Inspection on 05/07/06 for Eastfield Residential Home

This inspection was carried out on 5th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eastfield Residential Home 04/07/07

Eastfield Residential Home 21/02/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Sign Health

Springwood

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

CARE HOME ADULTS 18-65 Eastfield Residential Home Eastfield Residential Home Wawne Road Hull East Yorkshire HU7 5YS Lead Inspector Angela Sizer Unannounced Inspection 5th July 2006 09:00 DS0000064775.V302550.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 DS0000064775.V302550.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. DS0000064775.V302550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastfield Residential Home Address Eastfield Residential Home Wawne Road Hull East Yorkshire HU7 5YS 01482 838333 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) Eastfield Residential Home Limited Ms Jane Fenton Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (20) DS0000064775.V302550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21.02.06 Brief Description of the Service: Eastfield Residential Home lies to the north of the City of Hull, near to Wawne village. The home is positioned in its own grounds just off the main road on a main bus route leading to the nearby Bransholme shopping centre. Hull city centre is approximately 8 miles away. It is a family run home and the registered provider is also the registered manager. Eastfield Residential home is registered as a care home providing accommodation and personal care for 20 residents who have enduring mental health problems. Recently a new extension has been completed adding a further 6 bedrooms reducing the number of double rooms to three, a small communal lounge, bathroom/shower room and a drinks making area for the residents. In the original part of the building there are three lounges (1 smoking) and a dining room, an office, kitchen, laundry, toilet and bathroom facilities and the majority of bedrooms. On the first floor there is one bedroom for shared occupancy. This bedroom has an en-suite facility. Access to the first floor is by means of a staircase. All new residents are given a service user guide explaining what the home will provide. The weekly fees range between £295.00 and £327.00, this information was provided by the registered provider during the inspection visit. Additional charges are made for hairdressing, magazines, some toiletries and some transport. DS0000064775.V302550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was part of the key inspection process and took place over one day and took a total of 7 hours. Prior to the visit surveys were posted out to; 19 residents and 11 were returned, 6 relative surveys were returned, 12 were sent to staff members and 5 were returned, of the health and social care professionals 11 were returned and 1 of the general practitioners returned the survey. The registered provider returned the pre-inspection questionnaire and this gave some details about the service including staffing. From this information the decision was made about which staff and resident files would be looked at. A tour of the building was undertaken, some of the records looked at included 3 resident files, 3 staff files, the medication procedure and other paperwork relating to the maintenance of the home and the care of the residents. Several of the residents and two staff members were spoken to throughout the course of the day to find out what it was like for people who live here. The previous requirements were discussed with the manager and the majority have now been met, it should be noted that the staff and manager have worked very hard in order to improve the standards offered at the home. A discussion with the manager occurred regarding how the residents are currently supported to follow their religion of choice and practise their faith. Other issues such as physical needs including epilepsy and diabetes have caused problem areas for staff, training courses have being undertaken to ensure that all residents are treated equally and not excluded because of a diverse need. The registered manager/registered provider was present throughout the inspection and was told how the inspection had gone at the end of the day. The inspector would like to thank the residents, manager and staff for welcoming her into the home and contributing to the content of this report. What the service does well: DS0000064775.V302550.R01.S.doc Version 5.2 Page 6 The home continues to offer a very high standard of accommodation and the environment is clean, hygienic and the atmosphere is friendly and welcoming which makes Eastfield a very nice place to live. Some residents said, “it is lovely, my room and the staff are wonderful”, “I like it here and my family can visit whenever they want to”. All of the 11 surveys from social and healthcare professionals were very complimentary and spoke highly about the care, staff and management of the home, some comments included; “good well run home”, “homely and a good atmosphere”, “professional and have helped difficult to help residents”, “quality of care is the best in the area” “an excellent provision of care”. The care offered maintains and promotes independence and daily living skills, residents are supported to carry out activities/hobbies or chores within the home as part of their care plan. From speaking to some of the residents it was clear that they have good relationships with the staff, some comments included; “the staff are wonderful, always helping us”. Staff were observed interacting with the residents throughout the day and this was done in a