Inspection on 09/08/05 for Coleraine Road 30 & 37

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Coleraine Road 30 & 37 09/01/07

Coleraine Road 30 & 37 27/02/06

Coleraine Road 30 & 37 04/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 30 & 37 COLERAINE ROAD London N8 0QJ Lead Inspector Peter Illes Unannounced 9 August 2005 @ 09.40 am 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 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 Stationary 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. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 30 & 37 Coleraine Road Address 30 & 37 Colegraine Road, London, N8 0QJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8888 4348 020 8888 4348 Mr Edward W Marcus Mr Edward W Marcus PC Care Home 8 beds Category(ies) of LD Learning Disability registration, with number of places 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 8 adults with a learning disability (LD) not to exceed 4 accommodated at 30 Coleraine Road and 4 accommodated at 37 Coleraine Road. Date of last inspection 5 October 2004 Brief Description of the Service: The Coleraine Project is made up of two mid-terraced houses located opposite each other in Coleraine Road. The project is located in a residential area of Wood Green North London, less than a 100 yards from Wood Green High Road and the extensive shopping, transport and leisure facilities that the area has to offer. The two houses, which comprise the project, are registered as one care home offering personal care and support for up to eight service users whose primary need for care is that they have a learning disability. There are four bedrooms in each house, and the communal areas comprise of a lounge, kitchen diner, utility room and back garden. Both houses have a ground floor toilet, and first floor bathrooms and additional toilet. Neither house has been adapted to provide for service users with a physical disability. The registered provider both owns and manages the home. The staff team of the project work in both houses to ensure that they become familiar to all the service users. The aim of the service is to provide a home, which encourages and supports service users to build a ‘home life’ and participate actively in a lifestyle, which reflects their values and preferences. In addition, the home aims to promote the independence and integration of service users with the local community from a secure and homely base. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took approximately six hours. The senior support worker for the home was on duty at the time and was available or present throughout. There were eight service users accommodated and no vacancies. One service user was due to move to alternative accommodation soon after this inspection. The inspection consisted of: meeting six of the service users and independent discussion with three of them, discussion with the senior support worker and independent discussion with two other staff members. The inspector also spoke briefly to the registered manager who attended the home during the inspection to accompany one service to lunch and briefly to the home’s handy person. Further information was obtained from a tour of the premises, a pre-inspection questionnaire and comment cards that had been distributed earlier as well as documentation kept in the home. What the service does well: The home provides good quality care and opportunities to develop new skills to service users, some of whom have complex needs. Service users enjoy a wide range of activities including opportunities to develop their skills in the home, in the community and on exciting holidays abroad. Staff enjoy a wide range of training and development opportunities and are effectively supervised and supported. The home is particularly good at obtaining feedback from service users and others to help improve the support and care offered by the home. The home also has a strong commitment to the health and safety of all those that live in, work at or visit the home. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 6 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Prospective service users can be confident that their aspirations and needs will be assessed to ensure that these can be met should they move into the home. They can also be confident that when admitted to the home these needs will continue to be regularly assessed to allow their changing needs to be met. EVIDENCE: No new service users had been admitted to the home since the last inspection. Three service user files were inspected and each contained a range of assessment information for that service user that was supplied to the home at the time of their admission. The assessment information seen was detailed, multi-disciplinary and included a relevant hospital discharge summary where appropriate. There was also evidence that the service users needs continued to be monitored and reviewed on a regular basis and included an up to date monthly summary of their needs that was kept on each file inspected. There was also evidence of referring authority reviews on two of the three files inspected. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users assessed and changing needs are well documented in their care plans to assist the home’s staff and relevant others meet these needs. They are supported to make informed decisions about their daily lives with any restrictions being agreed with them and recorded. Service users are also supported to take appropriate risks in their lives to assist them to safely achieve their aspirations. EVIDENCE: Each of the three service user files inspected contained a detailed care plan. These gave clear guidance on how service users were to be assisted in meeting their identified assessed needs. There was evidence that the service users were involved in the development and monitoring of their care plan and service users spoken to independently confirmed this. Evidence was seen that each care plan was reviewed on a monthly basis and the record of this was signed by both a staff member and by the service user. The plans were also seen to be directly informed by current risk assessments. Service users spoken to indicated that they are well supported to make decisions for themselves. Seven of the eight service users can all travel 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 10 independently in the local area and some further a field on routes they are familiar with. One service user told the inspector that they wanted to move on from the home as they had lived there for a number of years and wanted a change of environment. There was evidence on file that the home had assisted the service user negotiate this with their relevant referring authority and plans had been made for that service user to move to another home in the near future. One service user had a significant restriction on their liberty while physically in the home that included a high degree of staff intervention throughout the waking day and related restrictions at night. This was clearly