Inspection on 12/06/07 for Goldcrest House

This inspection was carried out on 12th June 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

Goldcrest House 11/07/06

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

CARE HOME ADULTS 18-65 Goldcrest House 194 Boothferry Road Goole East Yorkshire DN14 6AJ Lead Inspector Janet Lamb Unannounced Key Inspection 12th June 2007 10:40 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 DS0000064804.V343020.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. DS0000064804.V343020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goldcrest House Address 194 Boothferry Road Goole East Yorkshire DN14 6AJ 01405 763329 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) goldcresthouse@onetel.net Genhawk Limited Mr Ralph Parish Care Home 10 Category(ies) of Learning disability (10), Sensory impairment registration, with number (10) of places DS0000064804.V343020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 Brief Description of the Service: Goldcrest House is owned by Genhawk Ltd and provides care and accommodation for 10 younger adults with a learning disability. The accommodation charges are currently between £950.00 and £1,950.00. The home is in the process of becoming accredited with the National Autistic Society. Goldcrest House is situated in the town of Goole in the East Riding of Yorkshire and endeavours to empower service users in order to maximise their social and independent living skills. Accommodation is provided in single rooms that have been furnished to a good standard. Service users have access to a range of shared space, including lounge, sensory room and a small well-maintained garden and patio area to the rear of the building, which is equipped with garden furniture. DS0000064804.V343020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Goldcrest House has taken place over a period of time and involved sending a request for information to the home in early May 2007 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in early June 2007 and questionnaires were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care, to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 12th June 2007 to test these suggestions, and to interview service users, staff, visitors and the home manager, if available. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with two bedrooms. A total of three service users and two staff were interviewed and two more staff were spoken to during the site visit to seek information. What was said was checked against the information obtained through questionnaires and details already known because of previous information gathering and contact with the home. Judgments were made using the information to say what it is like living in the home. What the service does well: Service users are assessed before they receive a service of care and support in the home, and they are provided with some information about the home and staff in order to decide whether or not their needs can be met there. Service users have their needs and changing needs recorded in a plan of care, which takes into consideration their individual differences. They are encouraged to make their own decisions about daily life, as much as possible, which may involve taking risks in order to achieve independence. However, these risks are reduced where possible. Service users take part in appropriate community based activities and pastimes within the home or in the community, they enjoy relationships of their choosing with good advice coming from staff, and have their rights and responsibilities as citizens upheld wherever possible. They said they enjoy shopping, going to the pub or disco, helping in a charity shop, going to college, DS0000064804.V343020.R01.S.doc Version 5.2 Page 6 and listening to music, singing with a music class, and watching television and DVDs. Their rights are respected and staff always try to encourage their involvement in the community or advocate for them when necessary. Service users also enjoy a variety of meals, but not always of their choosing, and assist in the provision of and preparation of food wherever possible. Service users say they receive the help and support with personal care and with physical and emotional health needs in a way that suits them, and feel their needs are met. They are well protected by the home’s systems for controlling and administering medication. They have their views listened to and feel confident they can make representations or concerns and complaints known to the staff or the manager. Service users live in a fairly homely environment that is clean and suits their preferences. Competent and qualified staff support service users in their daily lives and in sufficient numbers to meet their needs. Staff are well recruited so service users are cared for by safe staff. The home manager is well trained and experienced and provides consistent leadership. There is a good quality assurance system in place, which self-monitors the service provided. The health, safety and welfare of service users and staff are well promoted and protected. What has improved since the last inspection? The service has responded to requests made by the Humberside Fire and Rescue Service and the Commission to improve the fire safety systems within the home. The service now makes sure all returned, unused medicines are signed for when removed by the collecting pharmacy. The service now checks and records the fridge and freezer temperatures on a daily basis. The service now consults stakeholders about issues in the home via different ways; surveys, telephone calls and face-to-face conversations. Some redecoration has also been completed. DS0000064804.V343020.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000064804.V343020.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 DS0000064804.V343020.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): 2 only. