Inspection on 16/11/06 for Helen Ley Court

This inspection was carried out on 16th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Helen Ley Court 03/11/08

Helen Ley Court 15/11/05

Helen Ley Court 16/06/05

Helen Ley Court 09/03/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Helen Ley Court Bericote Road Blackdown Leamington Spa Warwickshire CV32 6QP Lead Inspector Sheila Briddick Key Unannounced Inspection 16th November 2006 09:15 Helen Ley Court DS0000063465.V308910.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 Helen Ley Court DS0000063465.V308910.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. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Helen Ley Court Address Bericote Road Blackdown Leamington Spa Warwickshire CV32 6QP 01926 331550 01926 888972 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.helenley.org.uk Multiple Sclerosis Society Carol Stevens Care Home 10 Category(ies) of Physical disability (10) registration, with number of places Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Helen Ley Court is a purpose-built home for 10 residents with physical disabilities who have Multiple Sclerosis. The building is owned by Orbit Housing and Helen Ley Centre is responsible for the management and upkeep of the home. The home has a shared entrance with Helen Ley House. Residents are accommodated in self-contained apartments with en-suite bathroom and small kitchenette. There is a shared lounge/dining room that can be partitioned off to make two separate areas. There is a main kitchen where all meals are prepared. There are extensive gardens for the Centre and a private courtyard for the residents of Helen Ley Court. The home is situated on a country road between Leamington Spa and Kenilworth, amid fields and sports grounds. The current scale of charges is £560 - £688.80. Additional costs for hairdressing, toiletries, papers and magazines, continence aids, some activities and transport have to be met by residents. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the inspection visit the manager had forwarded to the Commission a pre-inspection questionnaire, a staffing rota and menu records for the home. All pre-requested documentation was examined as part of the inspection process and the evaluation included in this report. The inspection visit was unannounced and took place on Thursday, November 16, 2006. at 09.15 am and ended at 3.45pm. The visit to the home involved: • • • Discussions with seven residents, the manager, three care workers and a visiting relative. Observation of working practices and of the interaction between residents and staff. Two residents were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for residents. A tour of the environment was undertaken, and home records were sampled, including staff recruitment, the last quality assurance survey, the complaints record, health and safety and fire records. • I would like to thank residents met with for sharing their views about their experiences of living in the home and for the co-operation of the manager and staff during my visit. What the service does well: The service continues to provide a safe, warm and welcoming place in which people can live and work. The management of the service is accountable and competent and residents said, There is a lovely pleasant atmosphere here, everyone is friendly. People who had recently come to live at the home said, I have settled in well, and This was definitely a good move. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 6 People are consulted on in all aspects of the care provision saying, My choices, wishes and needs are discussed with me. and We have regular resident meetings, which are good, and have been fully involved in recruiting new staff”. One resident was particularly appreciative of the support they had received since coming to live in the home to develop their confidence and re-gain some independence. Family members are confident that their relative will be well cared for saying, The care is excellent here, I couldnt wish for better staff and The care is good, they do look after him well. When asked what the service does well residents said, There is lots of socialising and If you need help you get It.. Staff felt that they were very good at meeting individual choices and of Seeing the person first and the disability second. What has improved since the last inspection? What they could do better: Medicine management is generally robust however it must be improved upon so that the records maintained on the Medicine Administration Record, (MAR Chart), of all medicines received into the home and returned at the end of the month. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 7 The service determines the competency of residents who are self- medicating through risk assessment, however the record should include the competencies expected, including the resident’s understanding of their responsibility for keeping their medicines safe and secure in their room. Whilst it was demonstrated that staff records were in good order and contained the required documentation to show safe and thorough recruitment had taken place the manager is advised that a checklist of all documentation required would minimise the possibility of any information being overlooked. 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. Helen Ley Court DS0000063465.V308910.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 Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People coming to live in this home can be sure that they will have their needs assessed by a competent person to be sure that the home will be able to meet their needs, wishes and choices safely. EVIDENCE: The admissions process for the two residents whose care was being looked at was examined and the views of each resident’s experience of this listened to. One resident had been able to visit the home prior to coming and staying there and the manager visited the other resident in their living environment at that time. Comments from the residents regarding their admission included; I did come to meet the manager and a couple of residents. I have settled in well - it was definitely a good move. I couldnt visit but the manager came to see me.” Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 10 The care plans for these people where looked at and showed that the manager had completed a full assessment of needs with them prior to their admission. These were comprehensive covering all health and social care needs of the individual and any risk that there might be in the care that they would require. The Statement of Purpose and Service User Guide were looked at and this confirmed that the Multiple Sclerosis Society has amended both documents to show the change of ownership and the change of Responsible Individual. This was a Condition to the Registration of the home that has now been met and can be removed. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place that adequately provides staff with the information they need to satisfactorily meet resident’s needs. People are involved in their care planning and supported to take risks as part of promoting an independent lifestyle. EVIDENCE: Two care plans were examined and the views of the residents involved were sought. Each resident was able to give a clear indication of their involvement and satisfaction of the care planning process and their comments included; Care planning is done in the office but my choices, wishes and needs were discussed with me. The manager talked about my care needs with me. A family member met with who was visiting at the time said that they were still involved in the decision-making with their relative. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 12 The care plans looked at were clear and well documented showing that through the assessment process care needs are monitored and evaluated as the staff get to know the resident better. The advice of specialist services is sought as part of this process and includes specialists in speech and language, district nursing teams and the residents GP. Specific support from speech therapy services has enabled two residents to communicate more easily about their needs and choices through development of communication boards or books with them. As part of service development the manager said that it is a future aim of the service to review the care planning process and implement a system that is more ‘ Person Centred’ and realistic for the person. The key working system is also to be reviewed and this will include training for senior staff in the key working role as they will have responsibility for this. Risks for people are managed reasonably well and reviewed as needs change. Care plans looked at showed reviews had been regular and guidance for staff was clear in its instruction to them about keeping a person safe during an identified activity. Staff spoken with felt that care planning was good and said Meeting individual choices is something we feel we do well. It was pleasing to listen to staff talking about “seeing the person first and not their disability. Residents spoken with continue to be confident that their views regarding their care and the service provision are listened to and acted upon. They said that their resident meetings were good and that staffing issues were discussed at these meetings. Helen Ley Court DS0000063465.V308910.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home are able to make choices about their lifestyle, and supported to develop their life skills. Social, cultural and recreational activities meet individuals expectations and promote ordinary and meaningful lifestyles. The meals in this home are generally good offering some choice and variety and catering for special dietary needs. EVIDENCE: There has been significant progress in supporting people to maintain their independence and live ordinary and meaningful lives both in the home and the local community. Lifestyle aspirations vary according to individual choice and a person’s health. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 14 Staff spoken with felt one of the things that had improved since the last inspection was that people were involved more in activities and going out in the community more. They also felt that they were supporting and encouraging residents to be more independent. Residents spoken with were also satisfied with opportunities available for them for personal development, independence, activities and access into the community and comments included; Since coming to live here I am feeling more independent. I do my shopping on the Internet and have explored Kenilworth, Leamington Spa and Coventry for shopping. I can continue my hobbies and it pleased me when a staff member asked me to teach her crochet. I was attending college for computer studies but taxi services locally became difficult. I may look at completing this on the Internet. We prefer to join activities at Helen Ley House, rather than organise our own. We meet more people that way. There is lots of socialising with the House. I am able to do little jobs here, like folding napkins. Residents have recently been involved in the recruitment of a new cook and were looking forward to being involved in reviewing the food provision in the home with them. Residents were joined for the lunchtime meal of chicken casserole and potatoes or stuffed pepper with potatoes and vegetables. For dessert there was a choice of fresh fruit salad, sponge pudding with custard or cream, or yoghurt. The food was hot, cooked nicely and well presented. Residents had differing views about the food provision although all agreed that they thought this was going to improve to everyones satisfaction when the new cook started work. Residents sit together at mealtimes and the two dining tables have been put together to form one large dining table. They were asked if this was because of the decorating that was taking place and replied, No - we now like to sit at the tables joined together, it is more sociable and generally the one-time we really meet. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 15 One resident’s choice to eat separately was seen to be respected. People requiring 1:1 support received this, having their meal at the same time as other residents which meant their food was hot and they were able to listen to the conversation going on around them. People were provided with protective clothing if this was necessary and staff joined in with the conversation at tables. Each resident lives in their own bed-sit accommodation but can access shared areas of the home freely when they choose to, with residents generally coming together at mealtimes. People spoken with said that the staff respect their privacy when coming into their accommodation by knocking on doors. One resident said that on the occasion when staff forget to do so she feels able to remind them to do so. Dietician support is accessed and specialist foods such as thickening agents for liquids are provided. A resident and their visiting relative sought the advice of a staff member about how a thickening agent would affect the taste and flavour of drinking chocolate as the resident had said they would like to drink this on occasion. The staff member was able to offer good advice about how this could looked at. Helen Ley Court DS0000063465.V308910.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support in this home is offered to people in such a way as to promote privacy, dignity and independence. The healthcare needs of the people living in this home are assessed and recognised with evidence of specialist services being readily available to them. Medicine management is generally safe however the home was eager to improve their current systems for medicine management. EVIDENCE: The two care plans looked at showed that the personal care and health care support needs of each resident continue to be reviewed with them as needs change. Care planning is supportive to people in maintaining their independence which includes being able to self-medicate and access their GP surgery or dentist independently. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 17 Residents spoken with said, Personal care offered is good. Care practice observed promoted independence and support offered to people when moving them was sensitive, caring and safe. A resident said, I lost my walking ability when I was living at the other home but now I have ‘physio’ support, staff are encouraging me with this. People spoken with felt that staff supporting them had a good knowledge of multiple sclerosis and the effects this had on people when moving them and communication with people. The individual needs of people and risks to them are clearly identified on their care plan, this includes provision of pressure mattresses and risk assessment for the prevention of pressure sore. A resident said that their bed was “very comfortable”. Medicine management is generally thorough and protecting people from harm however two minor shortfalls were identified during the visit. As part of promoting independence residents are supported to be selfmedicating through a risk assessment process however, the criteria for assessing a persons competence to be self-medicating. This is not written down nor is a process for monitoring that the persons medication is taken routinely or that they maintain their competency. For example, one resident who is self-medicating said, I keep my tablets on the table, close at hand. They also indicated that they did not have a locked cupboard to keep their medicine in. The manager said that the resident chooses not to keep their medicine in the cupboard that has been provided for them. The risks involved about this were discussed with both the manager and the resident. The manager agreed that self-medicating competency should include the residents understanding of their responsibility to keep medicine safe and secure. Records relating to the administration of medicine in the home were looked at and in general were in good order showing clearly when medicine had been administered and by whom. The medicine administration record, (MAR), chart however did not record the quantity received from the pharmacist each month or the amount returned at the end of the month. Without this knowledge it cannot be determined that the quantity of medicines held in the home is correct at any time against the amount administered. The home does however keep its own record of medicines received and returned in a separate book. The manager recognised the risks around the shortfalls with current practice and was keen to implement changes to minimise these risks. Helen Ley Court DS0000063465.V308910.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The people living in this home feel that their views are listened to and acted upon. Adult protection policies and procedures in place for the protection of vulnerable people provides a safe environment for the people living in this home. EVIDENCE: Pre-inspection information received indicated that three complaints had been made to the home in the last 12 months. There has been no complaints made to the commission about this service since the last inspection in November 2005. The record of the three complaints were examined during the visit to the home and found to be comprehensive and included discussions, agreements and actions that had taken place with all people concerned. Discussion with residents confirmed that they are able to talk through with the manager and staff any issues they have, or concerns there may be about their service. One resident did say however, Staff dont always understand me and this can be frustrating. All resident spoken with said that they felt safe and staff were kind. Staff said, Residents tell us if they are not happy. . Family members met with also said that they felt they were able to talk with the manager and staff if anything worried them. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 19 Policies and procedures in place for the protection of people from harm, are robust and easy to understand. They include a recruitment and selection programme that ensures proper checks, i.e. criminal record bureau clearance and POVA checks, are taken prior to people coming to work in the home and training for staff. POVA training is undertaken by all staff who come to work in the home during their induction training. Two staff were spoken with about their understanding of policies and procedures in place the protection of adults. One staff member was very clear of their role and responsibility within this, the other staff member was completing their induction training and knew they would have opportunity to develop their understanding and knowledge through this. They had however been working at the home for a number of months and had not seen the policy document for the protection of vulnerable adults, however, they did know that this would be in the office. Helen Ley Court DS0000063465.V308910.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is enabling people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence and promotes an ordinary lifestyle. EVIDENCE: At the time of the visit to the home the premises were safe, comfortable, bright, cheerful, airy and clean despite the redecoration programme that was taking place at the time. All residents spoken with expressed satisfaction with the standard of the environment and of his or her particular living unit. They said they had been involved in the refurbishment and decorating programme by choosing colours, furnishings and fabrics. The dining-room carpet had been replaced with wooden flooring and residents said, Having no carpets in the dining room is much better, it is now more clean and easy to move around on with wheelchairs. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 21 The manager said that the refurbishment programme had also involved agreeing timescales with residents so that this was at a pace to meet their individual and collective needs, that is, not having too much done in the environment at the same time so that people could move around easily and disruption to their lifestyle could be minimised. Two people who had recently come to live at the home said that they were satisfied with their accommodation, both said that their bed was comfortable and that linen was changed regularly. They also said that their personal clothing was laundered well. Infection control policies and procedures are in place and cover all areas of care where there may be risk. This includes provision of protective clothing, aprons and gloves for staff, appropriate hand washing facilities in all areas where necessary and provision of a laundry area and sluice facility that is well away from food preparation areas. Two new washing machines have been purchased recently and these have a sluice facility. Soiled linen is placed in red bags to be carried from the bathroom/toilet area to the laundry area and then placed directly in the washing machine. The red bag dissolves as the washing is cleaned at a high temperature. This arrangement ensures that risk of the spread of infection remains at a minimum. The refurbishment of the home will continue over the next few months to include the refurbishment of the communal bathroom into a wet room facility, provision of new furniture and curtains in the dining room and lounge and redecoration in a number of bedrooms. Helen Ley Court DS0000063465.V308910.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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective staff team who listen to residents, understand their needs and have opportunity to develop and maintain skills. The recruitment policy and procedure for this home ensures that residents are involved in choosing the people who will be caring for them and that they will be protected from harm. EVIDENCE: Two staff were met with during the visit to seek their views on the service provision and their training opportunity. Care practice was observed and the views of residents regarding the care offered to them by staff were talked about with them. All residents spoken with said that personal care offered to them was supportive and respected their dignity. They did feel that at times though there was not always sufficient staff support readily available and this was generally in the mornings and evenings. They said, There are always three staff on duty but there are some busy periods and then staff are stretched. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 23 Residents said however that, Staff issues can be discussed at resident meetings. Care practice observed respected privacy and promoted independence. Staff spoke kindly to residents and responded to requests promptly. Residents spoken with felt that the staff team had a good knowledge of the specific needs of people with multiple sclerosis, especially when moving them and providing personal care. A new member of staff spoken with was looking forward to developing their knowledge and understanding of multiple sclerosis on completion of their induction. New staff complete the Skills for Care induction programme. There continues to be an active NVQ programme in place with 70 of the staff team having an NVQ at level 2 or above. The manager is closely involved with the Warwickshire Partnership Board and seeks training opportunity for the staff team through the Board. The pre-inspection information received indicates that future training planned for includes further training in multiple sclerosis, disability awareness, abuse awareness, (for new staff,) and continuation with the NVQ programme, which will include supporting new staff to start at Level 2 and another