documented in a current risk assessment and on the service user’s care plan. Evidence was also seen that this regime had been agreed with the service user and with relevant stakeholders including the person’s referring authority. Each service user file inspected contained a range of relevant risk assessments that gave clear guidance to staff on how to minimise the identified risk. Staff spoken to independently were clear about the issues involved regarding individual service users. They were able to explain in practical terms the actions they needed to consider in given situations. A recently reviewed risk assessment and amended care plan for one service user was not on the service user file when inspected. When the inspector queried this the documentation was produced. It was not physically on the file at the time as it was in the process of being circulated to all staff for them to read and sign that they understood the current situation for that service user. Staff spoken to were able to show an understanding of the support this service user needed and the reasons for it. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Service users enjoy a range of appropriate activities including within the local community and impressively they also enjoy regular holidays to long haul destinations abroad that contribute to enriching their social lives. Contact with relatives and friends is maintained and encouraged in accordance with the service users wishes. Service users rights are responsibilities are respected with any limitations agreed with them. They also enjoy balanced and varied meals of their choice that they are actively encouraged to produce. EVIDENCE: Three of the eight service users attend external day services and one attends a local education college. One service user spoken to independently was adamant that they did not want to go to work or college. They were clear that they were happy with their current routine of going out independently and undertaking activities planned by the home. Evidence was seen that staff were working with individual service users to develop a document called a communication passport. One of these was seen and contained evidence that service users were supported to record in this their likes and dislikes as well as 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 12 their aspirations for the future. The inspector was informed that this would lead on to developing individual person centred plans. The process of developing the communication passports allowed staff and service users to explore options for service users to try out new experiences including identifying valued daytime activities for them to undertake. Service users are able to access the varied local community resources including shops, pubs, restaurants, cinema and recreational facilities. Evidence was seen that one service user enjoys swimming and is supported by staff to attend a local swimming pool twice a week. The majority of service users and staff enjoy football practice on a Wednesday evening at a local recreation facility and evidence was seen that the service users were about to take part in an East London football tournament. Service users spoken to were excited about this. Service users are also supported to go on holidays abroad each year, often to exotic long haul destinations. All the service users had been on holiday to Malaysia in February 2005 and those spoken to clearly enjoyed this. The inspector was informed that holiday destinations in previous years have included Croatia, Mexico, Thailand and Goa. The inspector was informed that service users had recently gone on a day trip to Brighton and that other day trips were being considered over the summer. All but one service user has regular contact with relatives to the extent that they wish. Evidence was seen of support needed with this on one of the care plans sampled. One service user did not have any relatives. Two service users spoken to confirmed that they had regular contact with relatives, both by relatives visiting the home by them visiting relatives in their own homes. Service users are encouraged to have contact with friends as they wish and evidence was seen on one care plan of staff support needed to assist the service user avoid situations were they may become unduly vulnerable. Service users confirmed that they had keys to their rooms and, where appropriate, keys to the front door of the home. Where the latter was not considered appropriate for one service user it was seen recorded on their care plan. Service users confirmed that they could choose when to be on their own and when to be with others in the home. There are clear rules on the use of alcohol and regarding smoking that service users spoken to were aware of. There was a detailed risk assessment and appropriate record on the care plan for one service user who was a heavy smoker. The home had a four weekly menu with evidence that service users were involved in planning at monthly service user meetings. Meals are prepared, cooked and eaten in the kitchens of both houses. Service users are actively encouraged to be involved in the preparation and cooking of meals. The inspector was impressed by the individual support given to service users regarding this. Records of individual sessions with service users were seen and included sections on what was needed, a shopping list for the identified meal, detailed small step instructions on how to cook the meal and a feedback 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 13 section. The home had also developed a detailed menu book with colour photo’s and small step instructions for each of the meals. One service user enjoyed a cookery session supported by staff during the inspection and feedback to the inspector was that the meal cooked was chicken curry and this was enjoyed by all those who ate it. Another service user went out to lunch on the day of the inspection accompanied by the registered manager who attended the home on the day for that purpose. The service user was keen to tell the inspector about this. The kitchens in both houses were inspected and were clean, tidy and generally satisfactory. The food was stored appropriately and matched the menu. Satisfactory records of fridge and freezer temperatures were seen. One of the kitchen floors had been identified by the home as needing to be tiled and evidence was seen that arrangements had been made to deal with this. A general requirement about a range of planned maintenance tasks is made in the environment section of this report. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Service users receive appropriate personal support in accordance with their needs and preferences. Their healthcare needs are met on an individual basis including being supported to attend health screening appointments. Service users are protected by robust polices and procedures regarding medication and its administration although an identified issue with the dispensing pharmacist needs addressing. EVIDENCE: None of the current service users need direct physical assistance with their personal care although some require verbal prompts on occasions. Directions to staff on this were seen recorded on one of the care plans inspected. Service users spoken to indicated that they were happy with the assistance they received regarding their personal care generally. Service users were dressed appropriately in clothing of their choice and those spoken to confirmed that they bought their own clothing with support from staff as necessary. Service users also confirmed that they were no rigid going to bed or getting up times and that within reason they had a satisfactory degree of flexibility in their day to day lives at the home. Records indicated that all service users were registered with a local GP. One service user had an identified medical condition with evidence seen that this 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 15 was being appropriately monitored. Evidence was seen that service users were supported to attend a range of appointments with healthcare professionals and, since the last inspection, these had included appointments with: GP, psychiatrist, dentist, optician and chiropodist. There was also evidence on some files seen that service users are also offered annual health checks by their GP. The inspector was informed that seven of the eight service users were assisted with the administration of prescribed medication. There was evidence that all staff had received safe administration of medication training the previous year. The homes medication policy was sampled and included a satisfactory section on home remedies and authorisation for a homely remedy from a GP was seen on one of the files inspected. Medication and medication administration record (MAR) sheets are kept for the relevant service users in both houses and these were sampled. There was a satisfactory record seen for the temperature of the medication cupboard in each house along with satisfactory records of medication received and ordered and related guidance to staff. Evidence of generally satisfactory administration of medication was seen in both houses. It was noted that there was medication recorded by the dispensing pharmacist on the MAR sheets for two separate service users that had been discontinued by the GP. One of these was for PRN medication (to be administered as required). Staff spoken to were clear about the current medication requirements for those service users and records inspected indicated that the correct medication was being administered. A requirement is made however that the home ensures that the MAR sheets are accurately completed by the dispensing pharmacist when received by the home to minimise the possibility of mistakes being made. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Service users and relatives are able to express their views and concerns and have these appropriately dealt with by the home. Service users are also protected by a satisfactory adult protection policy that staff are aware of. EVIDENCE: The home has a satisfactory complaints procedure that was seen. Evidence was seen in each of the service user files inspected that they had been supported by staff to sign to indicate that they had received a copy of the policy and understood it. Two complaints had been received at the home since the last inspection, both were made by a service user about another service user. The complaints record showed that staff had dealt with these appropriately. The home operates a rolling programme whereby each staff member is informed in writing that they will be expected to ensure they are up to date with identified current policies and procedures and that they would be expected to evidence this in the near future. Each staff member then receive a questionnaire about the identified policies that had to be returned to their supervisor. This had recently occurred with the complaints policy and the inspector sampled returned questionnaires that were satisfactory. The inspector was told that this was an ongoing process to ensure that staff kept up to date with all the home’s policies and procedures. Staff spoken to indicated that this was a helpful process and the inspector’s view was that this was a clear demonstration of good practice. Service users spoken to confirmed that they knew how to make a complaint if they needed to. A satisfactory and detailed adult protection policy and guidance to staff was seen. The home also had the local authority adult protection policy and procedure for the local authority the home is situated in. Evidence was seen 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 17 that staff received both in-house and local authority training on adult protection since the last inspection and staff spoken to confirmed this. The home also had a satisfactory whistle-blowing policy that was seen along with evidence that this had been included in a recent questionnaire to staff using the same process as outlined in the complaints policy paragraph above. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 Service users live in a home that is comfortable, well decorated and well maintained although some routine maintenance items need to be attended to. The home was clean and tidy throughout creating a pleasant environment for those that live and work at the home as well as for those that visit it. EVIDENCE: The home consists of two separate mid-terrace houses in a residential area close to the main Wood Green shopping centre with good public transport. All accommodation is for service users who are physically able and there are no facilities for service users with physical disabilities. On a tour of the two buildings a number of routine maintenance items that needed attention were noted. The senior support worker showed the inspector evidence that arrangements had been made for these to be attended to and that he expected these to be completed within a month. A handyperson visited the home during the inspection and confirmed this. The items identified were: the wooden floor in one kitchen was badly marked and was due to be tiled; one of the dining rooms needed new wallpaper, an identified door closure needed adjusting so that it did not close so fiercely; a carpet strip needed replacing in one bedroom 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 19 doorway; the wall in one lounge needed repairing after damage from a chair; some cracked tiles in one laundry room needed replacing and an identified area on the hall and landing in one house needed replacing. A requirement is made regarding these maintenance items. Apart from these identified items the home was generally well decorated, maintained and provides a comfortable and domestic type environment that meets the current service users needs. The home was clean and tidy on the day of the inspection. Laundry facilities in both houses were domestic in scale and were appropriate for the needs of the service users. The home had a satisfactory infection control policy and procedure and the inspector was informed that this had been the subject of a recent staff questionnaire to ensure staff were familiar with the policy. There was also evidence that staff had undertaken infection control training since the last inspection. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 & 36 The home has a well qualified staff team, in sufficient numbers, to support service users and to assist in meeting their assessed needs. Staff are offered a wide range of relevant training, including qualification training, to assist them in their own personal development and in meeting service users needs. Staff are also well supervised and supported to further enable them to develop their own potential that also contributes to their ability to meet service users needs. EVIDENCE: The staff rota inspected showed the following minimum number of staff on duty: the early shift, two staff members at one house and one staff member at the other house with one staff member floating between the two; the late shift showed two staff members on duty at both houses and one sleeping-in staff in each of the two houses at night. This level of staffing was satisfactory to meet the needs of service users accommodated at the time of the inspection. The staff rota clearly indicated who was the lead person on the shift if there was not a senior member of staff on duty. The staff on duty matched those recorded on the rota. No new staff had been recruited since the last inspection. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 21 There was substantial evidence to show that the home was committed to a range of staff training. A training folder was seen that contained individual staff training profiles and these were sampled; these profiles showed the core training undertaken and when this was due to be renewed. These also showed evidence that identified staff had undertaken a range of training courses including in the following since the last inspection: multi-media advocacy pilot course – linked to developing communication passports and person centred plans, infection control, healthy food preparation, moving and handling and fire prevention. The inspector was informed that five of the ten care staff employed had either completed or were in the process of completing the national vocational qualification (NVQ) level two in care. This complied with the requirement for fifty percent of staff to hold this qualification by the end of 2005. Staff spoken to confirmed the training courses and qualification training they had undertaken since the last inspection. Evidence was seen that staff received formal supervision monthly and that this is recorded with notes received by the staff member involved. A detailed format for supervision was seen that was satisfactory. The senior support worker stated that he supervised all the support workers and received supervision himself from the registered manager. Evidence was seen that the senior support worker had undertaken training in 2004 on how to supervise staff. In addition the home operates an annual staff appraisal scheme. This was seen to be comprehensive and included peer review of, and by, colleagues as an element in the process. The format was sampled and the inspector was impressed by this and the positive feedback received by staff spoken to independently about the process. From each appraisal a summary and annual development plan is agreed for the staff member. These were sampled and were of high quality. Staff spoken to stated that staff meetings are held regularly and that these were constructive and helpful. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 The home has a commendable range of ways of monitoring quality at the home to ensure that service users views are able to contribute to the development and ongoing improvement in the service they receive. Robust health and safety procedures in the home protect service users, staff and visitors to the home. EVIDENCE: The home has a commendable range of effective quality control mechanisms that were sampled. The home asks service users for regular feedback on the quality of the service they receive. This is in pictorial and accessible formats as well as written questionnaires. The latest round of consultation had occurred since the last inspection and on the one questionnaire sampled the service user involved was seen to have signed the form. In addition to this the home holds monthly house meetings were each service user’s views are recorded. The senior support worker also undertakes unannounced visits to the home at random times to undertake mock inspections. At these he invites staff to 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 23 demonstrate their knowledge of service user needs and the homes systems. The senior support worker stated that he found these mock inspections useful as it assisted in evaluating staff skills and possible areas for development. He went on to say that it also gave staff a degree of confidence for if they should be the lead worker on duty when a CSCI unannounced inspection takes place. From all of this information an annual development plan is written and a satisfactory 2005 development plan was seen. The inspector was pleased to note that service users as well as staff had some understanding of this process. One service user spoken to liked to write to senior staff on a regular basis with any observations or comments that service user may have, the inspector sampled copies of these letters which gave feedback on a range of issues relevant to that service user. A range of satisfactory health and safety documentation for both houses was inspected that included: gas safety certificates, electrical installation certificates and portable appliance testing. Satisfactory fire documentation including servicing of the fire alarms and fire extinguishers was seen along with the fire risk assessment and the fire plan. This provided satisfactory evidence that the health and safety of both the service users and staff remain a priority for the home. 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 30 & 37 COLERAINE ROAD Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 25 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. 1. Standard 20 Regulation 13(2) Requirement The registered person must ensure that the service users MAR sheets are accurately completed by the dispensing pharmacist when they are received by the home to minimise the possibility of mistakes being made. The registered person must ensure that planned maintenance items, identified in the environment section of this report, are satisfactorily completed within the agreed timescale. Timescale for action 31/8/05 2. 24 23(2) 30/9/05 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 none Good Practice Recommendations 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London, N14 6HA 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 30 & 37 COLERAINE ROAD G59 S10714 Coleraine Road V231697 09.08.05 Stage 4.doc Version 1.40 Page 27 - 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. 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