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their needs well assessed so they are confident their needs will be met. They receive sufficient written/pictorial information so they can decide if the home is the right place for them. EVIDENCE: Discussion with service users and staff and viewing of case files with service users’ permission, reveal service users are fully assessed by their placing authority before any placement is made and by the home manager as soon as the service user arrives for a trial period. Service users and relatives are provided with statements of purpose and service users guides prior to moving into the home. These documents are also held in service users’ rooms and are replaced or updated as necessary, especially after service users destroy or throw them away. The company’s base line assessment documents were seen for two service users, along with some psychological assessments undertaken in November DS0000064804.V343020.R01.S.doc Version 5.2 Page 10 2004, and their assessment of daily living needs. Where possible these had been signed by the service users. The original placing authority community care assessment forms were not available for viewing and one team leader understood they had been archived in the main office, as they are no longer needed on a day-to-day basis. They need to be available for Commission inspections. Assessment documents are comprehensive and include personal care and daily routines, health issues and medication, social needs and relationships, communication and behaviour, and activities and occupation. There are no service users that are self-funding and paying privately for their care and so standard 2.3 is not applicable. Any future development of the home’s assessment documents ought to make sure all of the items in 2.3 are included though, as good practice. Service users acknowledged they thought they had assessment forms and care plans in their files and said they had been included in the processes to obtain their views and opinions. They expressed satisfaction with the support and assistance they receive from staff. DS0000064804.V343020.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 and 9. Peoples who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People have good care plans that enable them to be independent and to make choices, and people enjoy making their own decisions in life, with good risk assessments being put into place where necessary, so they are confident their lifestyles meet their expectations. EVIDENCE: Service users and staff spoken to and documents seen in case files, reveal service users are encouraged to make decisions for themselves and to live as independent a life as possible. All service users have detailed care plans in place, which follow a format similar to one of the placing authority care plans. Service users have signed these and those spoken to are aware of them. Plans are reviewed monthly in DS0000064804.V343020.R01.S.doc Version 5.2 Page 12 the home and any changes are recorded. Annual reviews in line with placing authority’s requirements are held and also recorded. Care plans show in which ways service users are to be encouraged to make their own decisions and to manage their own finances where possible. All decisions taken and actions carried out that involve an element of risk are backed up by risk management strategies and service users have individually devised risk assessment documents for each area of daily living etc. Service users spoken to said they are aware of their care plans and ‘journals,’ which they know are used to record daily events and achievements. One said, “Oh my journal you mean,” when asked if their file and diary notes could be inspected. “Yes you can look at it.” Another said, “Our care plans tell the staff what we want to do. Staff ask us what help we need and it’s written down.” Files seen contain care plan documents and review meeting minutes. Individual monthly ‘journals’ are also available, which contain diary notes, GP visits, weight and dietary charts etc. and show what service users have done, where they have been and any medical health care that has been given. All journals include information on individual service users’ diverse needs, and especially in relation to their learning disability needs, as they are met. Discussion with service users and staff also shows service users’ needs are met according to their preferences and that risk assessments, written for the individual, are in place, known to staff and adhered to. As much support as possible is given to service users to enable them to be self-determining. DS0000064804.V343020.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): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People lead and enjoy appropriate inclusive, healthy and fulfilling lifestyles in the home and within their local community, so their quality of life is good. EVIDENCE: Service users and staff spoken to, and documents seen with permission reveal service users engage in fulfilling pastimes of their choosing. One service user works two days a week voluntary in a charity shop, while another is trying to set up a paid work placement in a hairdressers and also to do voluntary work with the WRVS in a local hospital. Other service users DS0000064804.V343020.R01.S.doc Version 5.2 Page 14 attend college courses and some also belong to activity groups such as singing class. All service users take part in some activity or pastime and generally those able to give an opinion feel their entertainment needs are met. They go to the pub, cinema, bowling, go out on trips, help with decoration in the home, help with shopping, go for walks, look after pet fish, listen to music and watch television and so on. However, one relative states, “Staff take the mini bus to Cleethorpes regularly, we could see ---- when they come through but every time it is the same service users that go, and that is the same for all trips. The home could improve if it provided more social activities and more interactivity between residents and staff to stimulate residents rather than watching television all the time. My son continually tells me he is bored within the house. As in all residential homes there are different needs and levels and residents should be assessed for this.” Only two relatives made any response in questionnaires but these comments are very valid and efforts need to be made to make sure service users are fully satisfied with the activity and pastime