Inspection on 26/04/07 for Dunelm Nursing Home

This inspection was carried out on 26th April 2007.

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

Dunelm Nursing Home 19/01/06

Dunelm Nursing Home 28/07/05

Dunelm Nursing Home 28/02/05

Dunelm Nursing Home 06/10/04

Dunelm Nursing Home 19/03/04

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 Dunelm Nursing Home Grove Road Chadwell Heath Romford Essex RM6 4XJ Lead Inspector Jackie Date Unannounced Inspection 26th April 2007 01:00p DS0000025952.V337533.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 DS0000025952.V337533.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. DS0000025952.V337533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunelm Nursing Home Address Grove Road Chadwell Heath Romford Essex RM6 4XJ 0208 597 0429 0208 559 0938 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) www.rchl.org.uk Redbridge Community Housing Limited [RCHL] Mrs Margaret Lutchmiah Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000025952.V337533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Dunelm is a 12-place care home that provides nursing care for adults with learning disabilities. It is one of a number of homes run by RCHL, a not-forprofit organisation. The home was in the grounds of a hospital but this has now been closed and a residential estate has been built. Most of the residents have profound learning disabilities and additional physical disabilities. Residents have little or no verbal communication skills, and limited ability to make decisions about their lives. The home was purpose-built and the ground floor is accessible to wheelchair users throughout. The first floor has an office and staff area. The ground floor has two units each with five bedrooms (one shared) and a large lounge/dining area. The kitchen is between the two units. At present 11 people live at the home. Bedrooms are decorated and personalised, according to the residents’ likes. Some of the residents attend day services. The home has 2 minibuses and residents go out a lot. Activities and physiotherapy are provided in the home. The basic charge per week for each service user is £1237.28. The manager provided this information the day after the visit. Information about the service provided is contained in the service users’ guide. DS0000025952.V337533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 1:00pm. It took place over five hours. This was a key inspection and all of the key inspection standards were tested. Nursing and care staff were asked about the care that residents receive, and were also observed carrying out their duties. Where possible residents were asked to give their views on the service and their experience of living in the home. The staff and the residents were spoken to. All of the shared areas and bedrooms were seen. Staff, care and other records were checked. Relatives were contacted and asked for their opinions of the service. Feedback was received from three relatives. Feedback was also received from a care manager from the placing authority. This was a key inspection and all of the key inspection standards were tested. The inspector would like to thank the residents and staff for their input during the inspection. What the service does well: The manager and staff team are committed to developing the service and to enabling residents to have a good quality of life. Residents are well looked after and receive good personal care and good healthcare, which exceeds minimum standards. The residents have a lot of activities and trips in the community. In addition the staff team put a lot of effort into organising celebrations within the home and this also exceeds minimum standards. A local authority reviewing officer said “I would recommend this as a good service”. Relatives said, “our son is well cared for”, “my brother is well stimulated”, “they take care of the little but important things”. Staff have received the training that they need to provide a good service to the residents. Residents’ cultural and spiritual needs are met. This is in terms of dress and food and also those that wish to go to appropriate places of worship. This includes church, synagogue and temple. DS0000025952.V337533.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000025952.V337533.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection DS0000025952.V337533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5 People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so, and to be confident that the home meets their needs. Residents and their representatives have a written and costed contract/statement of terms and conditions and will therefore be clear about what they are entitled to. EVIDENCE: The organisation has an admissions procedure that includes the gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. Assessments are carried out before residents move into the home. They are made by trained nursing staff and detailed information about individuals needs and preferences are also gathered. Prospective residents are invited to visit the home and to gradually DS0000025952.V337533.R01.S.doc Version 5.2 Page 9 build up from short visits to overnight stays. There has not been any new residents admitted to the home since the last inspection. Each resident has a detailed care plan that contains information about what they can do, their likes and dislikes and what help and support they need. The staff team know residents well and know what they can do, their likes and dislikes and what help and support they need and can meet these needs. Most residents are unable to comment on what it is like to live in the home, but they all appeared to be happy and relaxed. The residents have a contract between themselves and the Housing Association/provider. These include information about individual financial arrangements. The contracts were available at the home. This means that there is clear information available about the service that will be provided to individual residents. DS0000025952.V337533.