nonjudgemental, but supportive way. The menu is nutritious, wholesome and choice is offered, some comments from residents included; “the food is lovely, we get different things everyday”, “the cook will do you anything you like”. The home’s quality assurance system ensures that residents and other people who visit the home have their say about how it is run, what is good and what needs changing. What has improved since the last inspection? In relation to choice and restrictions during this visit several of the residents including those who had made the comments during the last inspection were spoken to, this time they confirmed that “things had improved, we all have keys to our rooms”, “we can make drinks in the residents’ kitchen and take a bath whenever we like”. From speaking to the manager it was clear that attention has been paid to these areas and residents’ are now able to make their own drinks between 10am and 11pm in their own small kitchen, which has recently being built. All residents are offered a key to their room unless a risk assessment states otherwise and the manager explained that since the last inspection respect and privacy has been discussed in supervision with staff. DS0000064775.V302550.R01.S.doc Version 5.2 Page 7 Training has improved and all new staff undertake the Skills for Care induction and foundation courses within 6 months of employment commencing, this ensures that the staff on duty are trained and competent to undertake the responsibilities expected of them. More than 50 of the staff group have obtained NVQ level 2 or above. The medication procedure has improved since the last inspection particularly the recording onto the Medication Administration Records. The manager stated that monitoring and observation has been taking place to ensure that all staff understands the importance of this procedure. 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. DS0000064775.V302550.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000064775.V302550.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People’s needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. EVIDENCE: During the visit several of the residents were spoken to and they gave their views about the home and what it was like for them when moving to Eastfield Residential Home. Comments included “I visited the home before coming to stay”, “I came to meet the staff and other residents, I had a look at my room and decided that I wanted to come here”. Three residents’ case files who had recently come to stay in the home were looked at, this was to find out if their needs had been properly assessed. There was evidence to confirm that prospective residents are visited and an assessment undertaken detailing whether the home can meet that person’s needs. On each of the resident’s file was an assessment both from the Social Services Department and one that the home had developed, these clearly define what support is required. Surveys returned from six relatives stated that the staff are very caring and high standards are maintained. Surveys returned from 11 social and DS0000064775.V302550.R01.S.doc Version 5.2 Page 10 healthcare professionals were very complimentary about the standard of care offered. DS0000064775.V302550.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans and risk assessments are in place, but not specific about what staff should do and when. Residents are enabled to make decisions and choices about their lives, support is offered when necessary to achieve this. EVIDENCE: Three residents’ files were looked at all of which were fairly recently admitted into to the home. All of the files contained two care plans one that the Care Management team had prepared and one that the home had developed. Although the manager stated that these had been updated since the last inspection it was still unclear about what tasks staff are required to do and when. The care plans require further amendment and must be prescriptive giving clear direction to staff telling them what action is required and by whom and how regular the intervention would need to be. Other more specialised DS0000064775.V302550.R01.S.doc Version 5.2 Page 12 intervention (dementia) is not described in depth in particular for those residents who require a lot of input. Risk assessments have been updated since the last inspection, these do not fully cover all areas and mainly focus upon risk and relapse of mental health, other areas require developing including the risk of falls, mobility, epilepsy. Both care plans and risk assessments do not included information about who does what and when. 11 surveys were returned from residents 10 of them stating that they are given encouragement to lead an independent lifestyle and that all their needs were catered for. 1 resident stated on the survey that they sometimes do not like living in the home and staff do not always treat the residents’ well. During the visit this person was spoken to and could not remember why these comments had been written, they also confirmed that staff treat the residents’ well, ensuring privacy is respected and independence promoted. Several of the residents stated that staff respect their privacy, comments included; “staff usually knock before coming into my bedroom”, “the staff are very good you couldn’t ask for better”. During the last inspection it was identified from speaking to residents that their were restrictions in place in relation to making drinks and taking a bath when they wanted to, these were detailed in the report and requirements made. During this visit several of the residents including those who had made the comments were spoken to, this time they confirmed that “things had improved, we