Inspection on 12/02/07 for Ivydene

This inspection was carried out on 12th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Ivydene 10/02/09

Ivydene 21/12/05

Ivydene 11/08/05

Ivydene 29/11/04

Ivydene 27/07/04

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

CARE HOME ADULTS 18-65 Ivydene 1 Station Road Ormesby St Margaret Great Yarmouth Norfolk NR29 3PU Lead Inspector Silas Siliprandi Unannounced Inspection 12th February 2007 09:40 Ivydene DS0000027469.V331419.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 Ivydene DS0000027469.V331419.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. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivydene Address 1 Station Road Ormesby St Margaret Great Yarmouth Norfolk NR29 3PU 01493 731320 NO FAX # maureenmartin1@yahoo.co.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) Mr Charles Martin Mrs Maureen Martin Mrs Maureen Martin Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: Ivydene is situated in the village of Ormesby St Margaret, close to Great Yarmouth, with a variety of facilities provided locally. It is owned and managed by the proprietors Mr and Mrs Martin. It is a two-storey house with an attached bungalow. It has ample communal space for activities and socialising with a large conservatory being the most recent addition. The home is spacious, well decorated throughout and has 16 single bedrooms. The garden is well maintained and there are car-parking facilities at the front of the building. Many of the service users have lived at the home for a number of years. (One of the service users is a relative of the proprietors and is not included in the registered numbers, increasing the overall number to 17.) The home provides long term care and support to the sixteen service users with mental health needs. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was made as part of the ordinary cycle of unannounced inspections. The visit ran from 9.40 am until 7.45 pm. Before the inspection the Commission had asked the home for information [provider information] about how the home complied with the general range of issues relevant to its registration and the legislation that the home has to comply with. In addition to this material the home also sent the Commission a copy of the detailed survey that it had carried out to find out how well the people living in the home [and their relatives and representatives] thought the home was doing in meeting peoples’ needs properly. The provider information was helpful in providing a baseline of evidence. The survey was certainly really useful in gaining an early insight into how people felt about the home. It was also useful in helping us understand that the home was actually consulting formally with the people who used its services and taking note of what they said about what was going well and what might need some extra thought. The home’s own survey did show a solid general level of satisfaction, but also [and equally positively in our view] pointed up areas where the home might try other different approaches. The Commission also invited people living in the home to fill in a comment sheet and return their personal remarks to us directly. People living in the home did write back to us [fifteen responses]. We are grateful to them for that, but we also believe that this very high level of response says a lot about how far people feel in control of their own lives, and that they believe that their contributions will be taken notice of. Again, this is likely to mean that the home is providing a positive, safe environment and culture to live in. The fifteen comment cards were all broadly very positive about the home and the way in which care was offered. As well as giving views about the ten general areas covered by our survey service users added extra comments about the manager, about the staff, and about the other people they found themselves living with at the home. Once again these comments were all complementary and positive. Eleven relatives or representatives of people living at the home responded to a similar invitation to make written comments in advance of the inspection. Their responses were equally positive. Three people living at the home made time to speak to the inspector during the visit, as did one visitor [a relative of somebody living at Ivydene]. Three members of staff were interviewed, as was the manager. What everybody had to say on the day of inspection tallied well with the impression gained from the information received in advance of the inspection. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The system of management is obviously genuinely flexible, and some changes were made to plans for upgrading the maintenance and decoration because some better opportunities presented themselves. A solid range of management ideas and practices can be seen to move forward steadily all the time. The system of Key Working [where one key worker takes special responsibility for one or more service users] is now well-established and paying dividends. Research shows that key worker systems improve communication and relationships between people living in a home and the people staffing it. Research also shows that service users gain better control of their lives and Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 7 say that the quality of their lives improves. Staff say similar things about improved effectiveness of working and increased levels of job satisfaction. People living at Ivydene and the staff who work there had things to say that exactly parallel what the research would indicate. Service users and staff can identify specific items of better communication that has led on to better results. The system of Quality Assurance [where the home sets out to be sure that it carries its promises through into actual practice] is shaping up well, and is already moving in a direction where it could become an even more integral part of everyday life in the home. The system of assessment and planning for care is also now consolidating in a very sound way, and also a way that would lend itself to a direct link into Quality Assurance processes. The system of staff supervision and appraisal has already got off to a good start and is proving to be yet another way of ensuring good consistent practice and helpful support for staff. 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. Ivydene DS0000027469.V331419.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 Ivydene DS0000027469.V331419.