arrangements. Perhaps discussion with relatives needs to be held to determine their expectations for service users as well and agreements reached. Service users have very fulfilling lives in respect of taking part in community life. Those able visit the local shops, pubs and entertainments both independently and supported. One or two attend specially selected venues and always have the support of the staff. Service users are able to make choices about their leisure activities and receive very good support from those staff with similar inclinations. Staff spoken to explain that one service user in particular enjoys and often takes up cycling to use up his excess energy. It is not always possible for him to do this though if staff on duty do not share the liking or are not able to ride a cycle. Staff explain he sometimes has behavioural problems when this arises. The management need to ensure the rosters enable this to happen to fulfil the service user’s needs. All service users maintain fairly good family links and those spoken to do not have any areas of concern. Relatives’ questionnaires make comments however, that they would prefer the home to help and support the service users better to enable them to see relatives more often. There are records in files of when service users visit or meet up with relatives and these occasions appear to be good. Journals show contact with family and friends on a monthly basis. Routines within the home are few and usually revolve around individuals to suit their personal preferences. Service users rise when they choose, as seen on the day of the site visit, and make their own decisions about what to eat for lunch and how to pass their spare time before returning to college, etc. They DS0000064804.V343020.R01.S.doc Version 5.2 Page 15 have freedom of choice to use their rooms when they please, come and go as they please if capable, and have keys to their rooms after being risk assessed. Some service users assist with shopping and cooking. Although there are no comments from service users and relatives about the quality or variety of food provision, some staff feel service users are not always offered healthy choices as planned on menus. Service users do say they feel they have no real control over what goes on the menu. One said, “We have to have what is on the menu. Staff pick it and we eat it.” They do not say that the menu is deviated from, but some staff believe it is. There was no evidence seen to support this. DS0000064804.V343020.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 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users receive good assistance and support to maintain their personal and health care, so they are confident their needs will be met. They do not experience the opportunity to selfmedicate, because of risk, but their levels of choice and independence are good in other areas. Medication systems are good in respect of storage and recording so service users needs are met. EVIDENCE: Discussion with service users and staff reveals service users are encouraged to take responsibility for their personal healthcare and they are assisted with personal support in a flexible, dignified way, but are not especially encouraged to retain and administer their own medication. Service users spoken to are satisfied with the flexibility of the support they receive from staff. One said, “The staff listen to us and do what we want.” DS0000064804.V343020.R01.S.doc Version 5.2 Page 17 Service users have varying levels of need in respect of personal and health care support, but all of those that are assisted with personal care receive assistance in privacy, and according to their preferences and wishes. This information was obtained only from staff and via service users’ questionnaires, but staff had assisted almost all service users to complete the forms, some trying to speak as though they were the service user and using the knowledge they have gained while caring for them. The only two relatives responding via questionnaires feel that service users needs are not always met and one feels that the staff do not have the right skills to be caring for service users with a learning disability. Those service users spoken to that gave an opinion are also those that need less support and assistance with personal care anyway and therefore their view only reflects their situation. On balance it would seem that not all service users have all of their personal and health care needs met. There are no service users that self-medicate in the home. The home controls everyone’s medication. There is a policy and procedure for handling drugs and staff follow these well. Some of the drugs are administered from the Boots monitored dosage system, but some are administered from boxes and bottles etc. Medication administration record sheets show drugs are recorded correctly and that designated staff, trained to handle medication at Selby College, are the only ones to administer it. The staff ensure medication trail checks are done on a regular basis half way through each month, and record this in the home’s communication book. There is a drugs returns book, which the pharmacist now signs on receipt of returned items. This is also done in response to a recommendation made at the last inspection. DS0000064804.V343020.