Inspection on 16/05/07 for HWCGS

This inspection was carried out on 16th May 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

HWCGS 23/01/06

HWCGS 28/10/05

HWCGS 17/03/05

HWCGS 22/06/04

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 HWCGS Segal Gardens 436 Fleet Lane Parr St Helens Merseyside WA9 2NH Lead Inspector Mr Paul Kenyon Key Unannounced Inspection 16th May 2007 13:00 HWCGS DS0000022458.V343562.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 HWCGS DS0000022458.V343562.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. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service HWCGS Address 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) Segal Gardens 436 Fleet Lane Parr St Helens Merseyside WA9 2NH 01744 28828 01744 25941 Www.segalgardens.com/hwcgscare@ukonline.co .uk HWCGS Ms Gillian Louise Gilmore Mr Damian Alan Leslie Cummings Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 4 MD and up to 4 LD Date of last inspection 23rd January 2006 Brief Description of the Service: Segal Gardens is owned by the company HWCGS. This company was formed by a group of experienced carers all of whom work within the service in one form or another. The home provides care and support to four younger adults that have various mental health problems and/or learning disabilities/difficulties. Segal Gardens accepts referrals from all parts of the U.K. It is unique as it has two Managers who have achieved registered mental nurse status and who oversee the dayto-day running of the establishment. The home is situated in the Parr area of St. Helens. It is a detached bungalow with a separate detached extension. The extension is used for a variety of hobbies; horticulture, crafts, computer studies, ASDAN classroom and a quiet lounge for visitors and for care reviews. The service aims to support Service Users with all aspects of personal development .The aim is that they will return to their home town once they are equipped with the skills to live a more independent and fulfilling lifestyle. Fees currently stand at £1753 to £1967 per week. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection to take place at Segal Gardens since January 2006. The home had no indication that the visit was to take place and the visit took place over two days. National minimum standards for young adults were used to measure the quality of care provided by the service. The inspection included a tour of the premises, observation of care practice, examination of records relating to the support provided, a discussion with a relative and individual using the service and staff interviews. In addition to this surveys were sent out to other family members. One survey was returned at the time of writing and all comments are included in this report. What the service does well: The service is very good at obtaining the information relating to the needs of residents before they come to live at Segal Gardens. This process also includes consideration in ensuring that residents are empowered throughout the process. The service is very good at identifying the needs of residents and enabling them to agree with the contents of their plans and presenting them in such a way that residents are involved in them. Care plans are reviewed and change as the needs of individuals change. The service is good at providing information to those who use the service so that they can make decisions and is good at identifying the risks faced by individuals in their daily lives. The service is very good at providing educational opportunities for residents and is good at ensuring that there is access to the local community and beyond. The service is good at ensuring that residents are able to maintain contact with their families and friends. Residents also benefit from being involved in the running of their daily lives and have their rights promoted. The service is very good at involving residents in the provision of food and ensuring that preferences are catered for. The service is very good at identifying the level of support required by residents. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 6 Residents have their health needs met and benefit from a safe system of medication. Residents and their relatives have the information they need to make a complaint if they so wish although no complaints have been received by the service. The service is very good at making arrangements to ensure that residents are protected from abuse. Residents benefit from an environment, which is very well maintained, comfortable and clean. Residents are protected through the recruitment process and are supported by staff trained to meet their needs. Residents benefit from a service that is well run and is managed by individuals who have the necessary skills and experience to do the job. Residents benefit from a service that has gone to great lengths to gain their views on the quality of the service and have used a variety of tools to do this. The health and safety of residents is promoted. Comments from residents, relatives and staff included: ‘ I have lived here for two years’ ‘Staff are nice, people are nice’ ‘There are activities, I can go into town or out with mum window shopping’ ‘I am out and about all of the time’ ‘I wash up, hoover and clean my room’ ‘I like the building and my room is very nice’ ‘I have worked here for five years, enjoy it’ ‘I have received Protection of vulnerable adults training, breakaway techniques, mandatory training, NVQ Level 3 and training in bi polar condition. ‘I am aware of whistle blowing and abuse policy ‘Managers are excellent they give feedback and involve you in future projects’ ‘ It is a relaxed environment’ ‘ I have been made to feel very welcome here’ ‘Staff are very open and I am fully involved. The focus is on the people here’ ‘The manager listens to us, care planning is really good’. As a mother I felt that I have made the right choice with here’ ‘Formal newsletter to keep me informed’ ‘I can phone anytime’ ‘ The level of support is good’ ‘I get privacy’ ‘Staff are receptive’ HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 7 ‘Contact from the home is frequent and supportive’ They have an excellent understanding and professional approach at all times in dealing with our relative’s problems’ ‘My relative is encouraged to send letters and he also has own email address so that frequent contact can be made-we also arrange regular visits’ ‘The care exceeds our expectations’ ‘ The staff show great compassion understanding and professionalism and there is a consistently high approach to care and meeting needs’ ‘We have never had any reason to complain’ ‘They take particular care in understanding the complexity of my son’s needs and are always looking for new strategies to re-inforce his self assessment’ ‘It is difficult to make suggestions about improvements as all aspects of the care are excellent’ What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. HWCGS DS0000022458.V343562.