Inspection on 17/05/06 for Highwater House

This inspection was carried out on 17th May 2006.

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

Highwater House 26/10/05

Highwater House 20/04/05

Highwater House 06/12/04

Highwater House 05/07/04

Highwater House 16/12/03

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

CARE HOME ADULTS 18-65 St Martins House Westwick Street Norwich Norfolk NR2 4SZ Lead Inspector Jenny Rose Key Unannounced Inspection 17th May 2006 10:30 St Martins House DS0000027464.V296246.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 St Martins House DS0000027464.V296246.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. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins House Address Westwick Street Norwich Norfolk NR2 4SZ 01603 766627 01603 766672 angela.herbert@stmartinshousing.org.uk 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) St Martins Housing Trust Miss Angela Herbert Care Home 22 Category(ies) of Learning disability (22), Mental disorder, registration, with number excluding learning disability or dementia (22), of places Physical disability (22) St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2005 Brief Description of the Service: St Martins House is a care home operated by the St Martins Housing Trust, a Norwich based registered charity working with people who have experienced homelessness. The care home is registered to accommodate up to a maximum of 22 people who fall within one or other or a combination of categories: people with mental disorder, learning difficulties (excluding dementia) or physical disabilities. Service users may also have problems with substance or alcohol misuse. Although the care home does not offer specific rehabilitative services, service users are encouraged to develop confidence and skills to potentially enable them to ultimately acquire greater independence. The premises were originally designed to offer hostel accommodation to homeless people and as such fail to meet National Minimum Standards for a care home. However, this should be rectified as a substantial redevelopment of the property is planned. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over six and half hours. On the day there were eleven residents living at St Martin’s House; there were five in the house during the inspection and although four residents were seen, only one wished to speak with the inspector. The Manager, Ms Angela Herbert was present throughout the inspection, and Mr John Hales, Head of Operations of the St Martin’s Trust was making a visit to the home. Four members of staff were spoken with, two privately. A tour of the premises was undertaken, which were in the throes of radical rebuilding and due to be completed in May 2007. A selection of records and care plans were examined. Preparation had taken place in the CSCI office beforehand; a pre-inspection questionnaire, five resident surveys, as well as a GP’s comment card had been completed. A comment card from a health and social care professional in contact with the home and two comment cards from two relatives/visitors to the home had been received. The views expressed in these surveys are included in the report where appropriate. What the service does well: * “The standard of care and professionalism of this care home is very high. The reputation of the Home reflects this.” “A very caring environment for the residents”, are two comments from healthcare professionals visiting the home. * Historically, the staff group has been very stable with little turnover, which helps to ensure there is a consistent service for residents. * Many of the staff are very well qualified and possess different areas of expertise. There is a robust training programme which is based on the challenges presented by the residents and the support they require, as well as the development of specialist staff skills. * Staff spoke of the strongly bonded staff team and it was evident from staff comments and from observation of interaction with staff and residents that the management style is open and inclusive. * There is a creative, inclusive and holistic approach to the support of residents, in the specialist support services, complementary therapies and activities available to them, including music, the provision of a holiday home on the coast, and the acquisition of an allotment, with a large shed where residents may spend time and/or participate in gardening if they wish, as well as the more usual activities in the community and the keeping and adoption of pets for those who have an interest in animals. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 6 * The development of the new premises had been discussed over a long period with residents and staff and the reduction of resident numbers had taken place naturally. The remaining residents had been offered the choice of staying on the present site, or moving whilst the alterations were taking place. * There had been no reduction in staff numbers with the reduction in resident numbers, which enables there to be the continuing flexible support to residents, especially during the challenging time of rebuilding work. Also to support residents in activities away from building noise and to attend to health, safety and security issues within the home during the alterations. * There is a good quality assurance system, with frequent residents’ surveys which ensures that the service is ‘resident led’ as far as is possible, including the planning of the new premises. What has improved since the last inspection? The home was originally built as a night shelter for homeless people. As a result, historically, none of the standards concerning the premises could be met and there have been lengthy negotiations over the years between the Trust and the City Council regarding upgrading, rebuilding or resiting the premises. * On 8 May 2006 building work started on the same site on a purpose-built 22 bed residential care home, all with ensuite bathrooms and many other facilities, including a gym, which was requested in a residents’ survey. This will provide accommodation for homeless individuals, or individuals at risk of becoming homeless, with priority given to those with connections to Norfolk, who present with a dual diagnosis; this is defined in the Vision Statement: “An individual who presents with co-existing mental health (and/or Personality Disorder) and substance misuse problems (drugs and/or alcohol)” . A nominated number of those beds will be for individuals undertaking an integration phase to ascertain eligibility for the home, either long-term, or for more appropriate onward referral. It is not the intention to look towards cessation as the only treatment goal. Social inclusion and harm minimisation will be the underlying principle for all residents. * With the acquisition of the holiday home and the allotment, there are opportunities, during the time of the building work, for residents to get away from the disruption of the work on site. * Members of staff are attending a course at the University of East Anglia in Dual Diagnosis in preparation for the new development of the service. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Martins House DS0000027464.V296246.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 St Martins House DS0000027464.V296246.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): 2 The home has developed a good assessment process to ensure that prospective residents’ needs are assessed and are supported by the staff group, and are aware this will require review as the two phases of building work are completed and the home admits new residents. EVIDENCE: There have been no new admissions since the last inspection and resident numbers have been reducing naturally in preparation for the building work. However, each resident has an admission assessment and a detailed admission booklet has been developed by the home, covering physical and mental health care needs and a risk assessment process, as well as the contract. All residents have a review assessment by an allocated social worker every four months. The manager reported that the assessment process would need review in preparation for the admission of new residents at the appropriate stage of the phase completion of the new premises, as well as the preparation of a new service users’ guide. The staff training programmes are flexibly aligned to the needs of the residents and two members of staff are attending training courses in Dual Diagnosis, in preparation for the move into the new premises and which is dealt with elsewhere in this report. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents are actively involved in setting their care plan goals with staff. They are involved in decision making in the life of the home and supported by staff in minimising risks to themselves. EVIDENCE: The care plans examined and the one resident spoken to confirmed that there was goal setting and records of progress in such areas as behaviour and the use of appropriate language, harm reduction and money management. There is a link worker for each resident and residents meet monthly with their link worker and signed reviews were seen. The manager reported that changing link workers was discussed between staff and residents at a time a resident was deemed to have had changing needs and she gave a recent example of this. There was evidence from in-house questionnaires, the CSCI surveys, from staff and from a resident spoken to that residents are involved in decision making in the life of the home and had been consulted over the period leading up to the planning of the new premises. One of the results of the in-house questionnaires was to include a gym in the new premises and a soft drinks machine in one of the communal areas was a result of another survey. All the St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 11 residents living in the home at the time of the inspection had been offered the choice of moving to temporary accommodation, or staying in the home during the building work. There was evidence of personal choice for residents in the way the medication is administered, in agreement with the GP, for example, some residents choose to have medication dispensed under the Nomad system. There was evidence from the residents’ surveys that residents felt they had choice in their daily living. There are individual choices made over meals and mealtimes, all of which are dealt with in another section of this Report. Residents’ meetings are held regularly and the Minutes for the meeting on 7 May were seen, which was largely concerned with the building work which would be starting on 8 May and giving changes to the entrance and where the residents would be coming into the building. However, previous meetings and residents’ questionnaires have resulted in a drinks machine available in the home and proposals for a gym in the new building. One resident confirmed that he had been kept informed of the building plans and was excited about the prospect of a room in the new building and understood that there would in the meanwhile be a certain amount of disruption and noise in the home. There was evidence from the care plans seen that residents’ goals are designed to minimise harmful behaviours and this was discussed with one resident. However, as commented on in previous inspection reports, reducing the risk of self-harm will depend on the degree of compliance by the residents themselves. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 12 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): 12,13,15,17 There is a creative, socially inclusive and holistic approach to supporting residents pursue their personal development goals through diverse activities and access to the local community. There is considerable flexibility in meals and mealtimes, which supports not only residents’ choices about the food they eat, but also the way in which it is prepared to support harm reduction for those residents with an eating disorder. The kitchen and dining area will be vacated shortly, in order for this area of the building to be completely rebuilt. EVIDENCE: The detailed care plans show an emphasis on the acquisition of daily living skills, such as doing laundry, money management, developing a more stable lifestyle and behaviour modification. On resident spoken to said “There are plenty of things to do…I feel secure here…safe…this is my home”. This resident confirmed that he did his own laundry and was going on a money management plan, in order to manage his own money. He also confirmed that he felt supported by all the staff and particularly his link worker. The staff had enabled him to care St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 13 for his pet rat, goldfish and hamster. He also described his positive experience of acupuncture and reflexology therapies, which are available to residents. The manager spoke of one resident being enabled to adopt a horse, to which he pays visits, and other residents are interested in the possible adoption of more exotic animals, which staff are investigating. Some members of staff bring their pets into the home whilst they are working, which is enjoyed by some residents. The home is very well situated for residents to be able to make use of community facilities, as it is within easy walking distance of the city centre and residents also have access to the home at any time. The manager described several residents being able to visit the theatre, cinema, restaurants, the library, bowling, or going out individually with their link worker, which was