Inspection on 19/07/07 for Elmsmead

This inspection was carried out on 19th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmsmead 09/08/06

Elmsmead 21/02/06

Elmsmead 25/07/05

Elmsmead 16/02/05

Elmsmead 13/09/04

Elmsmead 22/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Elmsmead 82 South Road Taunton Somerset TA1 3EA Lead Inspector Gail Richardson Unannounced Inspection 19th July 2007 10:00 Elmsmead DS0000039961.V346594.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 Elmsmead DS0000039961.V346594.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. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmsmead Address 82 South Road Taunton Somerset TA1 3EA 01823 333529 01823 327559 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) Home First & Foremost Ltd Paul Binding Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 12 persons in categories LD and PD. Date of last inspection Brief Description of the Service: Elmsmead provides care and support for up to 12 people who have a learning disability and physical impairments. Elmsmead is located on a bus route and within walking distance of Taunton town centre. The home consists of a two storey detached property which was previously extended and adapted. The people living at Elmsmead have access to secure enclosed grounds to the front and rear of the property. There is also an indoor swimming pool on site. The range of fees are between £1176 and £3328, further charges are made for some activities and some décor to personalise bedrooms. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 1 day (6 hours) on the 19th July 2007 by inspector Gail Richardson. There were 11 people using the service residing at the home. There is currently one vacancy The Inspector viewed a selection of bedrooms and all communal areas of the home, viewed records in relation to care and support plans, staff recruitment, health and safety and medicines records. On the day of inspection 10 of the people using the service that were at home; The Inspectors spoke to 5 people who were able to give an opinion of the services that they receive and all were positive about the help and support they receive. The registered manager has now been in the post for 15 months and has created a stable staff team. All staff that spoke with the inspector appeared confident and clear in their role and were positive about working at the home. The vast majority of comment cards sent to relatives/visitors, care managers and health care professionals indicated that staff demonstrate a clear understanding of people using the service needs. Surveys were received from 4 people using the service,7 surveys were received from relatives and visitors, 3 from staff and 1 from a care manager and one from a GP. On the day of inspection the home appeared busy with people being supported by staff to attend dental appointments, visit the gym and take trips into Taunton on the bus. The atmosphere was settled and homely and people using the service appeared to be comfortable and content. The Inspector would like to thank the people using the service, and the staff team for making the Inspector welcome at the home and for their contribution to the inspection process. What the service does well: Comments from people using the service included “Elmsmead is a very nice house to live in.” and “I love Elmsmead “ another comment was “I am very happy with the home and the staff at work here “. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 6 The staff team are clear in their role and provide a level of support which empowers the people using the service. Comments received included “The staff are very good, they support me” “Paul binding (Manager) is the man- he gets things happening” One relative stated “I think they do a wonderful job” and another commented that “I think Elmsmead is the best home my relative has ever lived in “. The provision of activities has increased in both content and frequency to support the preferences of the people using the service “There is lots to do here, if there was anymore to do I don’t know how we would fit it in”. The standard of food appeared very good one comment was, “The food is always good and we can do cooking” another person said “If we don’t like it we can have something else “ and “I go with staff to Asda to help with the shopping”. The manager of the home has a clear management style and people using the service and staff feel supported by this. One person who uses the service said, “We couldn’t get rid of Paul” What has improved since the last inspection? What they could do better: No requirements or recommendations were made at this inspection. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 7 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. Elmsmead DS0000039961.V346594.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 Elmsmead DS0000039961.V346594.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to be able to provide prospective people using the service, with sufficient information in the format of brochures, the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective people using the service receive a pre admission assessment by the registered manager and are able to visit the home prior to admission. EVIDENCE: Surveys asked, did you receive enough information about the care home before you moved in so you could decide if it was the right place for you? All 4 said yes. There has been one new admission to the home since July 2005. The home has admission and assessment polices and procedures in place which were followed prior to this admission. The person admitted explained that they had visited the home before admission to look around and had had written information about what the home was like. The home had undertaken a pre admission assessment and obtained information from the funding authority, the care management assessment and proposed care plan. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 10 Contracts were not available at inspection as they are stored at the head office. The registered manager confirmed that he is involved in all financial contractual negotiations and reviews. Elmsmead DS0000039961.V346594.