Inspection on 19/10/07 for High Road 410-412

This inspection was carried out on 19th October 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

High Road 410-412 21/07/06

High Road 410-412 27/02/06

High Road 410-412 19/10/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 High Road 410-412 410-412 High Road Ilford Essex IG1 1TW Lead Inspector Stanley Phipps Unannounced Inspection 19 to the 26 October 2007 11:00 th th High Road 410-412 DS0000063248.V354083.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 High Road 410-412 DS0000063248.V354083.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. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service High Road 410-412 Address 410-412 High Road Ilford Essex IG1 1TW 0208 252 6256 0208 252 6517 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.caretech-uk.com Sunnyside Care Home Ltd None at Presnt Care Home 7 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0), of places Physical disability (0) High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service can only admit a person where mental disorder is a secondary need to that of a learning disability and/or a physical disability. 21st July 2006 Date of last inspection Brief Description of the Service: 410-412 High Road Ilford is a Residential Home for seven adults with Sensory, Learning Disabilities and Mental Health Difficulties. The home has recently been registered and has undergone refurbishment of an existing double fronted three-storey house situated on the main Ilford High Road. Since its original registration the home has changed owners in that as of 18th May 2006, the service has been acquired by a large private organisation under the provider name of CARETECH - Community Services Limited. The home is close to community facilities such as swimming pools, shops, Churches, a Mosque, Hindu temple and Synagogue. The home also has good transport access and is near Ilford station and regular bus services. There are seven bedrooms, all with a full en-suite, which includes either a bath or a shower. Six of the bedrooms have ceiling re-enforcements, in case of a need for a ceiling hoist. There is ramped access to the front of the premises and also to the garden area from the lounge/dining room. A statement of purpose is made available to all service users in the home and is kept in the main Office. Given the level of disabilities service users are likely to have, this document is also made available to relatives and stakeholders. A service user guide is also given to each service user upon admission to the home. Fees are currently charged at £1350 - £1880 per week. Items not included in these fees are holidays, clothing, hairdressing, toiletries, items of luxury of a personal nature and unlimited support to access the local community. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out between the 19/10/07 and the 26/10/07. It was unannounced and a key inspection of the service, which meant that all the key minimum standards for ‘Younger Adults’ were assessed. The assessment also considered information provided in the Annual Quality Assurance Assessment (AQAA) by the registered persons. An assessment of policies and procedures, medication practice, activities, menus, all records required by regulation, service user plans and the environment was undertaken. Over the course of the inspection discussions were held with several staff, three service users, the deputy manager and the manager. Formal interviews were held with one member of staff and a service user. The inspection also considered comment cards completed by staff and/or service users. The inspection found that service users living at 410 High Road were receiving good quality outcomes. The registered persons acted upon most of the previously made requirements, which would have had a positive impact on the service, as a whole. However, there are some areas that require further improvement, which are identified in this report. Service users were observed throughout the inspection and on most occasions were positively engaged with all levels of staff. What the service does well: Service users continue to enjoy living a spacious and pleasantly decorated home. Detailed assessments are carried out in determining the suitability of the service for individuals considering living at 410 High Road. Staff continued to focus on working with individuals to achieve their aspirations and agreed outcomes. A key feature of this involves meeting the cultural needs of service users, including their dietary needs. Staff attitudes towards service users were positive, which had a positive impact on their confidence and willingness to engage with them. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. High Road 410-412 DS0000063248.V354083.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 High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (1,2) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users have updated information, which they could rely on in making a decision to live at 410 High Road. Their needs are assessed and in detail prior to admission to determine the suitability of the home in meeting them. EVIDENCE: An updated statement of purpose and service user guide detailing the; philosophy, aims and overall services provided were in place at 410 High Road. Both documents were available to service users and consideration has been to meeting the diverse communication needs of the service user group. As a consequence, the service user guide was available in pictorial style format. Plans are in place to develop both documents further to ensure that they meet the diverse communication needs of the service user group. At the time of the visit the service user guide was kept in the office as a matter of procedure. The management of the home was advised that they needed to offer it to all service users to comply with Regulation 5 of the Care Homes Regulations 2005. The inspector was assured that they would go out to all service users. In general both documents comply with the national minimum standards and the Care Homes Regulations 2001. There were up to three admissions and one discharge since the last inspection. As part of the inspection, the admission records of the three most recently High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 10 admitted service users were assessed. The assessments were detailed using a format designed by CARETECH and involved a senior manager along with the home’s manager. The pre-admission documents were found in order and service user plans have been developed from the assessments that were carried out. The home’s current admissions’ process ensures that service users participate in choosing whether to live at 410 High Road, part of which involves them having a trial stay at the home. Service users have some assurances that their needs would be met, once they decide to live there. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,8,9) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users have the benefit of a comprehensive plan that is developed with their needs in mind. Staff continue to engage with service users to enable them to achieve their individual objectives. This involves taking risks within a risk management framework to ensure that their safety and independence is promoted. There has been little evidence of service user participation in all aspects of the home. EVIDENCE: Service user planning was in place for each individual living in the home and from discussions with two individuals, they were quite happy to be part of the process. This document is used as a working tool by staff in the home and each service user is assisted by their key-worker in developing this document, which sets out their aims and aspirations. One individual stated; ”My key worker helps me set down what I would like to do”. Another stated; “Having a key worker is a good thing, as I could go through my plans with him. I think he is fantastic”. The plans viewed were reviewed regularly, updated and reflected the needs of service users. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 12 Staff continued to support service users to make decisions about their lives and there were various forums available for them to so do. They included; ‘talk time’, care - planning, reviews, and service users’ meetings. One individual continues to do computer and music and is able to engage with music that was suited to his culture. Another individual was observed choosing an exercise DVD, just prior to having lunch and all staff worked towards enabling that process. Most service users engage with the opportunities provided and so retain control of their lives. It must be noted that the levels of support provided, varied from individual to individual, which meant that service user engagement was specific and purposeful. There was evidence that service users were involved in some aspects of life in the home. Examples of this included; determining their menus, types and levels of activities, receiving same gender care along with their healthcare requirements. However, this did not go far enough as areas such as staffing recruitment, staffing levels, changes to the service and the service user mix needed improving. With regard to staffing levels, it was not always clear that the needs of service users, determined the numbers of staff on duty. This needs to improve and would be covered in greater detail under staffing. Risk assessments were in place for each service user, which were linked to their individual plans. They were updated and reviewed annually or as and when the need arose. One of the service users interviewed showed an awareness of why a risk plan was in place for her. More importantly, she was party to its development and so, felt in control while being safer. On examining the risk assessments, clear actions were recorded to keep the risks to a minimum and this forms an important part of safeguarding adults. The risk management plan was aimed at promoting service users’ independence and as such was developed in the least restrictive way. This is positive. High Road 410-412 DS0000063248.V354083.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): (12,13,15,16,17) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users are enabled to participate in their community, enjoy a range of activities and, are able to maintain and develop social and personal networks of their choosing. They are supported to exercise their rights, which are respected and promoted by staff in the home. Service users also enjoy a variety of meals that meet their cultural and nutritional needs. EVIDENCE: There was evidence that each service user is supported to participate in activities of that was best suited to them. During an interview with one individual, he outlined what he currently did, which included attending a centre for up to three days per week to do computer and music. He was also clear that he is encouraged to do what he wanted to and he was quite happy with this. Another service user was having one to one sensory stimulation and though his communication with the world was limited, the occasional smiles were indicative of his involvement and satisfaction with the activity. Records viewed clearly indicated that service users were engaged in activities that were specific to their needs. It must be said that service users spoken to were pleased with the level and quality of personal activities provided by the home. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 14 Service users access the local entertainment centres, restaurants, shops, parks, church, the library and their local GP. Staff worked flexibly to enable this, despite the difficulties experienced in the availability of community resources for service users with specialist needs. Service users informed that they enjoy going out and were happy with the support given by staff in enabling this. It also became clear that service users were using various forms of public transport to go about their daily lives, which is positive. At the time of the visit, staff were involved in researching the community resources for an Asian Cultural centre for the benefit of one of the service users, which is positive. Service users have opportunities to engage with their communities, although staff reported that at times this is affected by lack of staffing. From discussions with service users and a relative, and from assessing their individual service user plans and care records, it was noted that service users are encouraged to maintain their friends and families network. Relatives were invited to functions and reviews held for service users and there was evidence that relatives are kept well informed of the progress and developments affecting their relations. Service users in some cases go out to visit their relations and it was clear that every opportunity is given to ensure that service users are able to maintain their personal and social networks, which is positive. Feedback received from service users indicated that they felt respected by the management and staff at the home. Throughout the course of the inspection, the rights of service users were respected as evidenced through the interventions undertaken by staff with them. Service users have information regarding access to advocacy services. They also have regular meetings where they are able discuss a range of topics that affected them. This included; outings, menus, internal activities and things that affect them in the home. A social diary is maintained for service users, one of which included; hand massages, sensory and reading. One individual spoke of positively of her experience with staff paying close attention to her individual plan. She advised that makes a big difference to her life, as she is able to enjoy her music and her love for watching DVDs, which she is supported to go out and buy. There was a high level of satisfaction with the meals provided at 410 High Road. This resulted from the level of service user involvement in this process, which included planning menus to helping out where possible with the meals. It was clear that there were varying levels of skills in this area, but opportunities for involvement were available to all. Lunch was observed and this was a very personal and relaxed activity. Staff often have a meal with the service users and engage with them for a more pleasurable experience. There was evidence that meals were freshly prepared and there was a fresh supply of fruits and vegetables. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 15 Meals were varied, diverse, and reflective of the nutritional needs of individuals. Menus are decided weekly, which then influences the shopping. There was evidence that pictorial menus were used a s part of enabling service users to make informed choices about what they would like to eat. Service users had access to healthy snack options, which were noticeable over the course of the inspection. Meals also took into consideration the health requirements of individuals and a system of monitoring service users’ weight was in place to in relation to the meals arrangements at 410 High Road. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy personal support in a manner that is best suited to them. Good arrangements are in place to provide for their physical and emotional health needs, although more attention must be centred on ensuring that all health action plans are kept updated and reviewed at all times. Health promotion has improved somewhat as the staff were more appropriately handling medication in the home. EVIDENCE: Feedback received from service users indicated that their privacy was promoted, where they were supported with personal care. The staffing arrangements are adequate to offer same-gender care, should this be required and a gender policy is in place to facilitate this. Most of the service user feedback received informed that they could do what they want, including going to bed, waking up, and doing what they want at anytime during the day. A key worker system is in place, which effectively provides the support mechanisms to enable service users to lead fulfilling lives. Staff interviewed, showed a good understanding of the service users needs, which provides a solid platform to provide good quality care. One example of this was where one service user has developed some independence in relation to an aspect of health dysfunction – which is positive. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 17 Feedback received from service users indicated that their privacy was promoted, where they were supported with personal care. The staffing arrangements are adequate to offer same-gender care, should this be required and a gender policy is in place to facilitate this. Service user feedback received informed that they could do what they want, including going to bed, waking up, and doing what they want at anytime during the day. All service users are registered with a GP and records assessed indicated that are in place for them to see other health professionals such as the dentist, community nurses, chiropodist and the opticians. There was evidence that professionals such as the physiotherapist and a psychologist has been involved Sound records were maintained where service users attended health related and professional appointments e.g. GP or a psychiatrist. In one case a food intake chart was maintained for an individual and this was to ensure that health and dietary needs were appropriately met. Good arrangements are in place for service users to see professionals privately. The health care needs though adequately provided for could by ensuring that health action plans are updated and used as working tools for service user. There was an improvement in the handling of medication in that medication charts were maintained in safe manner. Service users were given support with their medication and there was good evidence to confirm that all staff involved with this had training in this area. Feedback received from service users indicated that they were happy with the quality and level of support they received with their medication. The medication records were thoroughly assessed and they were well maintained. Instructions were clearly laid out for staff to follow, which minimised the risk of errors being made. Refresher training is provided for staff on an annual basis. The registered persons should consider relocating the medication cabinet, as the lighting cannot be maximised and the door opens into a frequently used pathway. This poses a risk and should be reviewed or risk assessed to ensure service users’ safety. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users and their relatives are assured that when complaints are raised – that they would be acted upon. Good procedures are in place to promote the protection of service users living at 410 High Road. EVIDENCE: Service users spoken to indicated that they could raise concerns in service user meetings, with the manager, their key-worker or social worker. A copy of the complaints procedure is available to all service users The complaints record was examined and was appropriately maintained. Staff interviewed demonstrated a sound understanding of the need to support service users to complain, should they become unhappy with any aspect of the service. There were good systems in place to safeguard service users from abuse, which included a clear and accessible protocol on abuse and specific training in relation to safeguarding service users. From observing practice in the home, speaking with the management and staff team – it was clear that from a practical point of view steps are taken to protect service users from abuse. Staff interviewed demonstrated a good understanding of issues around safeguarding adults, which is positive. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 19 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): (24,26,28,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy a generally safe environment, which has been enhanced with improvements carried out by the registered persons. A high standard of cleanliness ensures that the home remains a safe place for all. EVIDENCE: On the day of the inspection the home was clean, tidy and in good decorative order. Service users benefit from a range of facilities including: toilets, bathrooms, bedrooms, lounges for dining, relaxation and recreating, and a rear garden. The environment is homely and service users were observed enjoying various parts of it during the course of the inspection. Feedback from external professionals indicated that the home is always well maintained. Improvements were carried out to the damp patches to the base of the column in the main lounge and redecorative works were carried out to the wall opposite the column. However, there were a number of dining chairs that were in disrepair and unsuitable for the service user group. They were unsteady and rocking and posed a risk to service users. The deputy manager removed them on the day of the inspection and they needed replacing or repairing. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 20 It was noted that the rear glass doors are now locked for the safety of staff and service users, which is positive. Some bedrooms were examined and it was observed that the improvements required were carried out as required from the last inspection. Service users spoken to were satisfied with the facilities and décor in their bedrooms. There was evidence of low lying face basins, which made bedrooms suitable to the diverse and specific needs of individuals. It was also observed that satisfactory arrangements were made for ensuring good circulation of air in the kitchen. This was confirmed in discussions held with service users and staff. Both groups confirmed that they were now more comfortable using the kitchen and several service users were seen using the facility during the course of the inspection. The premises were clean and hygienic during the course of the inspection. The registered persons have put in place good arrangements to ensure that soiled linen is not passed through the kitchen. Adequate facilities remain in place for staff to clean their hands and policies and procedures for infection control were updated and available to staff. Staff interviewed showed a good understanding of their responsibility under health and safety. An alternative point has been identified to cut the water supply to the upper floors should there be an emergency involving water. The home complies with the Water Supplies Regulations 1999. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 21 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): (32,34,35) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit from a staff team that is committed and adequately supported providing care to them. Staffing levels need to reflect the needs of service users at all including peak times. Recruitment practices ensure that service users remain in safe hands, while living at 410 High Road, although, staffing recruitment information should be available at all times. EVIDENCE: Staff on the day were motivated and enthusiastic about the job they were doing and all service users echoed this sentiment, service users were receiving one to one sessions as outlined in their service user plans and two carers when this was required. However, during the lunch period, one staff member was out, two others were with another service user and the deputy manager was cooking and engaging another service user in the process. This left one service user doing what she wanted i.e. to watch an exercise DVD – once the staff had put in for her. It was observed that she was calling out to have it changed and had to wait for some time and this was eventually done. Staff were in a rush at this time and failed to ensure that the service user request was fully met before rushing back to support the other individual. This left the service user distressed as the DVD was just going over the menu repeatedly, while she called out to her key worker – to little avail. It occurred High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 22 that this was a peak period, which meant that staff were pressed to meet the needs of individual service users and failed