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 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users are confident their concerns and complaints are listened to and acted on, and they are safeguarded against harm or injury, so service users are properly protected. EVIDENCE: Discussion with service users and staff and viewing of documents and procedures reveals service users and relatives have opportunities to make concerns and complaints known, have made complaints and have had these satisfactorily dealt with in the past. The home has a complaint procedure on show and maintains a record of complaints received. Service users spoken to are open about the issues they take to the staff and management to deal with. When asked if they know how to complain one service user said, “I would talk to the staff. Sometimes I get upset because sometimes I get picked on at the college. I tell staff and they help me sort it out.” The two relative questionnaires received state that relatives do not know how to complain, but when this was discussed with a senior staff and the administrator they explained that letters had been sent to all relatives explaining how they may complain if they wish. A copy of the letter is kept DS0000064804.V343020.R01.S.doc Version 5.2 Page 19 in service users’ files. This was also done in response to a recommendation made at the last inspection. Staff spoken to are fully aware of the procedure to follow when a complaint is brought to their attention. They experience complaint training during one-toone supervision. They are also fully aware of the grievance procedure should they have concerns. There is also a procedure for dealing with safeguarding adults’ issues, and staff have done training, but those staff that are new to the home have not done the training at all yet. This has been booked for July 2007. Usually the senior staff undertake safeguarding training for managers, while care staff do the training for carers. Records on complaints and safeguarding adults’ issues are maintained and show five complaints since June 2006, but nothing on referrals. The complaints were all dealt with satisfactorily. Systems are effectively used. DS0000064804.V343020.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): 24, 26 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users enjoy a clean environment, in a home that is suited to it stated purpose, but they do not always enjoy comfort and homeliness. EVIDENCE: Service users and staff spoken to and a very brief look at rooms belonging to service users reveals that the premises is suitable for its stated purpose and that they are clean and comfortable. Requirements and recommendations made at the last inspection were discussed with a senior carer and the administrator, and some were observed as having been attended to. The front door has now been fitted with a locking device, which overrides on activation of the fire alarm and safety DS0000064804.V343020.R01.S.doc Version 5.2 Page 21 system. Fire doors have been fitted with new in tumescent cold seals, have been eased to fit better into rebates and have had their closers adjusted. This is an area the provider must continue to keep under observation and maintenance because of the age of the building and the fittings. Areas that required redecoration have been done, and there are now weekly temperature checks on the hot water outlets, and these are recorded in a monthly maintenance record. The fridge temperatures are also checked weekly and recorded and any general maintenance is logged for the handyman to complete or arrange to be repaired. The home is adequately decorated and furnished with some exceptions. Although standard 26 has not been assessed fully it is noted in information received from relatives in questionnaires and from discussion with staff that service users do not all possess the required furniture listed in standard 26.2. This needs to be addressed as soon as possible through an audit of furniture and any furniture or fittings missing should be provided. Staff explained that some service users are soon to have their rooms redecorated and that furniture will be supplied accordingly. The house was observed to be clean and comfortable in communal areas, although the dining room is fairly sparse and lacking soft furnishings as in table cloths, lamps, seat cushions etc. These would only be requested if deemed appropriate for the service users living in the home. Individual personal space is well respected by the staff and other service users, but according to relatives it could be more inviting and comfortable. An audit as requested and perhaps consultation of service users and relatives should inform the provider what is needed to make service users and their visitors more comfortable in their rooms. DS0000064804.V343020.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): 32, 33, 34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users benefit from appropriately recruited and well-trained staff in sufficient numbers to meet their needs, so they are confident their lifestyles will be respected. EVIDENCE: Discussion with staff and viewing of their personal files with permission, viewing of some records, viewing of staffing rosters and allocated hours, and calculating the recommended Residential Staffing Forum figures reveals that standards 32, 34 and 35 are met. Standard 33 was also assessed and considered met. Information received from the provider shows that new staff undertake induction and training appropriate to their post and needs. New recruits can expect to begin the Learning Disability Award Framework induction in their first week and the foundation training within their first month, unless DS0000064804.V343020.R01.S.doc Version 5.2 Page 23 circumstances dictate otherwise. Information and discussion with staff also show that there is 76 of care and support staff with the required NVQ level 2 qualifications. Staff spoken to, rosters viewed and the Residential Staffing Forum figures calculated show that there is sufficient staffing on duty throughout the week. Forum figures require 446.30 hours per week for 4 high and 4 medium dependency service users. The home provides 600 hours per week according to the roster and when the home is fully staffed. Occasional shifts may not be filled if such short notice of illness prevents it, but usually agency staff are brought in last minute where possible. These are usually rare circumstances, but recently two agency staff have been covering night vacancies. The staff pointed out that a new recruitment drive is underway to appoint in these vacancies. Staff discussed staffing levels and considered them to be appropriate, but they also commented on sometimes there not being the right mix of staff on duty to meet all service users’ needs. Particularly one service user requires a lot of outdoor activity to use up energy and reduce frustrations, and if there are staff unable or unwilling to ride a cycle or engage in brisk walks then this service user’s needs are not always met. Information received form the provider outlines the recruitment and selection process, which involves some interviewing by service users as well as by the management team. Checking of staff files with permission shows that recruitment follows the requirements of standards are adhered to. Staff do not begin working in the home until an initial security check has been done and a proper disclosure has been sent for. References are required and chased when not responded to. All staff complete mandatory training in health and safety, medication administration, safeguarding adults, fire safety, basic food hygiene, restrictive physical intervention, etc. if it is appropriate to their role and level of responsibility. Two new staff spoken to have yet to complete all of the planned training, but dates have been set for everything. Certificate copies are held in files. DS0000064804.V343020.