Inspection on 22/08/06 for Girling Street and St Faith`s Villa

This inspection was carried out on 22nd August 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 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

Girling Street and St Faith`s... 30/11/05

Girling Street and St Faith`s... 14/02/05

Girling Street and St Faith`s... 12/01/05

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Coopers Mill Ltd

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

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

CARE HOME ADULTS 18-65 Girling Street and St Faith`s Villa 34 Girling Street and 90 Queens Road Sudbury Suffolk CO10 1PG Lead Inspector Julie Small Unannounced Inspection 22nd August 2006 09:30 Girling Street and St Faith`s Villa DS0000044272.V308312.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 Girling Street and St Faith`s Villa DS0000044272.V308312.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. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Girling Street and St Faith`s Villa Address 34 Girling Street and 90 Queens Road Sudbury Suffolk CO10 1PG 01787 882082 01787 882082 regardmanagersudby@tiscali.com 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) The Regard Partnership Limited Mrs S Snelling Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: 34, Girling Street and St Faiths Villa, Sudbury are two residential care homes for women with learning disabilities, each home accommodates five service users. 34 Girling Street was first registered in 1997 and St Faiths Villa in 1999; the two homes are registered as on ‘core and cluster’ residential care home. The homes are within a short walking distance of each other and of Sudbury town centre. Both services are managed by one full time manager, Mrs Sue Snelling, who divides her time across the two sites. Mrs Snelling is supported by two small teams of staff who are allocated to each home, with some interchangeable shift arrangements. There are additional relief staff employed to cover for any staff vacancies, annual leave or sick leave. The primary role of staff within this service is to encourage and support service users to maximise their skills, abilities and interests. Service users are also provided with opportunities to pursue active lives in the community and to access a range of services and facilities available to them in the community. 34 Girling Street and St Faiths Villa are part of The Regard Partnership, which is responsible for other residential services for people with learning disabilities in other parts of the country. At the time of the inspection information for fees was obtained from service users contracts and range from £471.40 to £838.46 per week, dependent on support required by each individual. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Tuesday 22nd August 2006 between the times 13.30 and 17.40 and was undertaken by regulatory inspector Julie Small. The inspection was a key inspection which focused on the core standards relating to adults. The report has been written using accumulated evidence gained prior to and during the inspection. A tour of the two buildings and observation of work practice was undertaken and six service users and four staff were spoken with. Records viewed during the inspection included residents records, fire records, staff training certificates and medication records. Further records viewed are identified in the main body of the report. Both service users and staff welcomed the inspector and requested information was provided promptly and openly. What the service does well: What has improved since the last inspection? The service users guide, contracts and procedures had been updated to provide an accessible format for service users. Service users were included and participated in staff meetings when they chose to. Six monthly care needs assessments had been implemented, which had been used in the updating of care plans. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 6 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. Girling Street and St Faith`s Villa DS0000044272.V308312.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 Girling Street and St Faith`s Villa DS0000044272.V308312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 The quality in this outcome area is good. Prospective service users can expect that they are provided with the information they need to make an informed choice about where to live, that their individual aspirations and needs are assessed and that they are provided with an individual written contract. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes statement of purpose and service users guide were viewed and they included appropriate information. The service users guide had been updated and was in an accessible format for service users including text and picture/symbol format. There was a service users guide posted on a notice board in the dining room at Girling Street and in the kitchen area in Queens Road, along with the last two inspection reports, which were available for service users and visitors. There have been no changes in service users since the last inspection. Five existing service users records were viewed and evidence that their needs and aspirations had been assessed, four had transferred to the home from a larger home. One resident’s records had an assessment of needs, which had been undertaken prior to them moving into the home. Needs assessments were now being updated on a six monthly basis. Assessments included daily care, social needs and health needs. All records viewed have care plans, which reflect the information provided in the assessments. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 9 Each service user was provided with a contract which included terms and conditions of the service provided, including the fees. The contracts were in text and picture/symbol format, to provide access to service users, a staff member said that they had recently been updated. Girling Street and St Faith`s Villa DS0000044272.V308312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 The quality in this outcome area is excellent. Service users can expect that their individual plan reflects their needs and goals, they are supported in making decisions about their lives and that they are supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five service users records were viewed, each held comprehensive action plans which identified the individual’s needs regarding all aspects of their daily living and the support they needed and required. Action plans identified the service users goals, strengths and intervention required for each activity. A staff member said that the format of the action plans had recently been adapted to include the section which identified the service users strengths in each issue included in their action plans. Action plans were evaluated regularly with service users changing needs and progress. There had been a change in the homes procedures which included needs assessments to be undertaken and updated on a six monthly basis, documentation for the updated needs assessments were in service users records which were viewed. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 11 There were behaviour management records included in service users records. There were two service users records viewed which included a record of incidents of challenging behaviour and changes in behaviour. A staff member explained that the records had assisted in identifying patterns, which included identified changes in behaviour around a service users menstrual cycle. A communication book of one service users changes in behaviour was completed by the homes staff and by staff at the service users day service, which assisted to further identify patterns and triggers for certain behaviours. There were records of key worker monthly meetings in service users records, which included discussions between individual and a staff member regarding their progress, decisions and views about the care that they received. A staff member said that they do not have individual key workers, and that all staff support each service user. This decision had been made to ensure that service users received a good support system from the staff team. Residents spoken with confirmed that they felt supported by the staff group and that they could speak to any staff member who was on duty. Records of service users individual care reviews were viewed and evidenced that service users and their family or representatives were consulted on the service that they received and decisions about their lives. There were records of regular service user meetings, where choices of menus and activities were made. A record of a staff meeting identified that service users were to be invited to staff meetings with the exception of confidential discussions, such as staff discussions about individual service users lives. Staff confirmed that service users did attend and participate in staff meetings, if they chose to. Records of service user satisfaction questionnaires were viewed, and there was a published leaflet, which provided details of the results of the organisations services. There had been updates to the homes policies and procedures, such as the complaints procedure which provided an accessible format, including picture/symbols along with the text. Daily records viewed identified instances where service users had made decisions about their lives, such as activities they wished to participate in. Service users spoken with confirmed that they were consulted with in the decisions about their lives. Interaction between staff and service users was observed to be positive and in an open manner and provided an environment where service users could speak openly. Action plans cross referenced clearly to detailed risk management plans. Risk management plans identified assessments of risk in the service users daily life and identified actions of how the risks could be prevented. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 12 Girling Street and St Faith`s Villa DS0000044272.V308312.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): 12, 13, 15, 16, 17 The quality in this outcome area is good. Service users can expect that they are supported to take part in appropriate activities, including in the local community, they are supported in maintaining relationships, their rights are respected and that they are offered a healthy diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service records viewed showed that they attended day centres. Two service users did not attend a day centre. One service users bedroom viewed had certificates from training courses they had attended, such as literacy and independence training. Service users were observed returning from their day centres during the inspection, staff had welcomed them home and enquired how their day had gone. Service users records viewed identified their likes and dislikes including their chosen activities, including swimming, shopping and horse riding. Service users reported that they participated in a wide range of activities in the community. One service user said that they get magazines and a daily Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 14 newspaper each day from a local newsagents and they enjoyed shopping in the town centre. Another said that they enjoy swimming and go to a local swimming baths. Another service user said that they liked going to the pub, another service user said that they had gone to the pub for a meal with the others in the house for their birthday. A staff member said that service users had regularly attended a local spa and they enjoyed using the Jacuzzi. There were holidays planned, one at Butlins and one at a cottage. The staff member said that service users were holidaying with others who shared interests from within the organisation rather than holidaying with those who they shared a house with. Staff reported that service users had used public transport such as trains and buses to local areas. Service users said that they had regular contact with their families and friends; contact records viewed confirmed this. Staff were observed to ask service users permission to show the inspector their bedrooms, some had preferred to show their room and areas of the home themselves. Staff included service users in conversations and discussions throughout the inspection. Service users confirmed that they helped to clean the house. Their records identified that chores such as keeping their bedrooms tidy and support they required in undertaking the tasks. Staff said that service users were included in laundry and housekeeping chores dependent of their ability and choice. The menus were viewed and were well balanced, healthy and varied. Staff said that service users chose their menu each Sunday and staff showed the inspector pictures of food items which were used to assist them in making their choices. Service users were observed discussing their evening meal and who would be cooking. They said that they chose what they wanted to eat and cooked meals. One service user said that they liked cooking cakes and showed the inspector the cookery book and cards which they used. One service user was of Asian origin and said that they enjoyed foods such as noodles and could use chopsticks. A staff member confirmed that the home had provided the chopsticks and ensured that at least one dish each week was identified which reflected the service users culture and that they reminded the staff of this each week when the menus were decided upon. Service users bought themselves lunch at their day centre. Service users were provided with a range of drinks throughout the inspection including hot and cold drinks. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 15 During a tour of the building it was noted that there was a good amount and range of fresh fruit and vegetables. There were well maintained dining rooms which provided sufficient seating for those living at the home. Girling Street and St Faith`s Villa DS0000044272.V308312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 The quality in this outcome area is good. Service users can expect that they receive personal support in the way they prefer and require, their physical and emotional needs are met, they are protected by the homes medication policies and procedures and that their wishes regarding their death are carried out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users records viewed contained care plans which identified the care and support that service users require and need, including personal care. They included records of monthly key worker meetings, their routines, likes and dislikes and individuals who they maintain contact with or receive a service from. Changes in personal support were included in one service users records, which included the reasons for the changes. One service user was observed returning from the toilet with soiled hands and top, the two staff members on duty discreetly and sensitively advised the service user about washing hands and changing and one staff member went with them to their bedroom to help. Their records identified how they may require support after using the toilet. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 17 Three service users said that they chose their own clothing. One said that they enjoyed shopping for new clothes. A staff member and service user was observed discussing their choice of hairstyle. A service user confirmed that they had their hair styled for their birthday and chose the style and colour. Five service users records viewed showed their individual physical, emotional and health care needs and included health care plans. Details were provided of their doctors, chiropodist, placing authority, optician and any other services or specialist services individuals used. Records evidence that service users received regular health check ups such as dental, optical and medical. The homes medication storage and records were viewed and all met required standards. There were records regarding provided homely medicines and there were records completed by the service users doctor which identified homely remedies which they could and could not take. Medication records clearly identified when service users had been on home leave and there were clear records of medication which had been sent to the service users family home, for use when they were on leave. There were clear and detailed procedures for the storage, recording and administration of medication, which staff had signed and dated when they had read it. Training certificates viewed evidenced that staff had attended medication training. Service users records included details of their wishes and their families, where appropriate, wishes in the event of the service users death, included their funeral arrangements. A staff member explained that this had been recently introduced by the organisation and had been positively received by service users families. A staff member explained the support which had been provided to a service user who had recently been bereaved. Girling Street and St Faith`s Villa DS0000044272.V308312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality in this outcome area is good. Service users can expect that their views are listened to and acted upon and that they are protected from abuse, neglect and self harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On arrival to both homes the inspector’s identification was viewed and they were requested to sign the visitors book. The visitor’s book showed that all guests to the home are requested to sign in and out of the home. Five service users records viewed show support service users required to ensure their safety, risk assessments were in place where they may be at risk when participating in activities from both themselves and from others. Staff records were not available to view as the home’s manager was not present, staff spoken with confirmed that they had received CRB (criminal records bureau) checks prior to starting work at the home. A staff member said that the organisation had recently requested that checks were updated regularly. There was a whistle blowing procedure which was displayed on the notice board in the kitchen in Queens Road. Staff spoken with confirmed that they had received abuse awareness training; this was confirmed with training certificates viewed. Records of service users personal finances were viewed, these included a sum of money kept in the home and receipts for monies which they had spent. A staff member said that service users monies were kept in the safe and was provided to service users when they requested and required it. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 19 There were behaviour management plans in service users records and a staff member explained how they maintained records regarding changes in behaviour of two service users, this assisted in them identifying patterns and understanding their aggression and distress and understanding their behaviour. There was a clear complaints procedure and this had recently been updated and provided an accessible format including pictures and symbols which supported service users understanding, they were displayed in the home. There were no complaints made since the last inspection. Records viewed evidenced that service users were provided with opportunities to express their views about the service they receive, including key worker meetings, service user meetings, satisfaction questionnaires and involvement in staff meetings. Girling Street and St Faith`s Villa DS0000044272.V308312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 The quality in this outcome area is good. Service users can expect that they live in a homely, comfortable and safe environment, which is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both homes were comfortable, clean and well maintained, there were no offensive odours. The homes were within walking distance to the local amenities in Sudbury. The homes were accessible to service users who live there, they were not accessible to wheelchair users. Bathrooms and toilets had hand wash gel and disposable paper towels. There were laundries in both homes which had a washing machine and dryer in each. A bathroom in Queens Road had a disposal bin for soiled pads. There were disposable gloves and aprons available for staffs use. There were infection control procedures provided, staff signed and dated when they had read procedures. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 21 Service users showed the inspector their bedrooms which were well maintained and provided sufficient furniture and fittings. All bedrooms reflected service users personal choice, with individual memorabilia, pictures and entertainment items, such as televisions and music systems. One service users bedroom included items which reflected their Asian culture. Staff members confirmed that service users had chosen the décor of their bedrooms. Both homes had sufficient toilets and bathrooms for service users living at the home, there was the provision of a bath and shower which provided service users with a choice of their bathing preference. Three service users bedrooms and the staff sleeping in room at Queens Road provided en suite facilities including a toilet, hand wash basin and shower. Girling Street and St Faith`s Villa DS0000044272.V308312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The quality in this outcome area is good. Service users can expect that they are supported by competent and trained staff and are supported in the homes recruitments procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff recruitment records were not available to view because the manager was not present during the inspection. There had been no new staff recruited or staff who had left the home since the last inspection. Staff spoken with confirmed that they had received CRB checks prior to commencing work at the home and one staff member said that the organisation had requested that regular updates of CRB’s were undertaken. There was a recruitment procedure which clearly identified checks that should be made prior to individuals commencing work at the service. A letter has recently been forwarded to the organisation from CSCI’s (Commission for Social Care Inspection) Provider Relationship Manager following a meeting with the organisation stating that an audit of CRB’s would be undertaken in the near future and that recruitment records would be centralised by the organisation and that there would be a revised procedure for human resources. The letter also stated that the organisation had updated the induction process to lead into the Skills for Care induction standards and that they were working on ensuring that staff receive POVA training. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 23 Staff met during the inspection had a good knowledge of the service users they provided a service for, they clearly understood their roles and responsibilities and the interaction observed between staff and service users was open, friendly and respectful. A staff member was spoken with and confirmed that all permanent staff at the home who had not yet achieved their NVQ level 2 in care were working toward their qualification. They said that one staff member was not undertaking their award and were going to decide if they wished to complete it. Staff spoken with confirmed that they had received training including first aid, manual handling, behaviour management, health and safety, medication, abuse awareness and food hygiene. Certificates viewed at Girling Street confirmed training staff had undertaken. A schedule of training updates was viewed at Queens Road, which identified dates and training individual staff were undertaking. Two staff members said that they felt the training they received was of good quality and that the training staff provided them with information they required to support them in the service they provided. A staff member said that the organisation provided a ‘rolling’ programme of training, which ensured that all staff was provided with the opportunity of attending core training provided by the service. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality in this outcome area is good. Service users can expect that they will benefit from a well run home, which is run in their best interests and that their health, safety and welfare are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The managers certificates were viewed which evidenced that they had achieved the NVQ level 4 in care and the RMA (registered managers award). The manager was supporting another of the organisations homes which had no management support. Service users quality assurance records were viewed and there was a published leaflet produced by the organisation which stated the responses they had received from the questionnaires in the organisations services. A staff member spoken with said that if a service user stated that they were unhappy with an aspect of the service they received, this would be incorporated into their action plans, with a view to improve their experiences. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 25 Fire records were viewed which evidenced that regular fire safety checks were made, fire drills were undertaken and that staff received regular fire safety training. There were health and safety procedures in the home including infection control, COSHH (control of substances hazardous to health), first aid, food hygiene and manual handling. Procedures were signed and dated when staff had read them. Staff confirmed that they had received training on first aid, manual handling, food hygiene and health and safety. Records of checks of water temperatures, food temperatures, refrigerator temperature and electrical items were viewed. An electrical inspection had been undertaken September 2005, there was a gas certificate dated July 2006 and a legionella certificate from July 2006 were viewed. At Queens Road there was a record of all electrical items which service users had in their bedrooms. Staff checked the water temperature before service users used the bath or shower to ensure safety. Records of weekly environment health and safety checklists were viewed. There were risk assessments of the environment and a staff member said that these were being updated. Records of accidents and injuries were viewed and were noted to be appropriately completed. Bathrooms and toilets provided hand wash gel and disposable paper towels. There was a store of disposable aprons and gloves for staff use, a toilet at Queens Road had a disposal bin for soiled pads. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 26 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 X 4 X 5 3 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 X 26 3 27 3 28 X 29 X 30 3 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 4 4 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 27 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. 1. Refer to Standard YA35 Good Practice Recommendations It is recommended that each staff member is provided with an individual training and development profile. Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Girling Street and St Faith`s Villa DS0000044272.V308312.R01.S.doc Version 5.2 Page 29 - 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. 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