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 HWCGS DS0000022458.V343562.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 excellent. This judgement has been made using available evidence including a visit to this service. Prospective young people benefit from a thorough assessment process where their needs are identified in advance and they are empowered to make a decision to come to live at Segal Gardens. EVIDENCE: One new admission has taken place since the last inspection. Admission information is in place in the form of a referral document that is completed by the service. This covers every aspect of the individual in terms of medication, family contact, education, social activity, ethnicity, communication, selfconcept, social support and safety. Background information is also in place. In addition to this assessment information is available in respect of the funding authority as well as psychological assessments from professionals. Details were also available to suggest that the assessment process takes some time and is done gradually with introductory visits being used to further enhance the assessment process until a point is reached where the individual wished to live at the home. HWCGS DS0000022458.V343562.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. Individuals benefit from having their needs identified in a plan of care that provides a clear indication of the actions needed to successfully support them. Individuals also benefit from having the contents of the plan confirmed to them through appropriate formats. Individuals do benefit from having their needs or the risks they face through daily living reviewed consistently. All individuals do benefit from having the risks they face in daily living identified and devised so that they are specific to them. EVIDENCE: Care plans were examined for two individuals. Interviews with two staff members confirmed that they were aware of the care plans. Care plans are based on the needs of individuals. One care plan noted a focus on routines, medication, self-harm, risks, and behavioural strategies. Care plans are clear and indicate exactly what the staff team need to do to ensure the effective support of the individual. In addition to this, a care plan in a format suitable HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 11 for the communication needs of each person has been devised and there is evidence that the individuals have been consulted on the contents. Reviews have not been held for one person but this reflects the fact that they have not long been living in the home. One element of this care plan had been reviewed following issues that had developed after admission. Other care plans viewed showed evidence of review. Care plans cover all areas important to the individual and cover other aspects of National Minimum Standards such as meals, education and occupation and the level of support that individuals receive. Care plans are supplemented by daily record sheets which indicate progress for each person during the day as well as a handover book which enables short summaries of key information to be made known to staff. One resident was asked about finances. The impression was given that they have their own bank account and is able to access monies when needed. In addition to this evidence that the service provides individual with all the information they need about the service and events that are occur. Community meetings are held monthly and minutes for these were examined. All minutes of meetings are presented in symbolic form and include reference to events that are occurring within the home e.g. recruitment of new staff and request to individual about the future activities they may wish to pursue. In addition to this the service has a website and also publishes a newsletter on a regular basis. Evidence was available throughout the inspection of staff providing the opportunity for individuals to make decisions on their own. Evidence was available also about the last admission into the service. Trial visits were arranged and the service ensured that the individual was given the opportunity to decide that they wanted to live at Segal gardens rather than automatically admitting them. Risk Assessments are in place for all residents. Two risk assessments were viewed and have been reviewed in the last twelve months. Risk assessments include a statement of why risk assessments are needed and then outlines specific risks associated with each person. Such risks may involve aggression, activities and the environment. HWCGS DS0000022458.V343562.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 excellent. This judgement has been made using available evidence including a visit to this service. Individuals benefit from being provided with educational opportunities and significant access to the local community. All individuals are able to benefit from contact with their families and have their rights respected. Food provided meets the nutritional needs of individuals, respects their food preferences and emphasised the involvement of individuals in food preparation as well as healthy eating. EVIDENCE: All occupation undertaken is based on involvement in the running of the home or through involvement in the environment. In addition to this, the home has subscribed to an educational system and has become accredited to use its tools for individuals to be involved. This system is available to anyone despite their educational history and counts towards future educational goals. A separate building is available as a base for these activities and was viewed HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 13 during the visit. Documentation is also available for each person and outlines his or her goals in education. The service is located in a residential area of St Helens yet has the means to ensure that individual have access to local facilities. Public transport routes are close by and the home has its own transport. On the second day of the inspection, a group was going bowling and swimming. There was also evidence that all individuals can be involved in shopping and other domestic routines. Evidence was provided in respect of one person and the difficulties they are experiencing to obtain a bus pass. The staff team are acting as advocates in order