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs. EVIDENCE: Each resident has a care plan. These are very detailed and give clear information about each persons strengths, needs, likes and dislikes. For example “likes the garden”, dislikes pastry ”. They also indicate individual’s cultural and spiritual needs. For example “is a non practising Hindu but likes to go to the Temple periodically.” Health-care plans are also in place and these detail healthcare and nursing needs. The degree to which most residents can be involved in the development of the plan is very limited due to their profound learning and communication difficulties. However one resident is able to express himself and he is involved in developing his plan and is also able to choose who he wants to attend his review meetings. Each resident has DS0000025952.V337533.R01.S.doc Version 5.2 Page 11 a daily log and the staff record details of what the person has done, what care has been provided and how the individual has been. Residents have a key worker and also a named nurse. The care plans are reviewed and relatives are invited to these reviews. Relatives spoken to confirmed that they are invited to and do attend reviews. Information about residents’ needs is comprehensive and is kept up to date and therefore gives staff the information that they need to support each individual and to meet their needs. There are risk assessments in place. These identify risks for the residents and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. For example the support a resident needs when using a hydrotherapy pool, using a wheelchair, transferring from a wheelchair to a bed. DS0000025952.V337533.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents are supported to take part in activities, to be part of the local community, to celebrate their own and others cultures, special occasions and milestones in their lives. This exceeds minimum standards. Residents are supported to keep in contact with their relatives and relatives are made welcome at the home. This exceeds minimum standards. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: The residents all have profound disabilities and very high support needs. They are extremely dependent on staff. Some of the residents attend local day DS0000025952.V337533.R01.S.doc Version 5.2 Page 13 centres and others are supported to access activities by the staff team. One of the residents has a one-to-one worker to support her in activities. In addition some residents now receive support from an outreach worker to access the community. The residents go out a lot during the week. This includes shopping, bowling, swimming, cinema, and hydrotherapy. The home has the use of two adapted vehicles and a driver/handyman is employed. Residents go out to places of interest in the community or out for lunch. The sensory room in the home has been refurbished and new equipment purchased. It includes a ball pool, bubble tubes, music and other sensory equipment. Staff said that most of the residents really enjoy using this room. In addition every two weeks an organisation visits with additional sensory equipment. An aromatherapist visits every two weeks and some of the residents have aromatherapy sessions. Some residents go to the theatre at Southend and have been to see different shows. Tickets have been booked for more shows during the coming year. Residents are taken to different places to worship as required. This includes the church, the mosque and the temple. A relative said, “my brother goes out on a regular basis”. Special occasions are always celebrated at the home and family and friends are invited. There have also been big parties for residents’ special birthdays. On the Saturday after the inspection there was a party for a resident’s 50th birthday. They had a Christmas Party and celebrated Easter and St George’s Day. Diwali is also celebrated and the family of one resident provides the food. Some residents went on holiday to Centre Parcs last year and holidays are being planned for this year. Staff spoken to said that they are also trying to do more activities in the home. For example, making Mothers Day cards. The staff team are to be commended for the range of community and social activities offered to the residents and for their ongoing efforts to extend these further. This exceeds minimum standards. Several families and relatives are involved with the home and “the friends of Dunelm” has been set up for some time. Fundraising and social activities are organised by them. Relatives liaison meetings are held every 6 months. One relative said “I am delighted with the arrangements that they are making for by brother’s birthday celebrations. We are all looking forward to the party. Another relative said, “they bring my brother to see me and we go out for lunch”. Residents’ care plans contain information about their dietary needs and their likes and dislikes. For example “enjoys curry, is allergic to prawns”. “Needs a gluten free diet”. Residents use different plates and cutlery according to need. Some residents were given their food by the staff. Menus are based on staffs knowledge of residents’ likes, dislikes and needs. Fresh vegetables, meat and fish are used rather than processed food. The residents cannot always eat large pieces of hard fruit and therefore the cook buys soft fruits when available and also makes fruit salads. Two residents receive their food via a P.E.G. feed tube directly into the stomach and the nursing staff are trained to deal with DS0000025952.V337533.R01.S.doc Version 5.2 Page 14 this. The care plan for one of these residents gives clear instructions about using the P.E.G for ‘food’. This includes making sure the person is sitting upright. Therefore residents’ nutritional needs are met and they receive food they like. DS0000025952.V337533.R01.S.doc Version 5.2 Page 15 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 & 20. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents receive personal care that meets their individual needs and preferences. The principles of respect, dignity and privacy are put into practice. Care is taken to ensure that residents are nicely and appropriately dressed and this exceeds minimum standards Residents receive good quality health care. Medication is appropriately administered by the nursing staff. EVIDENCE: The residents all require a lot of support with their personal care and details of the help that they need and how they prefer to be supported are in their support plans. For example “offer a bath or shower”, “ wash hair twice a week”. It was evident that residents receive effective personal care and healthcare support in a person centred manner. This was observed by the inspector in the interaction between staff and residents in that staff were DS0000025952.V337533.R01.S.doc Version 5.2 Page 16 aware of non verbal signals that indicate likes, dislikes and the state of well being of residents. From viewing care plans, talking to staff, residents and relatives that staff are aware of the changing needs of the residents and that staff respect their preferences when providing support, including personal care. Whenever possible, even if to a very limited extent, residents are encouraged to be as independent as possible. Care plans also show that residents are encouraged to choose what they wear as far as possible. The staff team also make a lot of effort to ensure that residents are always appropriately dressed especially for special occasions and celebrations. In one resident’s room a set of clothing had been prepared and left with a note to