all have keys to our rooms”, “we can make drinks in the residents’ kitchen and take a bath whenever we like”. From speaking to the manager it was clear that attention has been paid to these areas and residents’ are now able to make their own drinks between 10am and 11pm in their own small kitchen, which has recently being built. All residents are offered a key to their room unless a risk assessment states otherwise and the manager explained that since the last inspection respect and privacy has been discussed in supervision with staff. Staff were observed during the visit to interact with residents and offer care in a sensitive and understanding way. Two members of staff were spoken to during the visit about what the residents’ needs were, both staff could clearly describe what support the residents required and how this was undertaken, they gave clear accounts of the residents likes, dislikes, symptoms of declining mental health and what backup support may be required. The staff team is experienced, professional and caring offering support in an anti-oppressive manner. DS0000064775.V302550.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 11,12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported to live their lives as they wish to with regard to partaking in activities, hobbies and interests, staff supported them to do this. Residents are able to develop and maintain relationships both inside and outside of the home. The menu offered is varied and nutritious, residents receive a healthy and balanced diet. EVIDENCE: During the visit the majority of the residents’ were either spoken to or given the opportunity to talk to the inspector about what it was like for them living in the home, some of the comments included; “This is an excellent home and I have no qualms”, “I have settled in well, my room is lovely and the staff are wonderful”, “I have a key to my room and can have a bath whenever I want to”, “Staff always knock before coming into my room”. From observation staff were seen to interact with residents in a caring and thoughtful way, chatting to DS0000064775.V302550.R01.S.doc Version 5.2 Page 14 residents whilst offering support. Written evidence was on residents’ files confirming that all are offered a key to their room, unless a risk assessment states otherwise. During discussion with the manager it was clear that the new residents’ kitchen has been a success, it is unlocked between 10 am and 11 pm as it is situated next to a bedroom and would disturb that resident if open all of the time. She also stated that all residents’ are offered a key to their door and bathing is only recorded as a minimum of 2 baths per week, this is to promote the self-care to residents and ensure that they maintain their personal hygiene, the manager stated that “no restriction or limit is placed upon the number of baths/showers a resident may take”. During the site visit lunch was observed, the dining room is pleasant, bright and homely. The meal itself consisted of sausage, egg and tomatoes followed by a selection of home made cakes, the meal was well presented and plentiful. From speaking to the majority of residents it was evident that they enjoy their mealtimes in the home, some comments included; “the food is marvellous, you couldn’t get much better”, “there is always a choice, if I don’t like something I just say and I can have whatever I want”. The menu is on a rotating three-week cycle and a copy of this was forwarded to the Commission for Social Care Inspection prior to the visit. It is varied, healthy and nutritious offering a variety of foods and catering for all tastes. The home offers a lighter lunch and a cooked dinner at tea time, supper is also served, drinks are available at set times on a regular basis throughout the day, in addition the residents’ kitchen is now in place and the majority of residents are able to make their own drinks as they choose. 11 residents returned the surveys confirming that staff support residents in maintaining family links, friendships and relationships inside and outside of the home. 5 relatives returned the surveys also commenting about how well the home is run and that the food is very good. From speaking to several residents it was clear that relationships and friendships are fully supported, one person explained that they have many friends in the area and often go and visit. The manager stated that the local community is accepting of the home and residents and include them in community events. Several of the residents attend the church or religion of their choice, this is fully supported by the home. One resident stated, “I go to church every week”. Residents are encouraged to attend education, community centres and local events, written evidence of this was present in residents’ files and this was confirmed when speaking to the residents themselves. During the inspection visit, five residents had gone out for the day to Sewerby Hall in Bridlington with a community group who are currently offering support to the residents with literacy and living skills. Another resident had gone on holiday with family. DS0000064775.V302550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The residents’ personal and healthcare needs are fully met. The medication procedure ensures the residents’ safety. EVIDENCE: Overall the personal support is delivered in a caring and appropriate manner, residents confirmed this when speaking to them, relatives and other professionals commented about the excellent care offered in the surveys that were returned to the Commission for Social Care Inspection prior to the inspection visit. Three of the residents’ files were looked at during the visit, written