Inspection on 24/10/07 for John Darling Mall

This inspection was carried out on 24th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

John Darling Mall 12/12/06

John Darling Mall 04/11/05

John Darling Mall 05/08/05

John Darling Mall 09/12/04

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

CARE HOME ADULTS 18-65 John Darling Mall Selborne Drive Eastleigh Hampshire SO50 4SE Lead Inspector Michael Gough Key Unannounced Inspection 24th October 2007 09:00 John Darling Mall DS0000040678.V347425.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 John Darling Mall DS0000040678.V347425.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. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Darling Mall Address Selborne Drive Eastleigh Hampshire SO50 4SE 023 80613101 023 80611497 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) Hampshire County Council Wendy Frances Burkill Care Home 24 Category(ies) of Physical disability (24), Physical disability over registration, with number 65 years of age (2), Sensory impairment (1) of places John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 Brief Description of the Service: John Darling Mall is a purpose built unit for up to 24 service users who have physical disabilities. The service users are mainly there for short breaks or in preparation to moving to more independent living. There are, therefore, both long and short-term service users in residence. Assessment and rehabilitation facilities are also available. The building is single storey, split into four units with a central communal area and some smaller communal lounges. There is a central dining room, and each unit has its own kitchenette and dining area. John Darling Mall is close to local shops, pubs and other amenities that are accessible to service users. Weekly fees are £891.00 and residents are responsible for paying for their own hairdressing, toiletries and items of a personal nature. Information about the home is available in welcome packs provided in each room. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at John Darling Mall (JDM) and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out in December 2006. The inspection took into account the homes Annual Quality Assurance Assessment (AQAA); and comment cards received from 3 relatives and 4 users of the service. Included in the inspection was an unannounced site visit to the home, which took place on the 24 October 2007. For this visit the inspector was assisted for part of the inspection by an “Expert by Experience” (this is a person who, because of their shared experience of using serviceS, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service). Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and users of the service. The expert by experience spoke to 7 residents during the inspection. 2 residents were in JDM for the 1st time. 2 had been in JDM before and had regular respite there. The other 3 had been in JDM for over two months for rehabilitation reasons. It was also possible to speak with 3 members of staff and the homes manager and her deputy who assisted the inspector throughout the visit. The home is registered to provide support for 24 residents and at the time of the inspection there were 14 people living at the home. What the service does well: The home provides care and support to enable service users to live meaningful lives. There is a well-established staff team willing to be flexible and who know a lot of the regular users of the service well, those spoken to were very complimentary about the support they received from staff. One said they were ‘very helpful’. Another felt that ‘if you treat them right, they will treat you right’. All felt they could ask for support whenever they wanted. One person liked going to bed after midnight and said this was never a problem. Users of the service seemed to feel happy and safe. There were positive relationships with the staff who all appeared to be polite and friendly and staff support residents in their day-to-day lives and they are treated as individuals and with dignity and respect. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 6 The management ensure that staff receive appropriate training regularly and offer support and supervision to staff. The service can respond to a range of needs and this includes admissions at short notice. There is an effective care planning system in place and residents are supported to access the local community. The home has a dedicated and stable staff team and they receive appropriate training to enable them to provide effective support to residents and there is a robust recruitment procedure, which helps protect service users. What has improved since the last inspection? What they could do better: There was 1 requirement and 1 recommendation made as a result of this visit and other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report, general observations were: Currently care plans are not always regularly reviewed and when they were reviewed there was no evaluation of how the care plan was working for the resident. In order to ensure that care needs are met care plans must be kept under review to ensure that residents needs in respect of their health and welfare are met by the home. There is no dedicated activities co-ordinator employed by the home and it was clear from speaking with residents that they would like more opportunities for recreation and leisure. Care staff said “they do not always have the time to engage in activities as they are carrying out care tasks”. The manager reported that there is a difficult balance between the recreational needs of long term residents and for those on short stay or respiteand a dedicated activities co-ordinator would improve the recreational opportunities for residents. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 7 There was some dissatisfaction with the choice of food provided at the home although this varied according to who was spoken with. At present the home does not hold residents meetings and it would be beneficial to both the home and residents if these were implemented to help residents to be more involved in the day to day running of the service. Staffing levels meet the care needs of residents, however the home needs to consider the staffing levels to enable residents to be supported out in the community. 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. John Darling Mall DS0000040678.V347425.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 John Darling Mall DS0000040678.V347425.