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): Key Standard two was re-inspected in detail. Standards 1,3,4 and 5 were looked at briefly to round out the picture and understand the processes. Quality in this outcome area is good. People who may use the service do have the information they need to choose a home that meets their needs. The home can demonstrate that it does meet the needs of prospective service users prior to admitting them. People are actually well supported by the home in making an informed choice. The home needs to consider the impact of a group of service users becoming older and physically frail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service users Guide form a good foundation, as do appropriate policies and procedures. These documents are [as yet] only available in a written format. The home aims to admit only on the basis of a full assessment. Responses from placing agencies is varied [as seen from samples] some are solid, others lack significant detail. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 10 The home does a good job in adding serious levels of detail to these original assessments during the pre-admission process. People do visit the home several times before moving in. This process can occupy from two or three weeks to three months depending on circumstances and need. This can include overnight stays and always includes “relevant others” whenever appropriate and desirable. The “Care Management” plan [mostly from hospitals] is usually acceptable in its detail. It was clear that it was unusual [or even rare] for this plan to be presented to the home by the placing agency in the format of a care plan. This is an area where the home itself is doing well in filling this professional gap. The home does now advise people in writing of the care that will [initially at least] be available to them prior to admission. Service users and their representatives said that they were quite clear that the home would meet their needs prior to admission, and that their choice had been an informed one. The one dissent from this point of view was clearly explained by one person being admitted in an emergency situation. Although this person hadn’t felt in full control during admission this was largely outside the control of Ivydene, and the person concerned said that once in the home they were happy that the move had been a good one. Everybody has an agreed contract/terms and conditions. This has been revised and improved since the last inspection. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): ey standards 6,7 and 9 were all re-inspected. Standards 8 and 10 were also re-visited briefly to gain fuller picture. Quality in this outcome area is good. Individuals are involved in decisions about their lives and play an active role in planning the care and support they need. Service users are supported to take appropriate risks as part of an independent lifestyle, and are confident that their personal information is not divulged without their consent. This judgement has been made using available evidence including a visit to this service. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 12 EVIDENCE: The original assessments are reviewed and kept up to date. The original care plans are also kept under review and amended as needs change. There is a particularly good piece of practice in selecting some few [only usually two or three] specific issues for change and development that are set out as discrete care plan ‘goals’. Service users have copies of their care plans in their rooms for their own use. All of this process is in complete consultation with the service user and relies on their full participation. Service users [and staff] were able to talk about this process and its outcomes in detail and depth. Key working is the norm [see ahead to staffing] and is a cultural concept well and fruitfully embedded in the home. There is a good advocacy service that the home worked hard to initiate and works hard to maintain. Staff and management are fully supportive of people making their own decisions within agreed therapeutic bounds. Records support this and service users say so. As a specific part of the information sharing process there are service users meetings, and questionnaires canvassing their opinions. Service users have an input into staff selection and are asked about their feelings regarding somebody who might be considering joining the group. Service users are not yet involved or part of staff meetings [which might well be the next development]? Service users rights and responsibilities are further promoted by being supported to take risks as part of an independent lifestyle. These risks are carefully assessed in partnership and appropriate care responses and strategies can be seen in the records. Staff have policies to follow in respect of safeguarding service users privacy and the confidentiality of their records. Staff were able to describe their duties in this respect in full. Service users’ relatives/ representatives pointed out that they were only told things with their relative’s/friend’s express permission. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards 12,13,15,16 and 17 were all re-inspected. Standards 11 and 14 were re-visited briefly as part of the evidence chain. Quality in this outcome area is good. People who use the home’s services are able to make choices about their lifestyle and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual expectations. The home’s daily routines promote independence, individual choice and freedom of movement subject to mutual agreements in each individual’s plan for care. This judgement has been made using available evidence including a visit to this service. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 14 EVIDENCE: The main evidence came from case tracking individual files where there was clear evidence of people being able to develop contacts and skills. Just as an example of the level of support and variation, one of the service users sampled [and this was not unique to them] had taken part in forty activity sessions [comprising of ten different activities] in a three-month period. Sadly, the manager reports that services outside the home are under continuing and growing pressure, leading to a steady erosion of choice for service users living at Ivydene. There was some debate about how much input individual service users had into ordinary everyday tasks. Some people felt that service users did enough, and were genuinely not capable of doing much more due to their personal circumstances and medication. Others suggested that service users could beneficially do more than they did. In addition to specific activities the home and the people who live there are quietly embedded into the local community, they also take advantage of specific projects set up by the manager over a considerable period of time that are of themselves now just part and parcel of ordinary local life. There is a specific policy [with appropriate safeguards and information] that helps people develop and maintain appropriate