to ensure that she is able to get this. All service users have daily planners, which involve community activities. There was also evidence that individuals are involved in the day-to-day issues relating to the house. One person was involved in work in the garden in horticulture with employed staff. Most individuals do not come from the local area and rely on staff to advise them on local activities etc. Links with community are also extended to a community centre based next to the home and this is used frequently. One individual confirmed that she prefers to do activities on her own and this is provided. Surveys were sent to all family members. One relative spoke to The Inspector in person and confirmed that she is able to visit her relation on a regular basis and this home facilitates this. All individuals are able to maintain contact with their relations and the home also provides information in relation to progress of their relation. Residents are able to receive visitors in private. Confirmation was made through a relative survey that their relation is able to maintain contact through email and telephone. All residents have access to computers and each have an email account. There is an expectation that all individuals are involved in the domestic aspects of the home-e.g. Laundry and food preparation with differing degrees of supervision. Rotas are in place for tasks. One individual confirmed her involvement in this. All individual have keys to their rooms. Staff interaction with service users is significant and respectful and this was evidenced throughout the inspection. One person confirmed that she prefers to be on her own and this is respected. Unrestricted access is provided for all individuals throughout the home both internally and externally although reminders are made not to enter rooms without permission. No one needs assistance aids as all are independently mobile and have no specific disabilities. Care plans noted that no one has specific nutritional needs although one person has needs with food that tend to be psychological rather than physical. A dining area is available as well as a kitchen. The kitchen is well equipped and domestic in scale. Kitchen duties are in place and on display although these are presented in symbolic form. Menus are also available as well as HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 14 information on healthy eating and ‘five a day’ reference to fruit and vegetables. All shopping is obtained from local supermarkets and there is evidence that individuals are involved in shopping on a regular basis. The menu indicates choice provided. One resident confirmed that they had a choice with food given that she is a vegetarian and this preference is respected. HWCGS DS0000022458.V343562.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. 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. All individuals’ benefit from being supported appropriately and in line with their needs and wishes. The health needs of residents are individually met. Medication systems are safe. EVIDENCE: No service users receive intimate personal care but receive prompting and assistance with emotional needs and support with promoting independence, life experiences as well as keeping individuals safe. One individual was able to confirm that she was able to get up when she wanted and go to bed as well as following her usual routines. All individuals are able to choose how they present themselves in terms of appearance. All individuals have a keyworker, all have access to medical services, especially access to a consultant psychiatrist and the home has been able to sustain partnerships with parents and significant others. All service users are reliant on the staff team to ensure that their health needs are met. Records are maintained suggesting that all service users have HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 16 received medical interventions over the past months which are linked to their needs. One person had experienced deterioration in mental health and as a result has received significant reviews from a consultant psychiatrist. Others have received more general interventions such as opticians, chiropody, general doctor appointments etc. Medication is securely stored in a lockable cupboard. No individuals self medicate fully at the moment Following risk assessments. All staff who deal with medication have received training. All medication records are appropriately signed. No controlled drugs are prescribed at present. All received medications are accounted for as well as disposed medications. The home has a medication procedure outlining these arrangements. HWCGS DS0000022458.V343562.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have the information they need if they wished to make a complaint. In particular residents are presented with the information they need in an appropriate format. Residents are protected form abuse and are empowered to be aware of what the service will do to keep them safe by the provision of specific policies. EVIDENCE: A complaints procedure is in place and is on display on a notice board in symbolic form as well as contained within a written procedure. Other procedures have been made available to individuals and these include reference to bullying, whistle blowing and the protection of vulnerable adults. All individuals have signed to say they have seen this and such policies are presented in symbolic form. The Commission For Social Care Inspection has received no complaints or concerns and none have been received by the home since the last inspection although a complaints record is maintained. One relative confirmed ‘we have had no reason to complain’. Two staff were interviewed as well as a student nurse on placement. Staff have had abuse awareness training and have access to the Local Authority procedure in relation to abuse. All are aware of whistle blowing procedure and restrictions in relation to residents’ finances. There is no need for restraint to be practiced in the home yet all staff have received training in respect of challenging behaviour and most recently awareness in the legal aspects of HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 18 individuals rights as well as techniques to diffuse situations. Risk assessments are such that interventions are outlined in respect of protecting individuals from self-harm rather than harming others. No allegations of abuse have occurred or been received. The service has a copy of the Local Authority abuse policy and recruitment procedures indicate that residents are protected through this process. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individuals benefit from living in an extremely home like, well-decorated, comfortable and clean environment. EVIDENCE: A tour of the building was undertaken. Refurbishment work continues when necessary yet there is an understanding that some changes to the environment or individual accommodation can have an effect on individuals and this is linked to specific disabilities e.g. autism. As a result, efforts are made to minimise changes to the environment and the staff team are aware of this. The home is decorated to a high standard throughout. A lounge is available as well as kitchen and dining area. Bedrooms are located on both lower and upper floors. The Inspector was allowed with permission to view one room and noted that this is extremely well decorated and personalised and significantly reflects the interests of the individual. The home blends in with the local community and cannot be identified externally as a registered care HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 20 home. A local community facility is located next door and this is used on a regular basis as evidenced through daily planners. The home is located so that there are links by road to the local town as well as public transport. Furniture is to a good standard and efforts are made throughout the building to ensure that individuals are able to stamp their identity on the building in respect of artwork. Information is also freely available in the home in the form of notices, menus and general information for individuals. The home employs domestic staff although there is still an expectation on residents to be involved with the daily running of the home. The environment is very clean and hygienic although the impression is still made that the building is home in the true sense of the word. A laundry is available and is located in a separate building. This is a well-organised facility with industrial appliances in place. There is an expectation that residents will be involved in laundering their own clothes and this was evidenced through discussions with one person. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals benefit from a robust recruitment process. Individuals do benefit from a staff team who have received training specific to the needs of individuals. EVIDENCE: One person has come to work in the home since the last inspection. This person has just qualified as a registered nurse in learning disabilities and it is hoped that this person will bring her expertise to those individuals who are there primarily because they have a degree of learning disabilities. The persons file contained two references. In addition to this the individual had applied for a police check and an initial police check (POVA First) system is in operation for all new staff in future. All other information in respect of application form, experience, medical declaration, police declaration and interview notes were in place. The Inspector spoke with staff about training and also examined training records. It was confirmed that training had been done in mandatory topics yet in addition to this there had been training in respect of those issues unique to HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 22 the individual. The Managers of the service have nursing qualifications and have been able to use this expertise to train staff and make them aware of various issues associated with mental health as well as learning disabilities. Other courses have included the protection of vulnerable adults/children, challenging behaviour management and autism/Aspergers awareness. A training programme is in place and certificates on personnel file evidenced this training. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive a service, which is managed by qualified individuals who take their views into account as part of the quality assurance process. The health and safety of residents is taken into account. EVIDENCE: The Registered Manager of the service has many years experience in this role and is a qualified nurse. In addition to this, there are Directors of the company that run the service who have significant involvement in the running of the home from working shifts, planning for the future of the home and training. All the management team have experience in the role and are able to use this experience to provide training to the staff team. The management team also have access to other external resources in order to keep up to date with issues HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 24 concerning younger adults with learning disabilities or mental health issues. The management team take their role seriously and strive to maintain that national minimum standards are adhered to or in some cases exceeded. The service has currently used three forms of quality assurance. One involves stakeholder surveys that were last done in 2006. This involved comments from residents, relatives and other agencies that are involved in the home. The service has also used the new annual quality assurance document from the Commission for Social Care Inspection to determine any improvements that the service may need. In addition to this, the service has used an independent quality assurance system. The Manager is currently working through this and has identified some areas that need further work. This related to infection control and involvement of residents in recruitment. A number of issues relating to health and safety were examined. Staff have received mandatory training as confirmed through interviews with staff and training certificates. Fire alarms are tested regularly as well as emergency lighting. Also fire drills are carried out weekly. A fire risk assessment is in place. Health and safety checks are carried out regularly. Fire procedures are posted within the home. Accidents are recorded and information is in place in relation to reporting incidents. Certificate of registration and insurance is in place. Risk assessments have been completed as well as a Control of Substances Hazardous to health (COSHH) risk assessments. Electrical wiring and gas systems have been tested as well as portable appliance tests. A recent environmental report from March 2007 highlighted no issues. A health and safety policy is in place. HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 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 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 4 X X 3 X HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 HWCGS DS0000022458.V343562.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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