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. Users of the service can be confident that there will be a detailed assessment of their individual needs before they move into the home. EVIDENCE: All admissions are made through care managers and a care management assessment is available. The homes senior carers, the deputy manager or the homes manager also carry out their own assessments and this is normally carried out before anyone comes to the home. The homes assessment forms the basis of the plan of care for residents and there is also input from district nurses if required to enable the home to obtain any specialist equipment that may be required before admission. The home on occasions takes emergency admissions and a care management assessment is obtained but the homes own assessment does not take place until they arrive at the home. The homes completed AQAA stated that residents are involved as much as possible in the assessment process. Residents have a welcome pack in their rooms and this gives them information on the facilities available and also details of their terms and conditions of residence. Residents spoken to said that they had been involved in their initial assessment and copies of assessments were available in resident’s files. John Darling Mall DS0000040678.V347425.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals assessed needs and personal goals are set out in their plan of care and residents are involved in the care planning process as much as possible. However all care plans need to be regularly reviewed to ensure that the changing needs of residents are met. Staff at the home respect resident’s rights to be involved and make decisions about their day to day lives. Hampshire County Council has a policy on equality and diversity and the home supports many people both male and female with a wide age range and the home applies its self equally to all residents in a fair and equal way. EVIDENCE: Each resident at the home has a plan of care, which details the support that was required. Care plans were seen for 3 residents and these had information on the individuals own abilities and also what support was required from staff. There was good information in care plans and residents who returned comment cards said that their care needs were met by the home. There was good recording for the care tasks that had been undertaken and this provided evidence of care delivery. All of the care plans seen by the inspector had been John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 11 signed by the residents. However 2 residents spoken with by the expert by experience said they did not know whether they had an ‘official’ care plan, however both stated that staff appeared to know what needs they had and met them in an appropriate way. All plans seen had a review section at the top of each section and this provided information that the plan had been reviewed, however there was no evaluation of how the care plan had been working and one care plan had not been reviewed for 6 months, although the daily recording indicated that there had been changes in the individuals care needs. This was discussed with the homes manager who understood the need for regular reviews to take place and also the value of having an evaluation of how the plan had been working. Residents are able to make informed decisions about their day to day lives and there are no restrictions on getting up and going to bed and staff support residents when they require assistance. Staff encourage residents to do as much as possible for themselves to maintain their independence. Residents can move freely around the units, although some require assistance to go out into the community. Each resident has detailed risk assessments and there are comprehensive moving and handling assessments in place. All staff receive regular training with regard to moving and handling and the risk assessments seen gave information on the potential risks and also ways to minimise any identified risks. Risks assessments were regularly reviewed and staff spoken to said that these provided them with good information. John Darling Mall DS0000040678.V347425.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 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some users of the service would benefit from more support to access the local community and a wider range of appropriate activities would be beneficial for residents. There is appropriate support to maintain social contacts and daily routines at the home respect residents rights and responsibilities. Meals at the home are flexible, however residents could be more involved in planning meals at the home. EVIDENCE: The expert by experience spent a considerable amount of time talking to staff and residents and there is an art and craft afternoon on a Wednesday. Two residents indicated that they participated in this and enjoyed it immensely, however one commented the room used for the activity was badly lit and this hindered the activity. A member of staff commented that although the art and craft materials were locked in a cupboard residents could ask for the key at any time. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 13 There were 2 computers with printers available for residents and the deputy manager told us that they were hoping to get internet broadband installed although one resident had already arranged to have it installed in his own room for at his own expense. The home organises a weekly trip out into the community on a Thursday but there appeared to be some confusion regarding the organisation of this. One resident said she enjoyed going on the trip but that space was very limited and she would only be told on the day whether there was room and where they would be going. Another said that priority was given to residents on ‘respite’ and felt this was unfair. The trip the previous week had been cancelled due to the driver being on holiday however it was reported that the trip normally went ahead as planned. The home has a bar, which is open on Fridays and all residents spoken with said they enjoyed using it, although 2 people said they would like it to be open more often. The bar was staffed by volunteers from the local church and this restricted how often it was open. Next to the bar there is a large common room and this is the smoking room provided for residents and this contains a pool table, and also a table tennis table, which was folded up. The room felt cold during the inspection, however three residents were interviewed in this room (all smokers) and had no complaints with the room. Those residents who do not smoke, said they tended not to use the room very much but did not find it a problem that the pool table was in the smoking room, however with the ever changing numbers of people who visit for respite this could become a problem for others. The manager is aware of this and is looking for other options. It was clear that opportunities to go out into the local community were limited and this was mainly due to the availability of staff to support people