Inspection on 20/12/06 for Highbarn Res.Centre. L.D. Section

This inspection was carried out on 20th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Highbarn Res.Centre. L.D. Section 25/01/06

Highbarn Res.Centre. L.D. Section 06/08/05

Highbarn Res.Centre. L.D. Section 24/01/05

Highbarn Res.Centre. L.D. Section 11/08/04

Highbarn Res.Centre. L.D. Section 29/03/04

Highbarn Res.Centre. L.D. Section 20/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Highbarn Res.Centre. L.D. Section Highbarn Street Royton Oldham OL2 6DW Lead Inspector Michelle Haller Unannounced Inspection 20th December 2006 10:00 Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highbarn Res.Centre. L.D. Section Address Highbarn Street Royton Oldham OL2 6DW 0161 633 3850 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) Oldham M.B.C. Ms Janet Edith Lomas Care Home 10 Category(ies) of Learning disability (10), Physical disability (7) registration, with number of places Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered to provide personal care for service users who fall into the categories: Adults with learning disabilities LD (10) and Adults with physical disabilities PD (7). 25th January 2006 Date of last inspection Brief Description of the Service: Highbarn Resource centre provides respite care for up to 10 adults between 18 and 65 years old who have a learning disability and physical disability. Service users live at the facility for periods of between one day and two weeks. While receiving a service people tend to choose to continue with their regular routine in respect of work, college or other activities. During the summer however, the service offers support for holidays away from the local area. The accommodation is easily accessible and is situated on ground and first floor level. Access to the first floor is via a modern, easy to use and large passenger lift. The bedrooms are all large, comfortable, well furnished and with en-suite facilities. The building has also been extended to provide good communal facilities such as dining and sitting rooms. The fees payable were not available to the inspector. The last Commission for Social Care Inspection report was not readily available or on display at the home. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection which included an unannounced site visit to the service took place on the 20th December 2006. During the course of the inspection the case files of six service users, policies and procedures and other reports relevant to the support of service users and the running of the service were looked at. Service users were discretely observed, as was the interaction between service users and staff. Three relatives and two members of staff were interviewed and a discussion with the manager also occurred. A tour of the building was also completed. Owing to the complex disabilities of the service users using the facility at the time of the inspection they were not able to comment directly about the care they received. What the service does well: The service makes sure that the needs of the service users can be met by making sure that a detailed assessments of needs including, social, health, communication and psychological are completed by those best qualified to do so. The service makes every effort to get to know the service users and enable the service user to become familiar with the staff and service prior to taking full responsibility for providing a period of care. The service is flexible and responds to the needs and developments in the lives of people who access the service and make every effort to provide the service requested by the individual and will advocate with service users if necessary. Relatives felt that activities were in keeping with expectations, the management was approachable, staff were capable doing their jobs and had a good understanding of how to relate to and empower service users. Relatives were very complimentary about the service and expressed a high level of satisfaction with the quality of support and services provided. The service maintains appropriate links with the main carers and other professionals. The service promotes the community presence of service users and supports them in maintaining a lifestyle in keeping with their expectation. The service also promotes the development of new skills through supporting people in trying out a variety of activities some of which are new to them. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 6 The service provides excellent accommodation that fully meets the needs of those who spend time there. The service protects service users from abuse through their recruitment process, the policies and procedures pertaining to adult protection and having a core of staff who are well informed, confident and feel able to inform managers about any concerns. The service provides excellent training opportunities for staff. The service provides a consistent well-supervised staff team. The service is interested in the views of service users and their relatives, and keen to have ideas that will improve what they do. The service is managed in a manner that promotes the health, safety and welfare of service users, staff and others who use the building. What has improved since the last inspection? What they could do better: The agency must make sure that they routinely inform the Commission for Social Care Inspection of any incidences that concern the health, welfare or wellbeing of service users. The service should consider further developing care plans and other documents (such as the complaints procedure) in different formats to meet the different communication skills of service users. The agency should continue to complete the quality assurance that has been started. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 7 The manager should ensure that she is aware of the fees payable in order that she may pass accurate information onto service users and/or their representatives. The manager also needs to make sure that the previous Commission for Social Care Inspection report is on display or clear arrangements for accessing this report are made known to all. 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. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. The service fully assesses the individual needs and aspirations of service users so as to be sure they can meet individual needs. EVIDENCE: All the care files examined contained copies of assessments of the needs of service users. The contents of these assessments demonstrated that they were developed with the involvement and contribution of the service users, their relatives, and professionals such as psychologists, speech and language therapists and community nurses and social workers. Notes and updates confirmed that these assessments were developed over a period time and evolved with the needs of the individuals. The contents of the assessments identified all the practical aspects of the immediate and shortterm, physical, communication, psychological and social support required. And also acknowledged wishes and aspirations when these were expressed. Although the format of assessments was for the most part written, some files contained pictures, diagrams and indication that the assessments had been discussed with service users so that they had access to the information. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 10 Comments from relatives concerning assessing needs included ‘Staff are very patient and accommodating and constantly reassessing his needs and trying new ways of helping him to settle.’ Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. The service can demonstrate that it promotes and supports the independence of individual service users in relation to the choices they make and the lifestyle they want to lead. EVIDENCE: Each service user care plan that was examined had been completed by the service user or their relative and provided detailed information about how the needs of the service user was to be met. The service users at Highbarn have complex communication needs and individual communication guidelines and aids were evident. In the main however the majority of information was provided by family, health and social care professionals and others with an established relationship with each person. Daily records and reports identified that, over time, staff and individual service users have became more familiar with each other and general understanding and communication improved and developed. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 12 It was noted that in light of this care-plans were updated and changes made in the support provided so that the wishes of the service users is upheld. Care files contained completed risk assessments ensuring all possible support and guidance was in place so that the service user could carryout whatever activity they wanted. The assessments included travelling in a car or vehicle, road safety, kitchen skills, danger awareness and personal relationship awareness. The focus of each assessment was to support service users in successfully achieving the activities as independently as possible. Highbarn is a short term care facility and the importance of having basic information available immediately has been identified and so a list of the essential support required at night or in relation to personal care has been produced for each person and placed in the bedroom they are to use. This is useful as a reminder to staff and increases the chance that the wishes of service users will be known in respect of personal care routine and night-time support. Daily records were completed in sufficient detail to identify when the needs of service users were fully met and the mood, general wellbeing and happiness of service users was also commented on. It was also clear to see when steps were taken to remedy any problems that were having a negative effect on individuals. Staff who were interviewed were aware of the service users plan and how to make sure that they were meeting the needs of service users. Each person was familiar with the process of ‘person centred planning’ and how to treat each person as an individual. Each also felt that as a short term facility the staff needed to develop a good relationship with the relatives and listen to what they said in relation to providing a service. It was noted however that service users did not always seem to want the same in respite as they did at home and so the staff had to be adaptable. This was acknowledged to some extent by relatives who identified that, though not detrimental, some things were done differently to home. On the day of inspection none of the service users could give a specific opinion about the service. Observation of their interaction with staff and the environment indicated that they were confident when approaching staff and could make their needs known to them. Relatives commented that ‘we can see by his responses when he comes in that he is happy- if he was unhappy he would make this known.’ Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. People who use the service are supported to maintain and develop their life skills and social, educational and recreational activities meet with individual expectations. EVIDENCE: The daily records and reports confirmed that service users were supported in attending their regular day activities such as college or work. Care plans and assessments identified the interests of service users and included a description of each person wanted to do for themselves and, the activities they would like to try out or join in with during their time at Highbarn. Daily reports and comments made by staff confirmed that service users were supported in completing domestic tasks such as operating the washing machine, making snacks and keeping their bedroom tidy. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 14 Records also indicated that a choice of activities was provided that promoted involvement in the local community including going to the local pubs and restaurants, going to the cinema, shopping, swimming, the local park and other activities as they become available. The service also arranges activities on site that includes armchair exercises, themed film evenings and manicure parties when appropriate. The manager, relatives and records made it clear that service users are encouraged to develop friendships, it was noted that part of the admission process was to identify whether service users had friends or acquaintance who might like to receive a service at the same time. Staff were observed talking to and spending time with service users, providing encouragement and guidance in relation to what was happening during the day and in how best to relate to those around them. Daily reports and other correspondence confirmed that staff encouraged service users and supported them to take responsibility and control of their lives whenever possible. Discussion with relatives confirmed that they felt staff were very enabling and respectful of the rights and needs of individuals. ‘He is able to come in on his own terms.’ As a short term care establishment, the agency’s polices and procedure concerning personal relationships, suggests that, bearing in mind the ability of those involved, service users privacy would be maintained and appropriate support, guidance and access to advocacy would be sought as required. Relatives feel that they are kept informed about the progress of service users and records confirmed that contact is made in accordance with the wishes of the service users and their relatives. The service records food likes and dislikes for each service users. A record of food provided is also kept and indicated that a variety of homemade and convenience foods and take-aways, on occasion, was provided. The menu included egg, bacon, fried egg, tomatoes and mushroom breakfasts, steak and onion, pasta dishes, sausages and mash and vegetable, roast dinners, soup, pizzas, fish fingers, and snacks including crisps, biscuits, chocolate bars and fresh fruit. Drinks included fruit juice, cordials, water, tea, coffee and hot chocolate. There is also a drinks machine that service users enjoy using. A weekly menu has been developed however the manager and staff felt that this was used as more for guidance as, unless there was a specific problem, the service users staying in the home generally chose the meals would like to eat. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 15 The manager stated that all staff had completed a Food Hygiene course and certificates that were on file confirmed this. Comments made about the lifestyle provided by the home included: ‘We have a good relationship with staff I like the way it runs.’ And ‘They seem to be able to have what ever they want to eat- we think we know what he likes but he will try different things here.’ Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Quality in this outcome area is excellent. This judgement was made using available evidence including a visit to the service. The service ensures that health and personal care is based on the individuals’ needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: All the needs assessments and care plans examined continued a detailed description of the health and personal care needs of service users. The emergency contact sheet also provided contact numbers for health care professionals such as the dietician, general practitioner and speech and language therapist. There was clear instructions based on the needs of the individual concerning the action that should be taken for a specific concern such as epilepsy or behaviours such as self-harm or mood swings. Daily records and discussion with staff and relatives confirmed that health concerns were dealt with in line with the care plans and that relative health care professionals and the relatives were kept informed of any changes. Specialist assessments and monitoring tools were in place including diet and fluid charts, body mapping for those who were prone to developing skin problems and behaviour monitoring charts. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 17 On the day of inspection it was noted that staff were friendly, relaxed and spontaneous when supporting service user, they were also respectful and treated people with dignity and patience. Records demonstrated that service users were able to dictate the level of personal and whether to accept this assistance. Staff training in health care matters includes medication training; epilepsy awareness and sexual health. The manager also stated that specialists in association with the needs of individual service users provide occasional training. Service users who access this respite facility do not manage their medication when at home. The medication policy was read through and the information provided staff with information about accepting, administering and recording medication. The storage system was examined and all medication was stored in locked areas and kept and administered from original containers or fully labelled blister packs provided by a pharmacist. Staff record the medication that has been given on a medication record sheet. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to the service. People who use the service feel able to express any concerns and have access to a robust complaints procedure and protected by a robust adult protection policy. EVIDENCE: The complaints procedure and adult protection policies were read through. The complaints, compliments and comments procedure was clear and easy to follow. The adult protection procedure gave clear information about the actions that could be considered as abuse and provided information about recognising abuse and whistle blowing. The complaints record was examined and no complaints had been recorded since the previous inspection. Relatives stated that they felt able to discuss any concerns and they were listened to and dealt with fairly and discreetly, relatives felt this attitude helped to prevent resentment or dissatisfaction that could result in official complaints. Relatives felt that their opinion was sought about the service provided and this helped to promote a positive relationship with the staff and management. An observation made by a relative concerning making complaints included: ‘I have never made a complaint- if I had a complaint –if it were against a carer I would speak to the manager- just have a quiet word depending on how serious it was- I know about the policy- if really necessary I would go to social services Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 19 but would discuss any concerns first- the staff are very approachable and we’ve known them for years.’ Certificates confirmed that staff had received adult protection training. Documentation and discussion with the manager confirmed that allegations of adult abuse were dealt with robustly and in line with Oldham Metropolitan Adult protection policy. Discussion regarding ensuring informing the CSCI also took place with the manager. Staff were clear about the actions they would take to safeguard service users in relation to adult protection. Comments included ‘I would talk to the person and report any suspicions immediately to the line manager.’ Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 and 30 Quality in this outcome area is excellent. This judgement was made using available evidence including a visit to the service. The physical design and layout of the home provides a safe, well-maintained and comfortable environment that encourages independence. EVIDENCE: Highbarn short-term care unit has recently been redesigned and extended and fully refurbished. A tour of the building was conducted. The rooms were clean and free from unpleasant odours. All furniture fixtures and fittings appeared domestic and homely, and all items were clean, well maintained and pleasant to use. All the bedrooms now have en-suite hand basin and toilet facilities and all areas have been fitted with track and hoist equipment. There are two shower rooms both of which were warm and ready to use. The hot water was checked and this maintained a comfortable temperature. The staff call system was checked and found to be in full working order and staff responded quickly. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 21 Service users were observed mobilising around the home freely. It was noted that rooms had been personalised as service users were encouraged to bring personal items such as games, soft furnishings and other favourite items during their stay. Care files also identified that service users were given the opportunity to choose the same room whenever possible. If service users expressed a room preference this was notes as were second and third choices as a back up. There communal areas have been extended to provide a medium sized lounge and separate dining area. The gardens have been fully landscaped and accessed through French windows with a ramp leading into a level path with raised beds. The kitchen is equipped with small domestic appliances and it is possible for service users to prepare drinks and snacks. The washing machine is also small and domestic in size and service users are encouraged to assist with dealing with their washing individually according to their wishes. The service has contracted a domestic cleaning agency for all cleaning and domestic duties and the agency is responsible for ensuring their staff have received the appropriate training. Certificates and discussion with the manager and staff verified that the majority of care staff had completed food hygiene training. Furthermore, files and other records confirmed that Oldham Health and Safety monitored the service under the ‘Better Business Safer Food’ initiative. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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, 34 and 35 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. The agency employs staff who are well trained and skilled and in sufficient numbers to support the people who use the service and to support smooth running of the service. EVIDENCE: The recruitment and selection process is highly developed and is led by Oldham Metropolitan Borough Councils (OMBC) Human Resource department. This department adheres strictly to recruitment and selection guidelines concerning vetting new staff and completing all criminal record checks and verifying proof of identity and scrutinising the application forms and references for new recruits. The manager of Highbarn STC is only able roster new staff after HR have confirmed that the recruitment process is complete and all checks have been satisfactory. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 23 Induction training is provided through OMBC training unit and the itinerary includes: an introduction to learning disability; prevention of adult abuse, introduction to infection control; fire safety; moving and handling; an introduction into person centred planning and communication skills. Staff receive high quality training through the OMBC training partnership that provide in-house training but also commission colleges and specialist agencies to provide up-to-date training. The manager of Highbarn stated that the majority of staff have now completed NVQ level 2 in care and more recent recruits have been put forward for the next intake. Certificates and other records kept with supervision notes confirmed staff training included: risk assessment management; Introduction and foundation courses in autism awareness; autism and sensory issues; introduction to dysphasia; Intensive Interaction; understanding anger and violence; objects of reference; using communication dictionaries, epilepsy awareness, completing life stories and Sexual health. The majority of staff have also undertaken, medication training, food hygiene training and a number have also completed NVQ level 3 in care. As previously identified staff also receive specialist training in relation to the individual needs of service users. Daily reports and discussion with staff and relatives confirmed that staff are employed, for the most part, in sufficient numbers to meet the needs of service users during the busiest times of the day and night. The roster demonstrated that the ratio of staff rarely falls below three staff to four service users, and on occasion one-to-one and two-to-one support is provided. Relatives and staff who were interviewed had no complaints about staffing in the home, with a relative commenting: ‘I have no problems with staff.’ Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. The management and administration of the home is open effective quality assurance systems have been developed. EVIDENCE: The manager of the home has completed the NVQ level 4 registered manager award, NVQ level 4 in social and health care and the NVQ assessors’ award. Discussion with the manager indicates that she has a clear idea of the ethos and way in which the service should be run and the actions she must take to achieve this. Staff and relatives were complimentary about the way in which the service is run and the leadership offered by the manager. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 25 Service users are supported in completing a quality assessment following each stay at Highbarn, a service quality assessment has also been undertaken involving service users and their representatives. The results and outcomes of this consultation were read through and demonstrated that Highbarn STC used the information to influence the running of the organisation in the following areas food, the environment, resources, activities and staffing. The manager takes her responsibilities for managing the building and health and safety protocols seriously and is competent. It was clear through maintenance records and discussions that equipment and services had been recently installed or serviced. A fire safety inspection had been completed and all recommendations had been complied with. The manager is in the process of developing a manual of the most relevant policies and procedure developed by OMBC. The aim of this is to provide staff with a more accessible and compact manual of the policies and procedures most relevant to the work they do. The manager has always co-operated with the CSCI inspection and registration processes. This area could be improved if the quality assurance report were presented in different formats so that it was accessible to people with different communication needs. Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 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 4 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 4 3 X 3 X X 3 X Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 YA39 Good Practice Recommendations The registered person should develop and provide information in as many formats as possible so that service users are given the opportunity understand their role and rights concerning the service they receive and understand what has changed because of their input. The manager should ensure that the CSCI is informed immediately of any allegations of abuse. 2 YA23 Highbarn Res.Centre. L.D. Section DS0000035576.V314055.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Highbarn Res.Centre. L.D. Section DS0000035576.V314055.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. 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