evidence was in place confirming what health care checks have been undertaken with the residents and these included optical, dental, chiropody, psychiatrist and other health care and social care professional involvement. From speaking to the residents it was apparent that they have access to all of the healthcare services they need, one person stated; “I am going to see the doctor today and the staff will take me and make sure I am ok”. A general discussion occurred with three residents regarding bathing, bedtimes etc, the residents DS0000064775.V302550.R01.S.doc Version 5.2 Page 16 stated that there are no restrictions upon bathing, but the rota is there to make sure that they receive at least two per week. One person stated, “I think it is a good idea because when I am not well I tend not to bother taking care of myself, staff just help and reassure me”. All of the residents spoken to could confirm who their key worker was and that they spent time with them on a regular basis. Staff spoken to could describe the needs of the residents who they were key worker to and what support was required from them. During the last inspection the medication procedure was not being followed and some of the Medication Administration Records did not correlate to the actual medication stock, the records were looked again and found to be in very good order, no gaps or errors in recording were found. The pharmacist had recently undertaken an audit of the procedure and any areas requiring attention have been attended to. Staff have all being booked a place on the accredited training course offered by the Local Authority. DS0000064775.V302550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a complaints procedure that meets the resident’s needs who feel their views are listened to. A vulnerable adults procedure is in place this protects the residents from abuse. EVIDENCE: The home has not had any complaints since the last inspection. The complaints procedure is clear and residents’ confirmed that if they have any problems they could go to the staff or manager and “get it sorted”. One resident said, “It is really good here, if I have anything to say I talk to Jane (Manager)”. Two staff members were spoken to and they confirmed their knowledge about what the Protection of Vulnerable Adults procedure entailed, some staff have undertaken the training and the remainder of the staff group have been booked a place with the Local Authority’s training section, written evidence confirming this was seen. Staff were able to talk about different types of abuse, signs and symptoms and what they would need to do about it. The recruitment procedure is robust and the home undertakes the appropriate checks prior to employing a person, this ensures the safety of the residents. DS0000064775.V302550.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s premises are safe and very well maintained. The home is clean, hygienic and domestic in style and this ensures that residents’ live in a nice place. EVIDENCE: A tour of the building was undertaken confirming that the previous high standards have been maintained. Since the last inspection some major refurbishment has taken place increasing the number of bedrooms to 20, but also reducing the number of double rooms to 3. The home has been extended and increased the number of bedrooms an additional 6 single en-suite bedrooms have been developed, these are decorated and furnished to a very high standard. Within the new extension there is a residents’ kitchen enabling to residents to make drinks for themselves, some residents spoken to state, “I use the kitchen whenever I want to”, “I like being able to make myself a drink”. There is also a walk in shower/bathroom room, additional communal seating area and storage facilities. Overall the standard of the environment is very good, there were no offensive smells throughout the building and during the visit the domestic staff were observed to be very hard working and conscientious about their job. The home has a separate laundry room and DS0000064775.V302550.R01.S.doc Version 5.2 Page 19 there are good infection control procedures in place, all staff have received infection control training. Some of the existing building has had it’s usage changed. A double bedroom has been changed into the smoking room, this has had appropriate ventilation, there are two further non-smoking lounges and a separate dining room. To the outside of the property two new patio areas have been laid, there is a large grassed area to the front of the building and a car park to the rear. During a walk around the building several residents were spoken to confirming that they had everything they needed in their individual rooms, some comments included, “I have a lovely room”, “my room is beautiful and really clean”. Surveys returned from relatives indicated that the home was very clean and hygienic. Surveys from residents also commented about the cleanliness of the home. DS0000064775.V302550.