who needed it, to leave the building e.g. go to the shops. One resident felt it was not equitable that some residents who were more independent could go out on a regular basis, whilst others might be ‘stuck in JDM’ just because they needed support. The manager acknowledged this was an issue but said that there would always be limitations on staff availability for this type of need unless extra funding was available. The manager understood the problems in organising meaningful activities and said it was difficult to find out what individuals wanted to do, when asked she said that they often do not know themselves. There is no dedicated activities co-ordinator and the manager said that she was looking to employ one as this would be a valuable resource for the home. Staff said they do not always have the time to engage in activities as they are carrying out care tasks. There is a difficult balance between the recreational needs of long term residents and for those on short stay or respite, which the home needs to manage. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 14 The expert by experience met with residents at lunchtime and this was seen as a social occasion where residents got together. There is a five week rolling menu and this is changed seasonally, breakfast is flexible and lunch is normally a snack type meal with 3 choices normally being available. The main meal is in the evening with 2 choices available. Residents are given a menu sheet to complete each week and this gives information on what is available each day and they are able to make their own choice. Alternatives can be provided if there is nothing to their liking and specific meals, which residents can cook themselves can be organised as part of their care programme. 2 residents referred to the food as ‘basic’ and 1 said it ‘lacked imagination’. Other residents said the quality of the food was very variable. One person interviewed said he preferred to buy his lunch from the local shops. The manager said that she had developed food questionnaires for residents to complete and the responses to these had also been varied. The inspector discussed this issue with the homes manager and she said that she would try to get the residents at the home more involved in menu planning and it was recommended that this takes place. John Darling Mall DS0000040678.V347425.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and their health needs are met. The homes has policies and procedures with regard to medication and these are used in conjunction with the organisations corporate policy and these provide protection for residents. EVIDENCE: Care plans for residents gave information on personal care needs and there was information on what support was required in the mornings and evenings and also information on individuals personal care skills so that staff could offer the correct type of support. The staff team are flexible round the times when residents want their personal support and there are no set routines. All of the residents have a health care plan. All respite residents are registered with a local GP surgery and all have the same GP, however those on long term stays are able to choose their own GP. Arrangements are in place for dental checks, and sight checks if required and residents have access to all relevant health care professionals and these are accessed through GP referral. Staff at the home monitor service users health and support service users to access appropriate healthcare professionals and to attend any appointments. The AQAA stated that any relevant information regarding health care needs are John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 16 gathered at the assessment and this gives the home the opportunity to ensure that suitable arrangements are in place. Residents spoken to confirmed that their health care needs were met by the home. The home has clear policies and procedures in place for the receipt, storage and administration of medication. All staff at the home have undertaken training in medication administration procedures and residents are encouraged to administer their own medication where possible and lockable storage is available in residents bedrooms. One care plan seen had a risk assessment in place regarding self-medication. Medication is stored securely in the home and there is additional security for controlled drugs. Records are kept of all medication administered and those records seen were clear and up to date. There is a clear system in place of the disposal of any medication and this is returned to the pharmacy for disposal. John Darling Mall DS0000040678.V347425.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a clear and accessible complaints procedure and the homes policies and procedures protect service users from abuse. EVIDENCE: The home has a clear complaints procedure and this includes timescales for the complaint to be addressed and gives details of how to contact the CSCI. None of the residents interviewed said they had needed to make a complaint but all of them said that they knew how to complain and that their complaints would be taken seriously. The AQAA indicated that there had been 2 complaints since the last inspection and these had been satisfactorily resolved. The inspector was shown the complaints log and there was one outstanding complaint made by a relative of a resident, the manager had responded but was still awaiting the a response before the complaint could be closed Staff receive regular training in the protection of vulnerable adults and those spoken to said that they would talk to the manager if they had any concerns, they were aware that they could go above the manager if they felt that this was appropriate and knew that social services would take the lead in any adult protection issues. There have been 2 adult protection issues at the home and these have both been appropriately reported and suitable action has been taken to protect individuals. John Darling Mall DS0000040678.V347425.