staff member to work towards achieving Level 4. The recruitment records of a recently recruited member of staff were looked at. This determined that appropriate references had been obtained before making the appointment and appropriate checks had taken place to be sure that the people living in the home would be safe. This included Criminal Record Bureau, (CRB) and POVA checks. There was however no photograph, or other means of identity, attached to the file. The manager was able to demonstrate that a photograph is usually attached to each staff members file and recognised the shortfall in this instance. Residents spoken with had been involved in the recent recruitment of a cook to the home and three had taken part in the interview process. They had been appreciative of their involvement and were looking forward to being involved in the development of the food provision with the new cook. Staff spoken with felt they worked well as a team saying, We all work to the same goal and respect each others views.. Helen Ley Court DS0000063465.V308910.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 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of this home is based on openness and respect. It has effective quality assurance systems based on seeking the views of the people using the service. Policies and procedures for safe working practice in this home are ensuring that service users health, safety and welfare is being promoted and protected. EVIDENCE: Residents continue to be involved in making decisions regarding their care and in the day-to-day issues of the service provision. This is being completed individually and at regular resident meetings. A record of the monthly meetings is maintained and the last meeting minutes were looked at. The agenda clearly showed that residents discussed staff Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 25 recruitment, refurbishment, fundraising, health and safety house rules and staff care practices. The Multiple Sclerosis Society complete quality audits of the service annually which includes seeking the views of residents and staff of the service provision. The manager receives feedback of the outcome of the survey and provides an action plan to the Society for addressing any concerns that may have been indicated. The result of the 2005 survey was very positive for the manager and staff team, with 100 satisfaction being given by residents and their family members in the areas of daily living, food provision and management. Residents had not been entirely satisfied with the standard of the environment however, the recent refurbishment programme is to their satisfaction. The survey by the Society does not include the views of other professionals, such as health care professionals and social services, Since the last inspection the manager has become more familiar with the Mental Capacity Act and intends to develop care planning in line with the rights and responsibilities of individuals as advised in the Act. When looking at home records some information that was sensitive and personal to residents was being kept in the kitchen area. Discussion took place with staff and the manager about this practice and they demonstrated an understanding that this was not appropriate and would consider new arrangements that would promote privacy and dignity. The service has a good record of meeting relevant health and safety requirements and legislation. Records looked at were of a good standard and had been routinely completed. This included the records looked at for fire safety and water temperature regulation. All working practices observed on the day of the visit were safe and in the event of an accident occurring satisfactory records are maintained. The manager ensures that all staff are trained in health and safety matters and has regular planned updates. Staff spoken with said that recent training has included moving and handling, fire training, first aid, food hygiene and infection control. Health and safety training planned for includes first aid, food hygiene updates as needed, health and safety, (including COSSH) and infection control. Helen Ley Court DS0000063465.V308910.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 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 X 27 X 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 3 3 X Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13.2 Requirement The manager must make arrangements for the safe keeping and management of medicines in the care home and this must include recording amounts received and disposed of on the medicine administration chart and the criteria for measuring a resident’s competency for being able to self medicate. Timescale for action 30/11/06 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 YA23 Good Practice Recommendations New staff coming to work in the home should be encouraged to become familiar with the content of the adult protection policy and procedure for the service during the first few weeks of their induction. The manager should develop a recruitment document checklist to ensure that all required documentation is gathered that is to be held on the staff file. DS0000063465.V308910.R01.S.doc Version 5.2 Page 28 2 YA34 Helen Ley Court 3 YA39 4 YA41 The views of other stakeholders, i.e., healthcare services and social care services, should be sought about the service provision at the home as part of the quality monitoring of the care provision to the people living there. Sensitive and personal information about residents should be kept in areas that are secure and only available to the resident and care workers providing the care to them. Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Coventry & Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Helen Ley Court DS0000063465.V308910.R01.S.doc Version 5.2 Page 30 - 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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