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and are reviewed on a regular basis. They are user friendly and people using the service are involved in the review and update. People using the service are supported to make decisions and choices about their life and are actively involved in several aspects of the home. Risk assessments are used to support people using the service to increase their independence. EVIDENCE: The Inspector viewed three care plans including the plan of the person most recently admitted. The care plans were clearly written and detailed providing staff with a clear account of each person using the services abilities, choices and aspirations and covered all aspects of personal and social support. These plans of care are Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 12 agreed with the person using the service and their input is used to adjust the plan to meet their needs. Two people using the service confirmed that they were part of the care planning process and used the risk assessments in a positive manner to measure changes and improvements. Each care plan contained a behavioural management plan which was very detailed and provided trigger indications and identified clear guidelines for staff to support people using the service. The home uses the input of a visiting psychologist in the assessment and care planning process to ensure that behaviour and psychological support is available. The care plans are reviewed and that review recorded every 3 months or as changes are identified in the interim. All reviews were up to date. Records identified when service users had visited health care professionals and with parents and relatives. The Inspector viewed day-to-day diaries for individual people using the service and noted that records were well maintained. All incidents of physical restraint are now recorded and audited monthly. Staff stated that they offer people as much choice as possible. This includes what people are offered to eat, drink, activities and what time to go to bed and get up. People using the service are involved in menu planning and are involved in the weekly food shopping. People using the service spoken to, confirmed that they are supported by the staff to make decisions to support their choices, this includes day-to-day choices and support with activities. All service users need the support in the management of their finances. During the inspection, people using the service were seen to be going out with staff throughout the day, this included shopping trips and staff were seen to support people using the service to make financial decisions. People using the service confirmed that they visit the manager in his office or in their rooms each Monday for a meeting to discuss the previous weekend and plan the week. There was also evidence of people using the service being invited to a staff meeting. The storage of all records within the home is in line with the Data Protection Act. Elmsmead DS0000039961.V346594.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are now offered a wide range of activities and experiences both in and out of the home. It appears that good links are maintained with relatives. The home now involves people using the service in the planning of and shopping for the homes menu. EVIDENCE: Leisure activities include cooking, art, gardening, swimming , t.v .and videos. The home supports trips to pubs and clubs, bowling and cinema with trips to the beech and Zoo. The home charges £50-£70 for transport. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 14 Activities are based on individual choice and need and people using the service were seen to be supported in these choices. On the day of inspection 2 people went to the dentist, one person went to the local gym, 2 people went on a trip to town and 1 person went bowling. The people who did not go out had the opportunity to do some cooking in the afternoon. The home has access to the homes pool each evening and at weekends and some people confirmed that they used this facility regularly. The home has also developed a vegetable patch in the garden for people using the service to develop an interest in gardening. Individual records are kept of all activities that each service user has accessed. One relative survey said, ”The staff are prepared to take risks and allow individuals to make choices for themselves rather than assume behaviour will be problematic in a given situation because it has been in the past”. It appears that there are good links with the relatives. The vast majority of comments received from relatives and visitors stated that they are kept informed about important matters that affect their relative, they are made to feel welcome at the home and can see their relative in private. Surveys asked, does the care home help your friend keep in touch with you? 3-always, 2 – usually. When asked, Are you kept up to date with important issues?, 4-always,1-usually. The home supports people using the service to take trips and holidays and planning was seen to support 2 people to a family event, which involved an overnight stay. This appeared to be carefully planned and supervised with ongoing support and reassurance given as needed to ensure that it was enjoyed as much as possible. Each person has a keypad code to access their own bedrooms and have cleaning rotas to clean and tidy their room. 4 people using the service showed the inspector their bedrooms and explained that they were responsible for keeping them tidy, this agreed plan was also evident within the persons care plan. Staff within the home cook meals and the choice was agreed with the people using the service to be pork chops, roast potato with vegetables. One person who did not like pork agreed an alternative. The manager explained that every person’s choices are considered and then the menu is planned to support all of those choices over the week. People using the service explained that they had a lighter evening meal and always had access to fresh fruit between meals or for desert. The meal looked plentiful and appetising and those people who required more support or supervision with their meal were assisted as required. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 15 There are 2 dining areas available and the staff take their lunch with the people using the service. The mealtime experience was observed to be comfortable and sociable. Three people chose to take their lunch in their rooms or the lounge. Records are maintained of all menu choices. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in the manner they prefer and ensure that they have access to all appropriate health care professionals. Good records are maintained in relation to the administration of medicines. People using the service are supported throughout the bereavement process. EVIDENCE: The care plans indicated the manner in which people preferred to receive their personal care. Care staff will assist people with personal care if needed in the privacy of en-suite bathrooms and people are encouraged to be as independent as possible. People were seen to be dressed in a manner of their preference and all people using the service appeared well care for. All people using the service have an allocated key worker. There was evidence within the care plans that staff are proactive in involving multi-disciplinary healthcare professionals, including appointments with psychology services and GPs. Records are kept of all visits. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 17 One survey received from a visiting GP was asked, are you satisfied with the overall care provided to service users within the home?, had responded yes. Further surveys from relatives and visitors were asked, Do you feel the care home gives the support or care to your relative that you expected or agreed ? 1-always, 3-usually. The home uses the Boots Monitored Dosage System. The Inspector viewed the arrangements in relation to the storage and administration of medicines. This was satisfactory. MAR sheets were well maintained and the inspector observed the medications being given and the process/protocols involved in administration of PRN medication. The home has recently suffered bereavement and people using the service and the staff team have felt this loss. The staff were sympathetic and supportive of the people using the service through the bereavement process and everybody was supported to talk about how they missed their friend. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed complaints procedure and there are policies and procedures in place to safeguard vulnerable people. Behaviour management guidelines and risk assessments to address episodes of challenging behaviour have now been updated to support both the staff and the people using the service. EVIDENCE: The home has no complaints currently under investigation and CSCI has not received any complaints about the home. There has been 1 Adult Protection investigation which the outcome is still pending. The manager confirmed that there have been 2 complaints since the last key inspection. Both complaints were responded to within 28 days The home has systems to safeguard vulnerable people and has a copy of the Safeguarding Vulnerable Adults Procedure which must be updated to the latest policy rolled out in May 2007. People using the service were clear about who to complain to and those spoken with and surveys received confirmed that people are confident to tell the staff any concerns and are confident that they will be dealt with. One person said, “I do know that if I tell my carers my problems they will help me “. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 19 The staff who spoke with the Inspector were aware of the home’s Whistle Blowing Policy and Complaints Policy. All staff have now received training in Non-violent Crisis Intervention and one staff member demonstrated a good understanding of the principals and techniques involved. The Manager has been very proactive in involving the staff in developing behaviour management guidelines and conducting risk assessments. Behaviour management protocols have been developed to address episodes of challenging behaviour. This includes behaviour management strategies, behaviour analysis and detailed risk assessments that are regularly reviewed. The home now also records the use of physical restraint where needed and these records are audited monthly. Detailed records are kept at the home of all people using the service individual expenditure with receipts obtained wherever possible. Access to people’s monies by staff is restricted, only named staff have access. The inspector audited 2 random financial files and all monies stored were correct. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appears comfortable, safe and homely with evidence of wear and teat associated with a house of this level of usage. People’s bedrooms viewed reflected individual needs and lifestyles and promote privacy and dignity. The home provides a clean and hygienic environment. EVIDENCE: Elmsmead is an old house which has undergone some maintenance and refurbishment. The manager confirmed that since the last key inspection the home has had a new bathroom fitted, new showers fitted in the swimming pool facilities and various bedrooms had undergone redecoration. The manager has made efforts to ensure that the home maintains a homely atmosphere, by adding pictures and plants to corridors and communal areas. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 21 Some areas remain worn and further work is planned to refurbish as funding permits. The home has a main lounge area and a smaller lounge that is primarily used as a games room. Inspector observed people using both rooms and both rooms appeared suitably furnished and comfortable. The people using the service also have the benefit of an indoor swimming pool. People from other homes within Voyage use the swimming pool, this does not have a detrimental impact on the home. The Inspector viewed several bedrooms with the permission of the people using the service. All bedrooms at Elmsmead have full en-suite facilities. The bedrooms that were viewed reflected people’s individual needs and lifestyles. All appeared very well maintained, comfortable and were furnished with soft furnishings of person’s choice. One bedroom seen is currently awaiting new windows, furniture and carpeting, all of which are on order. This person confirmed that they had been involved in choosing colours .The people using the service who showed the Inspector their bedroom were very pleased with their rooms and were happy to confirm that they were consulted in decoration and purchases of furnishings. The home has an attractive garden area, which is well maintained and enclosed. A small vegetable patch is being cultivated. A further hard surfaced area is available which contains outdoor furniture a barbeque and basketball net. This area was seen in use. On the day of the inspection the home was clean and hygienic. Hand washing facilities are provided in all appropriate areas. There are adequate laundry facilities and people using the service are supported to do their own laundry. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home strives to provide a qualified staff team and is recruiting to complete staff numbers required. On the day of the inspection the home appeared appropriately staffed to meet the needs of the service users. The recruitment processes are in place to ensure the people using the service are not at risk of abuse. Staff receive regular formal supervision. EVIDENCE: On the day of inspection there were 9 staff on duty plus the registered manager. Examination of staff rotas indicate that there are on average 7 staff on duty between 8 am and 10am, this number increases to 9 staff from 10am to 6pm. The evening is staffed by 4-5 staff with 3 staff on night duty. The home has changed the night staff support team arrangements to 2 waking night staff and 1 sleep in staff from the 15th April 2007. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 23 The manager confirmed that there had been a significant staff changes and that recruitment continued to be ongoing until staff capacity is reached. Increasing staffing is a priority within the home. The home currently uses staff from other homes in the group and the homes staff pick up overtime to cover shortfalls. The home does not use agency staff. One relative noted that “ Existing staff have to do considerable overtime as there is a shortage of staff, more staff would help the situation”. The Inspector spoke to a number of staff at the time of the inspection. Those spoken to were clear in their role and had obviously developed supporting and professional relationships with the people using the service. It appeared that staff were aware of peoples individual needs and were able to describe how they would react and respond to individual people. The inspector observed staff following the behaviour guidelines action plan identified in the persons care plan in a clear and professional manner. Staff have received training in the management of difficult behaviours and communication. One staff member stated that they felt that “The changes taken place at the home had been great and wonderful for all”. 49 of staff at the home have achieved an NVQ qualification and 5 more are approaching completion. Some staff are also undertaking LDAF training. The inspector was provided with the latest staff-training matrix that provides an overview of all training provided. All staff undertake training in health and safety, first aid, food hygiene and manual handling. The Inspector discussed with a member of staff, the training undertaken in restraint and that member of staff was clear in the procedures to be used. Staff spoken and surveys received, confirmed that staff had received adequate induction and staff are supported to undertake training. Staff were clear about what duties they must not undertake and they were aware of the policies available within the home including the safeguarding of vulnerable adults and recognising the signs of abuse. 2 staff stated on the surveys received that they sometimes have to deal with situations they feel unprepared for or do not have the right training for, this area must be addressed by the manager. An induction plan of training is supplied to all new staff, which incorporates the Skills for Care Common Induction Standards, and staff are supernumerary for one week and then other members of staff support them. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 24 Voyage has a robust recruitment procedure. The Inspectors viewed the recruitment files of 2 recently appointed staff. All records were complete, no staff commence employment until the recruitment process is completed and the Criminal Record Bureau Check is received. Routine health screening records are not undertaken, this was discussed and is a subject of discussion within the company. Staff confirmed that they receive regular formal supervision where they are able to identify personal training needs and discuss matters pertaining to the home. The records of this supervision were seen and the manager is developing an improved supervision form, which contains all the topics indicated in the National Minimum Standards. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 25 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 40 41 42 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appears to be well managed with clear leadership and direction. The Health and safety management within the home is well maintained and recorded. EVIDENCE: The registered manager Paul Binding has been working at the home for 15 months and has made a positive impact on the management of the home. Both staff and people using the service were happy to confirm that they felt supported by the management of the home. The inspector observed that Mr Binding has a calm manner, which encourages people using the service to approach him and communicate their concerns and opinions. He has approximately 12 years experience with working with people with a learning disability. Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 26 Staff spoken to at the time of the inspection stated that the Manager involves the staff team in decision making, development of care plans, behaviour management guidelines and provides a clear direction of the service. Staff meetings take place and staff confirmed that these are an opportunity to discuss opinions and concerns. One relative survey stated “Elmsmead has improved vastly since Paul became manager” The inspector examined quality assurance records audited in 2006, which reflected the opinions of the people using the service. The inspector suggested that the weekly meetings between the manager and the people using the service should be recorded as part of the quality assurance process. Voyage has comprehensive policies and procedures that are readily available at the home. All records seen by the Inspectors were well written, up to date and appropriately stored. All documentation relating to people using the service are stored securely in line with the Data Protection Act. People using the service have access to their own records and were happy to confirm this to the inspector. The home keeps records of all incidents and accidents and monthly reports are complied by the Manager and sent to Voyage Head Office for further audit. The Inspector viewed the following records relating to health and safety: All records maintained were clear and well recorded. • • • • • • • • • Monthly Legionella checks Pharmacy reports Hard wiring certificate Gas servicing certificate PAT testing records COSHH records Fire risk assessment Fire service records including fire extinguishers, weekly fire tests, staff fire training Emergency lighting checks Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 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 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 28 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 Elmsmead DS0000039961.V346594.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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