identity), age, sexual orientation, race, religion or belief and disability. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 17 Staff, ensure that care is person led, personal support is flexible, consistent, and is able to meet the changing needs of the residents. Staff respect people’s preferences and have expert knowledge about individual personal needs when providing support, including intimate care. However there was not an available policy for dealing with intimate care tasks for staff to follow. Staff, spoken with were able to explain how they respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in private and at a time and pace directed by the person receiving the care. People living in the home and their care records supported this. Aids and equipment are provided to encourage maximum independence for people using services; these are regularly reviewed and replaced to accommodate changing needs. Specialist advice is sought by the home to ensure effective use of equipment. The home fully respects the rights of people in the area of health care and medication. They recognise and work with the decisions made by the individual regarding any refusal to take medication, or any specific requests about how their healthcare is managed. Staff members are very alert to changes in mood, behaviour and general wellbeing and fully understand how they should respond and take action. Staff, are trained and competent in health care matters particularly in the care of individuals who remain immobile for long periods of time. The home arranges training on health care topics that relate to the health care needs of the residents, for example diabetes, epilepsy and peg feeding. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff, however two people’s medication records had handwritten prescriptions that had not been signed for by the person making the entry, neither had they been checked by a second person/or signed as such. The manager told us that she intends to introduce regular management checks to monitor compliance and records were in place for this. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home know how to make a complaint and are safeguarded from harm. EVIDENCE: The manager stated in the Annual Quality Assurance document that home has an open culture where individuals are supported to feel safe and supported to share any concerns in relation to their protection and safety. There have been no complaints made to the home or the Commission about the service. Policies and procedures regarding safeguarding adults are available to staff and give them clear guidance about what action should be taken. People using the service or their representatives are made aware of what abuse is and the safeguards, which exist for their protection. Access to external agencies or advocacy services is actively promoted. There is a clear system for staff to report concerns about colleagues and managers, which ensures that concerns are investigated in line with local policies and procedures. Staff who ‘blow the whistle’ on bad practice are supported. Although there has been no safeguarding referrals made by the home to date. The manager is clear when an incident needs to be referred to the Local Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 19 Authority as part of the local safeguarding procedures and confirmed she has the new updated Nottinghamshire safeguarding protocols. It is recommended that the manager and the deputy undertake training in safeguarding referrals under the new protocol to ensure they are fully up to date. All staff working within the home are fully trained in safeguarding adults and know how to respond in the event of an alert. Individual staff are also trained to respond appropriately to physical and verbal aggression and fully understand the use of physical intervention as a last resort. All staff understands what restraint is and alternatives to its use in any form are always looked for. Equipment, which may be used to restrain individuals, such as bed rails, keypads, recliner chairs and wheelchair belts are only used when absolutely necessary, with the home promoting independence and choice as much as possible. There was not however any written evidence that people using the service are fully involved in decisions about any limitations to their choice and agreement and this is recommended. There is a policy in place for use of physical intervention, but it needs to include use of equipment that may be used to restrain individuals, to ensure staff, have the appropriate guidance. One person’s personal monies records were examined and practice of staff found to be satisfactory. It is however recommended that staff have a clear policy and procedures for when they go shopping with or on behalf of people living in the home in respect of the use of store advantage/bonus cards. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a clean safe and well-maintained environment, which meets their needs. EVIDENCE: The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who use the service who live there. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. The service finds creative solutions to issues with the environment in ways that are not necessarily dependent upon cost. The service goes that ‘extra mile’ to provide an environment that fully meets the needs of all residents and plans for the diverse needs of people that might use the service in the future. There is an excellent sensory room and the kitchens are designed so that they are Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 21 accessible for people with mobility difficulties, work surfaces are provided at two levels and the dining table can be adjusted according to suitability. People who live in the home are encouraged to see the home as their own. It is a very well maintained, attractive home and has very good access to community facilities and services. It has a wider range of up to date specialist equipment and adaptations to meet the individual needs of people who use the service, for example bedrooms have en-suite facilities with walk in shower and two of the bedrooms are fitted with tracking hoists. The environment is fully able to meet the changing needs of people, along with their cultural and specialist care needs. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment are designed to fit within the homely environment. The management has a proactive infection control policy and they work closely with their own staff and external specialists, such as NHS infection control staff, to ensure that infections are minimised. It is recommended that a stock of protective gloves be supplied in the laundry room. The kitchen and laundry are designed to enable and promote the involvement of people in domestic tasks and as part of developing or maintaining independence. Where there are concerns about the health and safety of anyone using the kitchen and laundry arrangements are fully risk assessed with the involvement of the person. Access is only limited when the completed assessment indicates such a need. The bathrooms are homely and include aids and adaptations to meet the needs of the people using the service. There are sufficient toilets to enable immediate access. All bedrooms promote high levels of privacy and have locks or other innovative ways of promoting privacy (such as keypads). All residents have a key to their own room unless a person centred risk assessment indicates otherwise. They also have a key to the front or outer door where this has been agreed in their plan. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An effective staff team supports people living in the home. EVIDENCE: People have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. Staff members undertake external qualifications beyond the basic requirements. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. There are enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for residents and is not led by staff requirements. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 23 All staff receive relevant training that is focussed on delivering improved outcomes for people living in the home. The home puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people in a person centred way. Staff confirmed that they had a comprehensive induction and training and records viewed supported this. It is recommended that training in Equality and Diversity be provided for staff also. There is a mostly good recruitment procedure that ensures that appropriate checks are in place for potential staff such as criminal bureau and POVA [Protection of Vulnerable Adults] list checks and two satisfactory references, records of interviews are also kept. A tighter system/new procedure needs to be in place for cross- referencing of documentation of information supplied by candidates and information supplied by agencies. This procedure should be followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Staff meetings take place regularly. Supervision sessions are regular and staff find them helpful with a focus on improving outcomes for people using the service. Notes and action points are taken of meetings and sessions, and progress is regularly reviewed. Staff spoken with told us that they have a good team ethos with a clear focus that people living in the home come first and that they are well supported and supervised. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people who live in the home. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and is a qualified nurse for people with Learning Disabilities. She is able to describe a clear vision of the home based on the organisation’s values and corporate priorities. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the manager who is able to demonstrate a high level of understanding and demonstrate best practice in these areas. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 25 Additionally the manager demonstrated a well developed awareness and understanding of equal opportunity issues, development and implementation of the service’s policies and procedures, and if appropriate the corporate organisation’s policies and procedures, good people skills, strong leadership of staff, and be responsive to the needs of people living in then home. The manager ensures that staff follow the policies and procedures of the home and those of the parent organisation also. Staff have practice handbooks and easy access to training materials and documents. Practice and performance are discussed during supervision, staff training and team meetings. Quality monitoring systems provide management evidence that practice reflects the home’s and organisation’s policies and procedures. There is strong evidence that the ethos of the home is open and transparent. The views of both people who use the service and staff are listened to, and valued. The operations manager was undertaking a monthly visit, during the inspection and we viewed appropriate records of previous visits. The AQAA contains excellent information that is fully supported by appropriate evidence. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to residents. The home demonstrates a high level of self-awareness and recognises the areas that it still needs to improve, and has clearly detailed the innovative ways in which they are planning to do this. The home fully recognises the importance of the annual quality assurance assessment and has used the content to inform its own quality assurance. The data section of the AQAA is accurately and fully completed and supports evidence in the selfassessment section. The home has efficient systems to ensure effective safeguarding and management of residents’ money and valuables, including record keeping. People are supported to manage their own money where possible. Those who do not currently have the skills are encouraged and supported to develop to become as independent as possible. [See also standard 23] The Environmental Health Officer, who visited the home in November 2007, identified that legionella controls needed to be recorded. Evidence was viewed at this inspection that compliance with this request had been achieved. The Environmental Health Officer praised the homes moving and handling equipment and the layout of the building. Health and safety systems are regularly reviewed and updated and are developed on the basis of experience in the home, outcomes for people using the service and learning from external developments. The manager ensures that all staff are trained in health and safety matters. Individual training records reflect this and regular updates are planned ahead. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 26 Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 4 3 4 4 4 5 4 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 4 25 4 26 4 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 4 3 X 3 3 X Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 28 NA 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 YA7 YA23 Refer to Standard Good Practice Recommendations Any limitations on facilities, choice or human rights to prevent self harm or self neglect or abuse or harm to others are made only in the persons best interests, consistent with the purpose of the service and the homes duties and responsibilities under the law. The service needs to ensure the individual understands and agrees any limitations imposed/used [such as use of lap belts, bedrails, use of monitor alarms etc]; and that they are fully documented and reviewed regularly. Further development of the menu in formats and which offer more than one option would improve this area of the service. Where prescriptions have to be handwritten on the medication administration record, two signatures should be in place to evidence appropriate checks have been undertaken to minimise risk of error. Provide staff with a clear policy and procedures for when DS0000070766.V360657.R01.S.doc Version 5.2 Page 29 2 3 YA17 YA20 4 YA23 Church Street 5 6 7 YA23 YA30 YA35 they go shopping with or on behalf of people living in the home in respect of the use of store advantage/bonus cards. The manager and deputy manager should seek to undertake training in the referral process under The Nottinghamshire Safeguarding protocol. It is recommended that a stock of protective gloves be supplied in the laundry room. Provide training for staff in Equality and Diversity and Bullying and Harassment. Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Church Street DS0000070766.V360657.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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