say that this was the outfit for the party. The resident whose birthday party it was had been out to have a haircut ready for the party. His sister said, “they take care of the little, but important, things. Another relative said, “my brother always looks nice and that is important to him”. Several of the residents have “traditional clothing” and families either supply this or staff from the home purchase this, with residents as far as possible. This exceeds minimum standards. All of the residents are registered with a local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of nursing assessments and health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist, and when needed, the chiropodist. A physiotherapist visits the home twice each week and provides physiotherapy to the residents that need this. One resident has a special mattress on top of his normal mattress as he has painful joints and arthritis. Another resident has an electric bed and padded cotsides to prevent injury. All of these show that care is taken to make sure that residents are well looked after and kept as healthy as possible. Staff members are very alert to changes in mood, behaviour and general wellbeing and fully understand how they should respond and take action. It was apparent that staff would be very aware if a resident was in pain and they would monitor this and take any necessary action. Staff are trained and competent in health care matters. The home arranges training on health care topics that relate to the health care needs of the residents. None of the residents can self medicate and medication is administered by trained nurses. All of the nurses have had clinical update training and this included medication. There are policies and procedures for the handling and recording of medication. A random sample of Medication Administration Record (MAR) charts were examined and these were appropriately completed. Medication is appropriately and safely stored in locked cabinets. DS0000025952.V337533.R01.S.doc Version 5.2 Page 17 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 & 23. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a user-friendly complaints procedure that would be followed in the event of any complaints being made. Staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. Residents’ finances are appropriately managed and monitored and this lessens the risk of financial abuse. EVIDENCE: There is a complaints procedure and this is displayed in the home. However due to the degree of their disability it is unlikely that most of the residents would be able to make a complaint without support. However residents are able to demonstrate if they are unhappy with anything through facial expressions, behaviour changes or vocalisation. In discussions with staff they were able to demonstrate an understanding of this non-verbal communication. In addition one relative said that her brother always tells her if he is not happy about anything. She also said that he is happy there and looked after well. Another relative said that she believed her brother was well cared for and that her parents were very happy with the service and felt that it was the best place her brother had lived in. DS0000025952.V337533.R01.S.doc Version 5.2 Page 18 The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff spoken to were aware of the issues of abuse and aware of their responsibility to residents. They had received training on safeguarding adults and this subject also forms part of the LDAF (Learning Disability Award Framework) and the NVQ training. The home has an open culture and staff and relatives feel able to raise any concerns that they might have. Staff understand what restraint is and the use of any equipment that may be used to restrain individuals such as bed rails and wheelchair belts is decided within a risk assessment framework. All of the residents need help with their finances and most do not have the capacity to understand about the concept of spending or saving money. Some residents’ financial affairs are managed by their families. Others are managed by the head office. Records are kept of financial transactions. Regular checks are made by the manager to ensure that these are correct. The cash held for two of the residents was checked at the time of the inspection and were found to be correct. Appropriate receipts were on file. The organisation carries out annual financial audits. Therefore systems are in place to ensure that residents are protected from financial abuse and that residents’ finances are appropriately managed and monitored. DS0000025952.V337533.R01.S.doc Version 5.2 Page 19 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 & 30. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents live in a clean and comfortable home that has suitable aids and adaptations for their needs. The staff team continue to work to make the environment as homely as possible and are to be commended for their efforts. EVIDENCE: DS0000025952.V337533.R01.S.doc Version 5.2 Page 20 The home was purpose-built and is near to the local shops and bus routes. There are two units in the home and the communal space in each consists of a large lounge/diner. There is also a kitchen, laundry room and a garden. The ground floor of the building is accessible for wheelchair users throughout. Two residents share a large bedroom and the rest have single rooms. Special beds had been purchased for the residents that need these. The bedrooms are decorated and furnished to meet individual needs and likes. A lot of effort has been spent in making bedrooms comfortable and homely. They have nice curtains, bedding and soft furnishings. In addition most rooms now have sensory equipment and mobiles. The communal areas are large and quite difficult to make homely. However the staff team continue to put a lot of effort into improving the environment with soft furnishings, flowers and plants and photographs and make it ss homely and comfortable as possible. There is an ongoing programme of decoration and refurbishing to ensure that the home is well decorated, furnished and as homely as possible. Since the last inspection the hallways have been decorated and new carpets fitted and some bedrooms have been redecorated and have new furniture. One of the residents ‘helped’ with the decorating. The mother of one of the residents passed away and the family have purchased a summerhouse for the garden in her memory. The handyman had just put the finishing touches to this and this will be a nice space for residents to spend their time. There are enough baths, showers and toilets and these have the aids and adaptations to meet the residents’ needs. New flooring has been fitted in the bathrooms and new cupboards have been fitted. This improves their appearance. The kitchen is appropriately equipped and is clean. Food was appropriately labelled and stored. The cook carries out the necessary checks to ensure that the environment meets the necessary standards of hygiene and that residents’ food is prepared in line with good food hygiene practice. At the time of the inspection the home was clean and free from offensive odours. There is an infection control policy and advice is sought from external specialists if the need arises. DS0000025952.V337533.