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users benefit from a qualified and registered manager that is competent and maintains consistency within the service. They have use of a quality assurance system that is effective in demonstrating their individual development in relation to their care plans. They enjoy good protection from harm under the home’s health and safety measures in place and the practices carried out, so service users are confident their health, safety and welfare are well promoted and protected. DS0000064804.V343020.R01.S.doc Version 5.2 Page 25 EVIDENCE: Discussion with service users and staff, and viewing of documents, records and safety certificates reveals that the home fulfils its stated purpose and meets the needs of service users. The manager is suitably qualified and experienced, with the Registered Managers Award, a certificate in working with people with autism and a Certificate in Education. He has three years experience working with people with autism and learning disability and at a managerial level. He is respected by the staff and liked by the service users. There is a quality assurance system in operation for assessing the home’s quality of care, which involves surveying service users, relatives, GPs and social workers and checking of documentation and care practices etc. in the home. Systems were not fully inspected during this inspection, but the standard was met last year and there has been no change to or deterioration in systems. Areas of health and safety sampled during the site visit were fire safety, legionella testing, hot water testing and accident monitoring. Records show that there s a health and safety policy statement in place specifically for fire safety and procedures. There are copies of the fire safety building plans, regular checks on the escape routes, break glass points and extinguishers. There are monthly fire drills held and recorded, as well as monthly checks on the systems. Staff are instructed in fire safety awareness at least once a year, but a Fire Prevention Officer gave the last one on 18/04/06 and therefore instructions are over due by 2 months. This needs attention. There is a general fire risk assessment document in place on the possibility of being trapped in the building during a fire dated May 2006, and one on the whole of the house, which was done in July 2002. This risk assessment did not have any evidence of when it was last reviewed. Both risk assessment needs reviewing and evidencing. Service users have individual fire risk assessment document in place. Two were completed in June, two in July, and one in October and one in November 2006. One was done in January 2007. One service user appears not to have such a document. The fire safety system was last maintained 14/02/07, along with the fire extinguishers. Humberside Fire and Rescue Service last visited 04/09/06 and made recommendations to fit safety covers to all emergency lights beneath DS0000064804.V343020.R01.S.doc Version 5.2 Page 26 the floorboards to protect emergency lights from fire in the room above them. This was completed on 08/08/06. Although the home maintains hot water temperature checks and records these, there does not appear to be a certificate of testing for legionella. The manager needs to check this and arrange for a test as soon as possible, if none has been completed in the last three years. There is an accident record held in a Wallace Cameron Group publication, but the book is very small and only records basic details. It is data protection compliant and records are taken out and filed in individual service user files. The manager monitors accidents and takes action to deal with any recurring issues. Staff spoken to are aware of where the accident book is kept and when it needs to be completed. DS0000064804.V343020.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 X 2 3 3 X 4 X 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 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X DS0000064804.V343020.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 DS0000064804.V343020.R01.S.doc Version 5.2 Page 29 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 YA17 Good Practice Recommendations The registered provider should make sure service users are encouraged to eat healthy options of their choosing where possible, and to try to stick to the planned menu, which should be compiled with the agreement of service users, so they are confident their dietary needs are met in a healthy way. The registered provider should make sure all service users have furniture and fittings listed in 26.2 in their rooms, unless they choose not to, but this request must be recorded. This is so service users know their independence is being promoted. The registered provider should make sure all staff receive updated fire safety training in line with the service’s annual requirement, so that service users are confident they are safe. The registered provider should make sure the hot water storage system is checked for legionella bacteria on a regular basis. This test should be carried out before the end of August 2007 and evidence kept to show the result, so that service users are confident they are being protected. 2 YA26 3 YA42 4 YA42 DS0000064804.V343020.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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