Inspection on 03/10/07 for Homeleigh

This inspection was carried out on 3rd October 2007.

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

Homeleigh 07/09/06

Homeleigh 28/02/06

Homeleigh 28/09/05

Homeleigh 10/02/05

Homeleigh 12/08/04

Homeleigh 10/03/04

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 Homeleigh Middleton Road Crumpsall Manchester M8 4JX Lead Inspector Steve O`Connor Unannounced Inspection 03 October 2007 09:45 Homeleigh DS0000021618.V342070.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 Homeleigh DS0000021618.V342070.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. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Homeleigh Address Middleton Road Crumpsall Manchester M8 4JX 0161 795 2596 0161 720 9660 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) Southfields Care Homes Limited T/A The Regard Partnership Limited Susan Lesley Bradbury Care Home 30 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (24), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (5) Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person who requires personal care only by reason of learning disability is accommodated. Should this service user no longer reside at the home then the registration will revert to thirty places for mental disorder (MD). Five named persons are over 65 years of age but requiring care by reason of mental disorder excluding learning disability or dementia. Should any of these service users no longer reside at the home, the registration category for these places will revert to accommodation for people under 65 years of age with a mental disorder (MD). 7th September 2006 2. Date of last inspection Brief Description of the Service: Homeleigh is a care home providing 24-hour care and accommodation for up to 30 adults with mental health problems. The home is a detached 3 storey building set within its own grounds. Accommodation is spread over three floors with a combination of single and double rooms. There is a smoking and non-smoking lounge and a large dining area. In addition the home provides an activity room, a separate visitors room for private meetings and a training room. The home is situated in the Crumpsall area north of Manchester city centre. It is close to local amenities and public transport links. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in September 2006. This information included the home completing a self-assessment form (called an Annual Quality Assurance Assessment or AQAA) describing how they feel they have supported people in meeting the National Minimum Standards. Additional information includes incidents notified to the CSCI and information provided through other people and agencies, including concerns and complaints. People who live at the home were sent questionnaires asking them about their views of the service they received. In total seven people returned questionnaires. During the inspection site visit, time was spent talking with people who live at the home, observing how staff work with people and talking to management and staff on duty. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. In addition, as part of the inspection site visit the inspector was joined by an ‘Expert by Experience’. This is a person who does not work for the CSCI but has experience of mental health services. They were able to speak to a number of people to gain their views on the home. From this they wrote a report on their experience and this was used as further evidence within the inspection report. The inspection report of September 2006 highlighted areas that the home needed to work on and improve. The home had addressed all the changes. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well: To be able to support people to remain physically and emotionally healthy and to allow them to grow, a clear and detailed picture of people’s needs and goals needs to be identified. An area of work that is done very well is in the way that management and staff have worked with people in a very person centred way to clearly identify information that is important to the home and also important to the person. For example, several care plans were seen that provided very detailed support guidance on how to support people’s personal care, their emotional health and any risk behaviour they may experience. A comment made by a person’s care manager highlighted that the staff team had found a way of working with her that had reduced risk behaviours when other services Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 6 had failed to do so in the past. They commented that staff were seen as competent, approachable and have the best interest of people ‘at heart’. There is also very good clear information on what the person themselves feel is important in their life. An example of this was where a person wanted to go fishing. They were supported to go and the person wrote about their experience and what it meant to them. Examples were also seen where people had been encouraged to tell others about their life through writing and pictures. These life stories read as if the person themselves were telling their story and showing what was important in their lives. This was commended as an example of good practice. Another area that the home does well is in recognising the importance of people being offered the opportunity to participate in and enjoy social and leisure activities and to learn and develop new skills and have new experiences. Several examples were seen where people had been encouraged to take part in new activities such as gardening or with computers which had increased their skills and so their confidence and their emotional health. People made positive comments to the Expert by Experience and through the surveys about the activities that the home offered and a comment from a visiting professional stated that, ‘service users are encouraged to access leisure and social activities.’ People’s relationship with the staff team and management was seen as very positive both by people themselves and by observations from other professionals who visit people at the home. A number of comments from people expressed satisfaction with the way that they were treated and how staff and management deal with their concerns and worries. A visiting Community Psychiatric Nurse stated that they, ‘have always found the staff to be pleasant, caring and helpful.’ The Expert by Experience was able to talk to most of the people living at the home and his conclusions were that, ‘Service users seem to relate well with members of staff. There is a friendly atmosphere pervading all the relationships at Homeleigh’. What has improved since the last inspection? There is a need to make sure that people live in an environment that is comfortable, homely and helps in contributing to maintaining a persons general and emotional health. The way a home looks and is maintained could have an impact on the people who live and work there that can be either a positive or negative one. Since the last inspection report many improvements have been made not only in refurbishment, decoration and making the building feel more homely and welcoming but also in its layout and use of the space. A new activities room, kitchenette and a private visitors room have been provided that offer more flexibility and improved resources for people to enjoy social activities and to learn new skills. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 7 There is still a lot of refurbishment work to be completed but there now appears to be much more of a commitment to provide people with a quality home and environment. The previous inspection report made a number of recommendations to consider, that could improve the quality of the service they provide people. It was very positive to note that all the recommendations had been taken seriously and actioned. The most important of these was in releasing staff from undertaking domestic duties during their shift. Previously staff would be spending several hours carrying out domestic tasks. Now their role is to work with and support people in maintaining their health and achieving their goals. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Homeleigh DS0000021618.V342070.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 Homeleigh DS0000021618.V342070.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 has been made using available evidence including a visit to this service. The people living at the home had their needs assessed prior to admission to the home. EVIDENCE: Since the last inspection report there have been no new admissions. Prior to a person coming to live at Homeleigh the management ensure that they have received sufficient information from the relevant purchasing authority for them to be able to decide whether they can support the person’s needs. These can include Care Management and Care programme Approach assessments. Examples of these were seen in people’s files. People are also provided with a range of information about the home to help them make the decision of whether to come and live there. In addition, an in-house assessment is undertaken prior to and during the early stages of a person’s stay to ensure that the information they have is accurate and up-to-date. Homeleigh DS0000021618.V342070.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People’s needs and support are recognised and they are helped to try to make decisions and choices in their life. The risk behaviours people experience have been identified and guidance developed on how to support them safely. EVIDENCE: Since the last inspection report people’s support needs have been re-assessed and recorded in a new assessment format that looked at issues of general and mental health, personal care, communication, cultural and social needs. From this information two types of care plans have been developed. One looks in detail at a person’s primary needs to keep them well and safe. These care plans were very descriptive and contained clear guidance on how to support people. In addition, a social care plan was developed that looked at people’s more personal goals and their wishes. This showed a more person centred approach in working with people to find out what was important for them and Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 11 not the service. Examples of these were seen and included people’s wishes to go fishing, learning new skills and social interests. The previous inspection report highlighted that the new system of care planning would be based on the principles of Person Centred Planning (PCP) on how people want to be supported and be involved more fully in deciding their own goals and support needs. Examples were seen where information had been written as if the person was telling the reader about themselves and the things that were important in their lives. This was seen in the assessments and care plans. This commitment to PCP was further seen with some examples of how people had been supported to develop a written and pictorial presentation of their life and the things that mean the most to them. This was seen as an example of good practice and was commended. It is recommended that the principles of PCP continue to be applied to the way that people’s needs and goals were identified and supported through the care planning systems. People continued to be supported and given information to assist them in making decisions that affect their lives. Staff supported people in making decisions regarding such issues as housing, health, activities and routines. Information is provided and people are encouraged to make choices and or to make no choice if they do not wish. There were no restrictions placed on people unless agreed through a risk assessment