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents are supported and protected by the organisations recruitment practice, including the recruitment of bank and agency staff. Staffing levels are sufficient, and staff receive the necessary training, supervision and support, in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that know them well and who are committed to providing a good quality service. EVIDENCE: The staff team comprises nurses and support workers. Shift leaders are all qualified nurses. In addition there is a cook, a domestic and a driver/handyperson. The staff team have experience of working with people with learning disabilities and have access to a wide range of training courses. All staff have to complete the LDAF (Learning Disability Award Framework) as part of their probationary period. Most of the staff have NVQ level 2 and/or DS0000025952.V337533.R01.S.doc Version 5.2 Page 22 level 3. Staff spoken to said that there is comprehensive training available and that this included food hygiene, fire safety, moving and handling and safeguarding adults. The nursing staff have recently completed clinical update training. Staff were clear about their duties and responsibilities towards the residents and have the skills to meet the residents’ needs. The home is fully staffed now and any additional shifts are usually covered by the staff team. Therefore residents receive a consistent service from a staff group that are aware of their needs and how to meet them. The staffing on the early shift is one team leader (a qualified nurse) and four support workers. The late shift has one team leader (a qualified nurse) and three support workers. At night there is one team leader (a qualified nurse) and two support workers. Feedback from staff, relatives and other professionals was that staff availability was satisfactory. Staffing levels are sufficient to meet the residents’ needs. Staff have job descriptions and in discussion were clear as to their individual role in the home. An inspection, at the organisations head office, of a sample of personnel files showed that the previous requirements with regards to staff recruitment and checks have now all been addressed. The organisation worked cooperatively with the Commission and reviewed their procedures and all of their staff files. They then took the necessary action to address any shortfalls and to ensure that the future recruitment procedure would be robust and would safeguard residents. A random sample of staff records were checked during the inspection and were found to contain the required information. Staff meetings and staff supervision have been taking place regularly, providing staff with the opportunity to discuss problems and to be involved in the development of the service. Staff spoken to said that there is very good communication and teamwork in the home. DS0000025952.V337533.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The home is very well managed and provides a safe environment for the residents and this exceeds minimum standards. EVIDENCE: The manager has substantial experience of services for people with learning disabilities. She is an enrolled nurse, a registered learning disabilities nurse and has obtained a Certificate in Management Studies and a Postgraduate Diploma in Health Service Management. Staff, relatives, and as far as possible, residents are involved in the running of the home and discuss any developments and changes. A local authority reviewing officer said, “they provide a good service. There have not been any complaints from relatives or DS0000025952.V337533.R01.S.doc Version 5.2 Page 24 residents.” A relative said, “ there are no problems at all.” Another relative said, “the staff and manager are excellent”. The manager communicates a clear sense of direction and staff are aware of the standards that are expected of them. She also promotes equality and diversity issues and is aware of good practice issues. The quality of the service provided to the residents is monitored by the manager and by the organisation. The service manager carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. These indicate the action to be taken when deficiencies are identified. Copies of these reports were available in the home and copies are sent to the Commission. In addition to this the organisation carries out a quality audit each year and also a financial audit. All of the necessary health and safety checks are carried out and records are kept of these checks. The home has a comprehensive range of policies and procedures to promote and protect residents’ and staff safety. Staff receive the training that they need to understand and use these. Staff carry out monthly health and safety audits and every three months a ‘housing officer’ from the head office carries out a more in depth audit. Therefore the organisation also monitors health & safety. All the working practices in the home are safe and there have not been any preventable accidents. Records show that there are very few accidents at all and staff and relatives confirmed this. A safe environment is provided for the residents. During last year an inspection of a sample of personnel files at the organisations head office showed that not all of the required staff records were maintained. This was discussed with the organisation and the Commission received an action plan of how this was going to be addressed. A further visit to head office confirmed that all of the necessary action has been taken and that the necessary records are kept. All records inspected were appropriately kept and up to date. The requirement with regard to records has therefore been met. There was a significant incident at the home at the end of last year. This was appropriately dealt with and the necessary action taken. The Commission was notified of this as required by the previous inspection. DS0000025952.V337533.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. 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 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 X 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 4 4 X 3 4 X DS0000025952.V337533.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000025952.V337533.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 DS0000025952.V337533.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!