described by one resident. Some residents are able to participate in swimming, playing football or going to the gym. There is an Activities Organiser who organises the logistics of the use of the people carrier to provide group transport when required, these plans have to be flexible, “in order to respond to the need at the time”, the manager commented. The snooker room had at the time of the Inspection had to be vacated, as it was included in Phase 1 of the rebuilding work. However, the acquisition of the holiday home on the coast and the allotment with a large shed, which was described by a member of staff who has a neighbouring allotment, means that residents are able to spend time away from the building, particularly at this time of the building work. The provision of the shed also enables residents to spend time at the allotment, sometimes chatting to other allotment users and develop, or extend, an interest in gardening. One resident described his enjoyment about being able to have a holiday on the coast and participating in the leisure activities available there. There were two returned comment cards from relatives/visitors to the home which indicated that they were welcome to visit the home at any time and could see their relative/friend in private. The home work hard to distribute information to the residents, in addition to monthly residents’ meetings, one to one meetings with link workers, internal questionnaires, and the notice boards. Letters are sent to each resident with updates on information; there are also suggestion boxes and the manager has an ‘open door’ policy in her office. The menu is varied and one resident spoken to said, “The food is good”. The staff confirmed that the chef would always make something different if a resident does not like what is on the menu and the manager and the chef confirmed that food is always kept for residents who do not appear for the usual mealtimes. There is particular flexibility, and an example of good practice, in the preparation of meals for those residents at risk from self-harm St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 14 due to an eating disorder, even to the particular method of preparation and presentation of vegan meals from a dedicated shelf in one of the fridges. The manager reported that the Environmental Health Officer has been involved in giving the home advice on the temporary movement of the kitchen and dining room during Phase 1 of the building work. . St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 According to their individual needs, residents receive personal support according to those needs and individual preferences. Their health care needs are met to the extent that residents choose to comply with treatment programmes. Medication is properly stored and managed. EVIDENCE: The residents’ surveys returned to the CSCI office were positive about the care they received in the home. All the residents are extremely able and as a rule do not require ‘hands on’ care. The support offered by staff is through developing good relationships with residents and supporting and encouraging them to achieve more control over their lifestyles. This is evident from the care plans and one resident spoken to confirmed he felt very supported by staff and particularly his link worker. There was also evidence from care plans and from comment cards of the involvement of other healthcare professionals, including community psychiatric nurses, dentist, optician and the involvement of other support services, such as the alcohol and drug counselling services who visit the home, which was confirmed by staff and one resident spoken to. One visiting healthcare professional commented on the survey on the home: “A very caring environment for the residents”. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 16 The GP’s comment card reflected a positive opinion of the care received in the home. “The standard of care and professionalism of this care home is very high. The reputation of the Home reflects this”. There is an agreement as part of the admission process signed by residents agreeing to the medication being looked after by staff. Medications are stored securely in a metal cabinet secured to the main office wall. Controlled medications are also appropriately stored and recorded. One random record for controlled medications was checked against the number of tablets present and was correct. There was a clear audit trail from the records of the receipt, administration and returned medication. All staff who handle medication receive Boots training. Some residents, in conjunction with the GP choose to have their medication dispensed via the Nomad system. The manager said she meets with the GP on a quarterly basis to review the medications prescribed over the previous three months and the medications are received in the home on a 10 day basis. The manager explained that for residents who became capable of managing their own medication there was a facility within the St Martins Trust to which they could move on. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents are aware of the complaints procedure and there are processes in place to protect residents from abuse and to minimise self-neglect and selfharm. EVIDENCE: There had been no complaints received in the CSCI office since the last inspection; however, there had been one complaint about noise levels in the home and this had been appropriately logged with the action taken to resolve this issue. Residents’ complaints were taken seriously and responses logged, to the extent of explaining to one particular resident that there are events over which no one had any control. All the residents’ surveys and one resident spoken to confirmed that they knew to whom to complain. All staff receive internal training in the protection of vulnerable adults and the next updating of this is on 16 June. There are whistle blowing and adult protection policies in place. The staff spoken to were all aware of the issues involved in the protection of vulnerable adults and spoke sensitively of the fact that residents may have been subjected to abuse before coming to the home and this often needs to underpin the way in which support is offered to residents and in the minimising of self-harm, particularly for those with eating disorders, for example. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 18 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): 24,30 Historically, there has been unsatisfactory accommodation at the home in terms of small bedroom sizes, the nature of the bathroom and toilet facilities and the institutionalised atmosphere of the communal areas. This has finally been addressed in the radical rebuild of the whole site, begun on 8 May and scheduled to be completed in two Phases by May 2007. EVIDENCE: It was evident from the Minutes of residents’ meetings, in-house questionnaires, speaking with staff and one resident that the eleven residents who have elected to stay during the rebuilding work, have been kept informed of the plans for the new building and the logistics of achieving this in two phases. It is hoped that new residents may be admitted in July, on the completion of Phase 1 of the building work. The manager, staff and one resident spoken to confirmed that residents have been involved in the planning of their rooms, furniture and fittings and one resident confirmed that “it is going to be nice…quite exciting to be involved at the beginning”. There is building noise, but as staffing levels have not been reduced, it is possible for residents to be able to get away from this during the day to the holiday home, or to the allotment. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 19 All the decorating of the upstairs bedrooms has been completed and the Regulation 26 visit report speaks of staff working hard to keep the communal areas as homely as possible during the building work. One member of staff who has an advanced health and safety qualification has been designated to oversee any health and safety issues during the building work. One bedroom seen was clean and there were no hazards seen during the tour of inhabited premises. The normal routine of the home was described by one member of staff, as being the Project workers check resident’s rooms for housekeeping issues daily. During the building work, staff are reminding residents where building work is taking place and where residents should enter and leave the building. On completion, the home will offer purpose-built accommodation to 22 residents for homeless individuals, or those who present with a dual diagnosis. (see Summary). St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The staffing levels are satisfactory and there has been no reduction in staff numbers with the reduction in numbers of residents. It is an experienced, stable staff team who are in receipt of relevant training and supervision on a regular basis. This should ensure, as far as possible, a smooth transition to the new premises at a challenging time. EVIDENCE: The staffing rota for the week shows no reduction in staffing levels and it has always allowed for one-to-one work with residents, both inside and outside the home. During this particular phase of rebuilding, staffing levels allow for attention to be given to be given to minimising exposure of residents to building noise and to attending to extra health and safety issues whilst the work is in progress. As noted in previous inspections, there has been minimal turnover in the staff group. Most have worked at St Martin’s for several years and several are educated to degree level and have qualifications in psychology, counselling, nursing and music. The chef on duty on the day had a catering qualification, but was also included on all the internal staff training, including mental health and had a special interest in eating disorders. There is an ongoing training programme including NVQ and a wide variety of courses including blood borne virus training, handling aggression, equality and diversity, substance misuse and vulnerable adult protection, as well as training in dual diagnosis at UEA in St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 21 preparation for the new specification for the service. There is an induction training programme in place. Staff spoken to commented that the Trust supported them in training in their particular skills and to the particular needs of residents. One member of staff was hoping to train in music therapy, when the opportunity became available. From staff files there is evidence of written references and CRB checks on new staff. In a previous inspection it was agreed that head office would supply the manager with a letter each time a member of staff is employed stating the enhanced CRB check has been undertaken. Two members of staff were spoken to privately and both commented on the strength of the staff team and the good support they receive from the manager on a day-to-day basis and in their annual appraisal, as well as the wider management of the Trust. Seniors supervise project workers on a regular basis. One member of staff commented that there was a good handover period between shifts, which meant that residents’ changing needs were met as far as possible and that, in her view, issues of equality and diversity underpinned the working environment of the home. Another member of staff felt there was an holistic view taken in supporting residents and showed great enthusiasm in the way the allotment was developing, together with plans for some of the produce to be used in the home. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The manager is experienced and qualified and facilitates good communication within the home. Health and safety matters are monitored and records up to date, and there is a designated member of staff for health and safety issues during the building period to protect the health, safety and welfare of residents and staff as far as possible during the building work. EVIDENCE: The manager has many years experience and holds the Registered Manager’s Award. She is just completing a course in Dual Diagnosis at UEA in preparation for the new service specification in the new premises. From discussions with staff and one resident, together with information from the residents’ surveys and observations with staff and residents’, she is seen as approachable and supportive. “Great staff team, great boss”, was one comment from a member of staff. Various records relating to health and safety matters were examined, fire records, including the fire alarm and fire equipment is up to date. Certificates St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 23 are in place for electrical wiring and gas. Accident records are kept up to date. A weekly health and safety checklist is completed and submitted to head office. There are daily checks for health and safety issues during the building work and staff have been reminded of the need for increased security with numerous visitors involved in the refurbishment work in the Regulation 26 visit dated 12 April. As stated in a previous inspection, the organisation has achieved the Investors in People Award. St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 24 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 1 25 x 26 x 27 x 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 x 36 3 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 3 x 3 x 3 x x 3 x St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 St Martins House DS0000027464.V296246.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!