process that involves the person. People managed their own affairs as far as possible and support is provided to manage finances and medication. Their was a standard risk assessment format to look at situations, events and behaviours that may cause a risk to people’s wellbeing. Once identified, the home developed detailed information on the triggers and hazards that could lead to risk situations and hazards. Detailed support guidance for staff was then developed in how to minimize those risks. Some good examples of risk assessments were seen. The care planning system also included a way of identifying and recording risks and hazards that people may experience. Care plans and risk assessments were monitored and reviewed on a regular basis by the staff and management. It is recommended that people be offered the opportunity to sign these documents to show that they have been involved and understand them. Homeleigh DS0000021618.V342070.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are offered the opportunity to participate in social, leisure and community based activities. Links with families and friends are maintained based on peoples’ wishes. Routines are based on people’s preferences. Meals were provided that people wanted of good quality and with sufficient choice and quantity. EVIDENCE: Since the last inspection people’s access and opportunities to take part in activities that they enjoy and are meaningful to them has increased. People have been asked, in much more detail, about what interests they have and what they wish to do. Examples were seen where people had expressed a personal goal and had been supported to achieve this. Examples of people responding to the activities they did was seen and included the use of Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 13 photographs, writing stories about the events and a newsletter that included articles on what people had achieved. Many people accessed the community independently and decided what they wanted to do themselves. Other people were more reluctant so leisure activities were provided in the home such as film nights, darts competitions, bingo nights, crafts sessions and other indoor activities. The type and range of activities had been increased through the development of a dedicated activities room that also housed some computers where people were developing new skills. The care planning recording system was being used to record when people were offered the opportunity to participate in an activity relating to their goals. For those people who wanted to, a range of social outings was offered and several people had been supported to go on holiday over the summer. People were encouraged to join the Gardening Club that had access to its own allotment plot. Despite the difficult weather over the summer the group still grew vegetables that were used in the kitchen. People’s routines were still based on their own preferences and the historical routines that they have developed over the years. People were encouraged to spend mealtimes together to reduce isolation and give staff the opportunity to speak to people and find out how they are feeling. People are encouraged to take care of their own domestic tasks and to maintain the cleanliness of their rooms. People continued to be supported to maintain links with their families and friends based on people’s own wishes. People could now access to a separate room where they can meet family and visitors in private if they wish. People spoken to were very positive in the way they described the quality and choice of meals available. Drinks were available through the day and people had access to a small kitchenette. In the evening a range of snacks and fruit is available and people can ask staff for lighter meals such as sandwiches. Meals were taken together in a large dining room. Since the last inspection the cafeteria type tables and seating had been replaced with dining tables and chairs and the area had been redecorated and had a much more inviting and homely feel. A set four-week menu had been devised with people’s input at the residents’ meetings. Information regarding people’s dietary needs was available to the cook and alternative choices are provided to meet those dietary needs. People can come and talk to the cook about the menu and ask for alternatives if required. A record is maintained of what each person has for their meals and when meals have been missed. Food stocks were sufficient and stored correctly. The kitchen area had recently been inspected by the local Environmental Health Team and no issues or problems had been raised. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to maintain their personal, general health and mental healthcare needs. The medication administration system made sure that people took the required medication to remain healthy. EVIDENCE: People’s support needs relating to their personal care, general and mental healthcare needs are clearly recorded in detail within individual’s care plans and risk assessments. People’s needs had recently been updated and this included identifying risk situations relating to the administration of medication and other health issues. People’s general and mental health was supported by a staff team who had the knowledge of a person’s behaviour and triggers for ill health. This was backed up with thorough and detailed written information regarding how ill health affects people’s behaviour and how to support them in a safe way. People were supported to access general and specialist healthcare providers when required. Monitoring records for specific health issues were being maintained. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 15 The medication administration system was found to be accurate and only staff who had undertaken the required medication training would administer medication. Guidance for administering medication prescribed ‘as required’ (PRN) had been developed and administering was recorded accurately. An auditing and monitoring system was in place to ensure that people had received the medication they required. It was found that PRN medication was being returned to the pharmacist every month even if medication packet had not been opened. It is recommended that the pharmacist be consulted over the necessity of this practice. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The right systems, policies, procedures and working practices where in place that allowed people to raise their concerns and for staff to respond to incidents/allegations of abuse. EVIDENCE: A complaint policy and procedure was in place and people had been issued with a copy as part of the Service User’s Guide. A record of all informal and formal complaints would be maintained. At the time of the site visit no formal complaints had been made. People commented that they feel they can report any problems or complaints to the manager and that they will be taken seriously. People also feel they can direct complaints and suggestions to other support workers and believe their concerns will be acted on. Bullying and aggressive behaviour from anyone was not tolerated and, as one person commented, ‘would be sorted out’. The required policies and procedures were in place with regard to the protection of vulnerable adults and whistle blowing. All staff had received a copy of the procedures as part of induction training. The majority of staff had accessed a more in-depth adult protection training. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 17 A clear policy and procedures for supporting people to manage their own personal finances was in place. Risk assessments had been carried out to establish the level of support people needed. Samples of finance records were seen and found that they followed the required procedures and were accurate. Homeleigh DS0000021618.V342070.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The layout and facilities within the home meet people’s needs. EVIDENCE: At the time of the site visit the exterior of the building was covered in scaffolding as work was being carried out on the windows and roof. Risk assessments regarding people’s safety had been undertaken and were updated as the work progressed. The previous inspection report had highlighted the ongoing issues regarding the need for major investment in the fabric, refurbishment, decoration and maintenance of the building. Over the course of the last 12 months the environment and layout of the home has changed in a positive way. Offices situated in the building had been changed so that they could be used as an activity and staff training room. People have access to a small kitchenette and the staff facilities have been improved. There is also a new visitors room used Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 19 for private meetings with family and other professionals. One of the lounges has become the designated smoking room and the main lounge now appears more comfortable, fresher and more homely. The dining room has had the cafeteria style seating and tables removed and replaced with ordinary dining tables and chairs, the room has been redecorated and carpeted and now feels more welcoming. A number of communal areas such as corridors have been decorated and a number of bedrooms have been fully refurbished. There is currently an ongoing programme of bedroom refurbishment. The changes to the use and layout of the building means that it provides more flexibility to support people’s needs and makes the home a more pleasant, cleaner and more homely environment for people to live. There is still a lot of work needed to bring the whole building up to a good standard but progress is being made. It is recommended that the CSCI are provided with a clear action plan for the continued refurbishment and decoration of the home with clear timescales for action. A separate large laundry room is situated in the home with adequate equipment to meet people’s needs. Staff have access to the required aids and equipment needed to minimise risks of infection control. Policies and procedures were in place for the health and safety of people and staff. Homeleigh DS0000021618.V342070.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People do benefit from a staff team that are competent and knowledgeable regarding their support needs. The home’s policies, procedures and systems do provide the checks to make sure that staff are safe to work with vulnerable people. EVIDENCE: Since the last inspection report there has been a major change in the staffing structure of the team. To support the manager there were two deputy managers and two senior support workers each with specific tasks and responsibilities. In addition there were 14 support workers covering the day and night shifts. During the day there were between 3 and 4 support staff and two waking night staff, in addition to management cover. In addition, the home had a domestic team of cooks and a full-time cleaner. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 21 From information provided in the AQAA the home does not use any agency workers to cover holidays, sickness etc but offers the additional hours to the existing staff team. Evidence provided in the completed AQAA self assessment showed that all but two staff had achieved a minimum of NVQ Level 2. Several members of the team had achieved Level 3 and were undertaking the Level 4. The role of the support workers has also changed in a small but far-reaching way. They no longer have to spend several hours of their shift in cleaning the house. This meant that much more time was spent with people in supporting them to meet their goals. Observations made by the Expert by Experience highlighted that the relationship between people and staff was a positive one and comments from other visiting professions also highlight this. In addition, feedback from the survey questionnaires also pointed to the staff having a positive and respectful relationship with the people they work with. The Regard Partnership Ltd had worked with the CSCI and agreed that the company’s records relating to staff recruitment and employment checks would be inspected by a Provider Relationship Manager (PRM), a senior manager within the CSCI. They last audited the staff files in February 2007 and found, on the whole, that the correct checks were being made to make sure that staff who work with vulnerable people were safe to do so. The training schedule provided by The Regard Partnership Ltd, the company that manages the home, included dates for an Induction programme, mental health, and care planning training. The Induction training programme would be carried out over several days and was based on the Skills for Care Induction modules. Individual staff training records showed that staff participated in a range of training events based on the needs of the people they support and their own personal development. The issue of assessing staff competence was raised and the management team had already raised this and ways of assessing competence was discussed. It is recommended that a system for assessing the competence of staff in implementing the skills and knowledge they have gained through training events be implemented. Homeleigh DS0000021618.V342070.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and operational systems are in place for people to benefit from a well run home where it is safe to live, and invests time and resources to look at whether it is providing the service people want and need. EVIDENCE: The management structure of the home is made up an experienced and qualified registered manager and two deputy managers. The deputies are undertaking the NVQ level 4 and additional management training to further develop their skills and knowledge. The manager has overall responsibility for the operation and direction of the home whilst the deputies have specific roles and duties such as assessments, Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 23 care planning and reviews, monitoring operational systems and staff supervision. Since the previous inspection report the manager has been able to show that they have put in place new ways of working and new facilities for people and they have a clear idea of the direction and quality of service they want for people who live at the home. People commented in the service users surveys and to the Expert by Experience that they were able to talk to the management about any concerns they had and that these were taken seriously. As part of the quality assurance system a member of the Regard Partnership undertook monthly regulation 26 visits and also regular ‘mock’ inspections based on the National Minimum Standards. A copy of the August visit was seen and found that the results had been summarised in an easy read format for people to read the results. In addition, relatives, visitors and other professionals are asked to complete a questionnaire about the quality of the service. Several examples of these comment cards were seen. Other ways that people’s views were sought about the service they receive was through focused questionnaires asking people about the activities programme. People were also asked for their views on how new staff were doing their job and how they worked with people. Regular meetings are also held with people and staff to talk about issues that affect the home and people’s lives there. It was noted that these meetings were more focused on providing people with information rather than gaining people’s views. The meetings use a system whereby people can raise a coloured card to slow down, or join in or to have information repeated. The home had a good system of health and safety audits and checks to make sure that people and staff were safe in the home. Environmental safety checks were made as were regular fire safety checks. Equipment was being maintained and serviced on an annual basis. Information provided through the AQAA self-assessment showed that policies and procedures relating to health and safety were reviewed on an ongoing basis. Homeleigh DS0000021618.V342070.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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Homeleigh DS0000021618.V342070.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. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that the home continue to work to make the care planning system even more person centred on what the individual wants to achieve and to be more focused in the needs and goals identified and specific in the actual support provided. It is recommended that the home maintain evidence of how people are involved and consulted in developing and reviewing their own care and risk plans. It is recommended that people be offered the opportunity to sign these documents to show that they have been involved and understand them. 2 YA20 It is recommended that the pharmacist be consulted over the necessity of the practice of returning all PRN medication to the pharmacy, even if not opened, every month. DS0000021618.V342070.R01.S.doc Version 5.2 Page 26 Homeleigh 3 4 YA24 YA35 It is recommended that we are provided with a clear action plan for the continued refurbishment and decoration of the home with clear timescales for action. It is recommended that a system for assessing the competence of staff in implementing the skills and knowledge they have gained through training events be implemented. Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Homeleigh DS0000021618.V342070.R01.S.doc Version 5.2 Page 28 - 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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