relationships, specific features within the assessment and care planning process back up this policy. As part of ordinary life people do have a key to their own room, and use it. People have access to the kitchen [with limits while the evening meal is being prepared] and, as well as preparing their own lunch, can make snacks up until 10pm [this restriction only applies to ensure that one service users bedroom is not disturbed by noise after this time]. As well as having access to the kitchen there are tea and coffee making facilities in the lounge area, and some people have [risk assessed] facilities in their own rooms. Some people do make their own evening meals with support, but for the majority input into the evening meal is confined to helping with the preparation. There are numerous routes for people to make suggestions for menu changes or additions, such as the service users’ meetings, and everybody makes additions to the general food shopping list for the things they want for their own meals. Ivydene DS0000027469.V331419.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): Key standards 18,19 and 20 were all inspected. Standard 21 was also looked at briefly. Quality in this outcome area is good. The health and personal care that people receive is based on their individual needs. The principals of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were very clear that they felt that staff gave them the personal support they needed in a respectful way. Staff were able to describe the personal care they gave, and also to put that description into a context of respecting peoples rights and preferences. Staff are supported and guided by an appropriate range of policies and procedures. The assessments and plans for care were detailed enough to support good practice. The use of a key worker system was universally recognised as aiding the process of good communication about needs and preferences. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 16 The same comments apply to healthcare, which is a wide-ranging and considerable need for several people living in the home. Sampled records showed diligent attention being paid to assessed and recorded needs, also these needs could be seen to be kept under regular review and very close observation. There was a limited choice when it came to people accessing their ‘previous’ GP, but this was a matter that the home itself has little or no control over. The medicine administration processes are carefully managed and staff are appropriately trained for basic administration. People who wish to continue to keep and administer their own medicines can do so within a framework of what are seen as agreed and acceptable risks and safeguards [good practice]. The medicine administration system is audited twice a year by an outside specialist [good practice]. Peoples’ medicine use and prescription is regularly reviewed [good practice]. The home is currently actively planning to re-enforce and update training on how to ensure that the illness and death of a service user will be handled with respect and as the individual would wish. Ivydene DS0000027469.V331419.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): Key standards 22 and 23 were both inspected. Quality in this outcome area is good. People who use the service are able to express their concerns and do have access to a robust and effective complaints procedure. People are properly protected from abuse and do have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and their representatives were clear what they had to say during the visit and in their written comments to the Commission prior to the inspection that staff did listen to what they had to say, that they were aware of who to bring any concerns to, and that they felt comfortable with the idea of raising any personal concerns. Staff were clear in their explanations of their role in dealing with concerns appropriately, and could also describe a good awareness of how hard it can be for some service users to raise uncomfortable issues. There were sound policies and procedures to assist staff in behaving appropriately with training in these topics given as a matter of course. The home has a sound adult protection procedure, backed up with information easily accessible [on display] in the home. The home insists that all staff are only recruited after the ‘enhanced’ CRB check has been carried out. Ivydene DS0000027469.V331419.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): ey standards 24 and 30 were both inspected. Standards 25 to 29 were also looked at briefly to help gain a fuller picture. Quality in this outcome area is good. The physical design and layout of the home does enable people to live in a safe and appropriate environment. The home is comfortable and ‘domestic’ and can be used in a way that promotes independence. It would be prudent for the home to continue to take stock of changing needs of some people as they get older and potentially more frail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking at assessments and talking to people in the home showed that there was some growing need as people got older, but that it was not yet at a point where it ought to cause any immediate concern. The manager described monitoring the situation and also talked about some sensible responses already in place as recognitions of increased risks. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 19 There was general agreement that this was an issue that needed continued careful monitoring, and that a time was approaching when more radical approaches might be required. The home is accessible and ‘homely’ in its atmosphere. There have been changes to the maintenance schedule to reflect changes in opportunity and need [which demonstrates flexibility]. The overall level of maintenance and decoration is sound. Sample bedrooms demonstrated individual approaches suited to the person occupying them. The ‘public’ areas were varied, accessible and in good order. The home was seen to be clean and in good order, and this was endorsed by what people who lived in, or visited the home had to say. Ivydene DS0000027469.V331419.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): Key standards 34 and 35 were both inspected. Standards 31,32,33 and 36 were also looked at briefly to round out the picture. Quality in this outcome area is good. People living at the home are supported by enough staff who are all trained and properly skilled for the care they are expected to give. The staff roles are clear and appropriate for the work that actually needs to be done. The staff themselves are properly managed and supported. There are given clear understandings of what their jobs are, and the best way to carry those jobs out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff all have clear and comprehensive job descriptions which cover the kinds of issues that emerge from assessments and care plans. Staff interviewed could describe the people that they are key workers for in considerable, subtle and sensitive detail. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 21 The staffing roster [and the provider’s information] showed an appropriate range of skills and numbers of staff on duty. The staffing complement was reenforced to cover specific identified need. The care plans were not quite yet at the stage where an objective time-based measure of staff required could be used [and it probably would be difficult ever to achieve better that a ’rule of thumb’ quantification of staff time needed to cover all care plan needs]. People living in the home [and their relatives/representatives] were all abundantly clear in their view that the staff were genuinely supportive and concerned for their welfare. Staff interviewed were all very happy to be working in the home and were also equally clear in what they had to say about the positive way in which the home encouraged and supported them to reach a good standard of work. Staff also said that they felt comfortable in having clear expectations about good practice that were there for them to work to. The recruitment practice and procedure was sound and the home’s insistence on the ‘enhanced’ CRB check has already been mentioned. Staff training is kept under solid review [records showing a 3 monthly review as a minimum], recent specific needs have been identified relating to individual service user care needs and training has been sought to assist in ensuring the best responses [good practice]. Really good progress is continuing with staff supervision and appraisal. There was some discussion about the possibility of making every ‘supervision’ session contain a larger element of ‘appraisal’. Ivydene DS0000027469.V331419.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): Key standards 37,39 and 42 were all inspected. Standards 38,40, and 41 were also re-visited to broaden the picture. Standard 43 was not looked at during this visit. Quality in this outcome area is good. The home is managed in an open and flexible way that is supportive of staff and service users. Management of the home is not static, but moves ahead to take account of developments and changes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is solidly qualified and solidly experienced. The track-record in running the home has been consistently good over many years. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 23 In 2005 the manager added the final stage of the ‘Advanced Care Management’ qualification with a commendation. As can be seen throughout this inspection record management has not stood still in the home, but has consistently been advancing into new areas or areas that are in need of re-visiting and re-enforcement. Service users, their relatives/representatives and staff all said that the style of management helped to create an open, positive and inclusive atmosphere. The quality assurance process in the home is fairly well advanced and its development is continuing, but is already giving good feedback on what the home does well and where some additional effort or change of course would be beneficial. The policies and procedures of the home were found to cover a significant range. Revisions and updates could be seen. Staff are expected [as a minimum] to refresh their understanding of the entire policy and procedure set yearly and sign to say that they have done so. It was also clear that the majority of the policies and procedures were actually used in the workplace, rather than just taking up shelf space in the office. Records in respect of service users were well maintained [as sampled] and stored with appropriate safeguards for their confidentiality. The provider information showed a regular activity in respect of records and visits from outside bodies [such as the fire service] to help maintain and promote the safety of service users. Records showed service users taking full part in regular and realistic fire training exercises on a regular basis [good practice]. Ivydene DS0000027469.V331419.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 3 2 3 3 3 4 3 5 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Ivydene DS0000027469.V331419.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 YA2 Good Practice Recommendations Standards 3 and 24 also apply. It is recommended that the persons registered continue to look at the whole scope of the home’s purpose, and continue to think of the home’s longer-term future. This recommendation is especially in regard of meeting the longer-term needs of those people now most likely to choose Ivydene as a ‘home for life.’ This implies thinking about the physical facilities of the building as well as the potential for needing to respond to growing mental frailty as well. This kind of more ‘dependant’ dynamic is likely to be at increasing variance with the needs of people aiming to return to a more independent life. This will need some long-term resolution as well. For example, might some more independent people need encouraging towards and even more independent outlook on domestic chores? It is recommended that the persons registered consider DS0000027469.V331419.R01.S.doc Version 5.2 Page 26 2 Ivydene YA8 3 YA12 4 YA39 how best to increase service users’ participation in the conduct of the home. Being part of [possibly by representation?] staff and management meetings might be possible routes to consider. It is recommended that the persons registered consider the benefit of [say] groups of three people being given the responsibility to devise, budget for, shop for and prepare their own evening meals. This suggestion is only offered as possibly relevant to a fairly small number of people. It is recommended that the persons registered consider the benefits of using the present good system of assessment and planning for care as an integral part of the Quality assurance process. For example, fine tuning the present statements/questions in the survey to be more closely aligned to actual care actions in the plans for care would allow direct measures of how well those actions were carried out. The same goes for the more ‘general’ statements made in the Statement of Purpose and Service User Guide. Might alterations of this kind provide a sharper focus? If so, then a combined Statement of Purpose and Service User Guide might become the touchstone for all future Quality Assurance processes and systems. Ivydene DS0000027469.V331419.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Ivydene DS0000027469.V331419.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. 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!