to do so effectively. Feedback received from staff clearly indicated that staffing levels are inadequate at peak times, while at other times service users may be unable to undertake activities in the community because of staffing levels. This must be reviewed to ensure that the staffing levels are adequate to meet the needs of the service user group. Three of the most recently recruited staffing files were examined and he recruitment practices were found to be satisfactory. There was no information apart from supervision and training notes for one individual. Two references were in place for both staff and criminal bureau reference checks were in place appropriately carried out. One of the staff members interviewed confirmed that her employers carried out all the necessary checks as required by regulation and that she benefited from a detailed induction programme. She was also aware of the General Social Care Council’s code of conduct and the importance of this, in relation to her practice. It was not evident how service users were involved in the recruitment processes and some options were discussed with the registered persons. It was noted that the organisation was in a transition stage as the human resources department were to keep the recruitment information and make available for inspection a pro-forma with recruitment information. This was not the case in one instance and so the process could not be fully tested. An organisational training and development plan was provided following the site visit, which mapped out the areas required for staff development and the development of the service. Some of the training provided included: emergency first aid, brain injury, makaton, bereavement and NVCI training. Plans are in place for LDAF, equality and diversity, and COSHH. Further NVQ training is also planned for staff. They confirmed that the organisation provided a good training programme and opportunities for learning to enable them to carry out their roles, which is positive. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 23 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): (37,39,42) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Good management systems are in place to provide a quality service at 410 High Road. Improvement in quality assurance monitoring ensures that a better quality service is provided to service users. Systems for record keeping, reviewing policies and procedures, and the promotion of health and safety ensures that service users remain safe in the home. EVIDENCE: The manager is the second in post since the departure of the former registered manager. He has started his RMA award and provided evidence of updating his skills and knowledge in the related field. He works closely with his deputy manager and staff to ensure that the service provision is consistent. Staff and service users find him open and approachable and he has demonstrated a willingness to working with the Commission in meeting requirements. It is imperative however that the registered provider submits an application for the registration of the manager as soon as feasibly possible. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 24 There was an improvement in this standard as regular monthly provider monitoring reports were carried. Service user surveys had also been carried out and internal audit of the service had also been conducted. An annual development plan was also made available. However, the registered persons should demonstrate how they involve service users in recruitment and other key processes in the home. There was also an improvement in this standard as fire drills and key risk assessments were carried out. The health and safety policies and procedures and practices ensured that the home is safe for all that use it. Risk assessments for all safe working practice topics were now in place and service users were also involved in maintaining a safe environment. All staff had health and safety training and this starts at induction stage. A monthly health and safety audit is undertaken to identify any deficiencies, which are acted upon. Safety records for fire, gas and electricity were found in order. Records of accidents were maintained and the home was compliant with all the building, fire and environmental health regulations. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 25 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 2 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 x 32 2 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 3 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 2 3 x 3 x 3 x x 3 x High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA19 Regulation 12, 13 Requirement The registered persons are required to ensure that health action plans are reviewed and available at all times. The registered persons are required to replace or repair the damaged dining chairs. The registered persons are required to review the staffing levels to ensure that the needs of service users are met at all times including peak times of the day. Timescale for action 31/12/07 2. 3. YA24 YA32 23(2)(c) 18(1)©(i) 31/12/07 31/12/07 High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 27 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. 2. 3. 4. 5. Refer to Standard YA1 YA8 YA39 YA20 YA32 YA37 Good Practice Recommendations The registered persons should develop the statement of purpose in a more user friendly format. The registered persons should devise strategies to enable service user involvement in the home. The registered persons should relocate the medicine cabinet to ensure service user safety. The registered persons should ensure that recruitment information is available for inspection at all times. The registered persons should submit an application to the Commission for the registration of the registered manager. High Road 410-412 DS0000063248.V354083.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 High Road 410-412 DS0000063248.V354083.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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