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an experienced staff team who are competent and professional. Staff have clear roles and responsibilities, more than 50 have achieved NVQ level 2 or 3. The home operates a robust recruitment procedure that ensures the residents are protected. EVIDENCE: During the inspection visit three staff files were looked at confirming that the recruitment procedure is adhered to, all files contained a photograph and identification for the individual, two references and a current Criminal Records Bureau check. Evidence that staff have undertaken training in relation to the mandatory courses including moving and handling, first aid, infection control, protection of vulnerable adults, health and safety and food hygiene. The training has been updated since the last inspection and the requirement has been fully met, all staff received induction and foundation training that meets the Skills for Care specification. From speaking to staff it was clear that the training has been increasing and one person stated, “I have never done so much training, I am finding it very useful when I get back to work. I feel like I DS0000064775.V302550.R01.S.doc Version 5.2 Page 21 understand more about the problems the residents’ have now”. The home also has a written record/year planner for the courses undertaken. Two staff members were spoken to about their role and responsibilities, both were able to describe what their role was and how they support the residents. The staff demonstrated a good knowledge regarding mental health issues and confirmed that training has been arranged in relation to mental health awareness. One staff member said, “we work as a team, everyone helps out” “the residents come first and we try an make it as homely as possible”. More than 50 of staff have now achieved NVQ level 2, from talking to the manager it was stated that the remainder of the staff group are currently undertaking the qualification. DS0000064775.V302550.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is very well run; there is clear leadership and direction. The home has developed a good quality assurance system and residents are involved in this process ensuring that their views are listened to and acted upon. The health and safety of the residents is promoted. EVIDENCE: The training records for three staff were looked at confirming that all of the mandatory courses required are either undertaken or a place has been booked, these include health and safety, first aid, infection control, moving and handling, food hygiene and the protection of vulnerable adults. Since the DS0000064775.V302550.R01.S.doc Version 5.2 Page 23 last inspection the manager explained that a new induction and foundation training programme has been adopted and this now meets the Skills for Care specification, the manager is a qualified assessor. The registered manager continues to work towards achieving the NVQ level 4 in Care, she stated “I have nearly finished the level 4 in care and have 2 units left on the Registered Manager’s Award”. This ensures that the residents’ are taken care of by a team of well-trained and experienced staff who understand the holistic needs of the residents. The home has developed a quality assurance system, residents are involved in this process as regular recorded meetings are held and from speaking to some of the residents they stated, “when we meet it is a chance for us to voice our opinions and make decisions about things”. Surveys are sent to various people who either live in the home or visit the home in order to gain their views about the service. During discussion with the manager diversity and equality was discussed, the manager feels that all of the residents’ receive equal treatment and that the home takes seriously their role in enabling residents to become part of the local community. One resident who could not read or write has received support in the home to learn these skills, other residents have also taken up the course. Although the current registration is for Mental Disorder, some residents have physical difficulties too and staff have undertaken courses in Epilepsy and Dementia to gain a better understanding of the residents’ needs. A mental health awareness course is to take place next week when an outside trainer will come to the home and offer the training to all staff, written evidence confirming this was seen. Surveys from other healthcare professionals stated that; it is a good well run home, homely and good atmosphere, professional, have helped difficult/challenging residents and it is an excellent provision of care “probably the best quality of care in the area” stated a healthcare worker. The health and safety of the residents is ensured by having all of the appropriate maintenance certificates in place, regular checks on these take place and evidence was seen confirming this. Staff undertake all health and safety courses within the first 6 months of employment ensuring that the staff are knowledgeable and have the necessary skills to deal with emergencies. All accidents and incidents are reported and recorded appropriately; regulation 37 notices are forwarded to the Commission for Social Care Inspection. DS0000064775.V302550.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X DS0000064775.V302550.R01.S.doc Version 5.2 Page 25 Yes 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 YA6 Regulation 15,17 Requirement Care plans to be developed and include detail of need, any specialist or therapeutic intervention, action required, by whom and when. (Previous timescale not met – 21/05/06) Risk assessments require development to ensure clear guidance is given to staff about how to reduce or manage the risk. (Previous timescale not met – 21/05/06) The registered manager must complete the NVQ level 4 in Care and Registered Manager’s Award. Timescale for action 05/12/06 2. YA9 12,13,17 05/12/06 3. YA37 9,17,18 21/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000064775.V302550.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard YA34 Good Practice Recommendations All prospective employees must sign a declaration stating that they are mentally and physically fit for the purpose of their job. DS0000064775.V302550.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000064775.V302550.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. 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