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): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home appeared to be well-maintained and residents have access to reasonably comfortable indoor and outdoor facilities, however improvements to the garden area and also the lighting and decoration of the home would benefit residents. The home was clean and hygienic. EVIDENCE: John Darling Mall was purpose built for people with physical disabilities and has been suitably adapted. The inspector and the expert by experience toured the home with the deputy manager and found that the mall itself has dim lighting and this is mainly due to the construction of the roof, which is on a metal framework with plastic type sheeting, which was designed to allow maximum light into the mall, however over the years this roof has become dirty and stained and this restricts the light into the building, however none of the residents interviewed identified this as a problem. Residents rooms are in four sections each with shared facilities including lounge areas and adapted kitchens. Use of these kitchens varies from unit to John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 19 unit and depends on whether the resident is at the home for respite or for longer stays. Many of the communal areas of the home would benefit from redecoration. Individual residents rooms seen were equipped with all the required furniture including lockable storage, however lighting was quite dull. There is a programme in place to update the fire alarms system in the home and also to update the lighting arrangements and this will improve the overall quality of the lighting. The manager said that once this work had been completed a programme of decoration would take place. Two of the bathrooms in the units had been upgraded and refurbished and some rooms have had new track hoists fitted all residents who were spoken with were generally satisfied with the overall environment. There was a large communal garden, which ran the length of the building and this was tree lined, which also restricted light. The garden contained a number of raised planters, however these were empty and these would benefit from some colourful plants to enhance the garden area. One resident commented that they felt the garden patio might be used more if its appearance was improved. The garden area although outside is a no smoking area and the inspector received a comment from one resident who would prefer to be able to smoke outside in the large garden. The home has 2 laundry areas; one contains 2 washing machines and 2 tumble driers for use by residents who wish to do their own laundry. The other laundry area is used by staff and also contains 2 washing machines and 2 tumble driers. All staff at the home has received training in infection control and suitable protective clothing is available. John Darling Mall DS0000040678.V347425.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 & 35 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Staff employed at the home have the competencies and qualifications required to meet residents needs. Staffing levels meet the care needs of residents, however the home needs to review the staffing levels to enable residents to be supported out in the community. Residents are protected by the home’s staff recruitment procedures and service users are supported by trained staff. EVIDENCE: The home employs 20 permanent care staff with 13 having achieved a minimum of NVQ leve2 and 4 who are working towards this qualification. The inspector discussed staffing levels with the homes manager and she explained that with the numbers of residents changing each week and the level of needs also changing, the staffing levels were kept constantly kept under review. The regular staff are backed up by bank workers and also agency staff. Staff who completed questionnaires felt that staffing levels were sufficient to meet the care needs of residents but staffing numbers often restricted the opportunities for residents to go out into the community if they are not able to go out independently. The manager understood that this was not ideal but she is trying to improve the situation. On the day of the inspection there were 5 care John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 21 staff on duty as well as the manager and deputy and there were also 2 domestic staff members, 1 laundry assistant and 1 cook. Recruitment records were inspected for 3 staff members and these were found to contain all of the required information including application form, interview notes, driving licence, CRB/POVA, photo and passport. Recruitment is carried out by the homes manager with support from the organisation human resource department and there are clear policies regarding diversity and equality that are followed when recruiting new staff. Training records were inspected and staff at the home have individual performance plans, which set out their training needs. There is a set induction, which is based on skills for care and this is a 6 day induction programme, 2 days are dedicated to moving and handling and statutory training includes: fire, moving and handling, adult protection, first aid, values of care and support with dignity. There is also an in house induction, which covers specific issues within John Darling Mall. Hampshire County Council has a training co-ordinator who produces a learning and development guide and staff can access training through their line manager. Staff spoken to and those who completed questionnaires said that the training provided was good and the AQAA also gave details of a thorough training and induction process. Staff files seen contained training certificates for course completed and these included: epilepsy, NVQ, stroke care, health and safety, ethnicity, mini bus driving, continence management advocacy and self-advocacy. John Darling Mall DS0000040678.V347425.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and the registered manager is experienced and competent to run the home. Residents, relatives and other interested parties are consulted about the running of the home and there are policies and procedures in place. The health safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager has been running the home for over 5 years and has both the experience and qualifications to manage the home. The AQAA was well completed and staff said that the management staff were approachable and provided good support. The manager has developed an effective quality assurance system and residents are consulted as much as possible on how the home is meeting its aims and objectives. Each resident who leaves after a respite stay is invited to John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 23 complete a quality questionnaire and this is used to help improve the service. Regular monthly regulation 26 visits are carried out and this is another opportunity to see how the home is performing. The manager has regular conversations with relatives and staff meetings and supervision also give staff the opportunity to express their views. The home currently does not hold residents meetings and this was discussed with the homes manager who informed the inspector that she will implement these shortly to help residents to be more involved in the day to day running of the service and this will be beneficial to residents There are policies and procedures in place to ensure safe working practices in the home and all care staff undertake statutory training, which includes health and safety, food hygiene, first aid and manual handling. The home has an acceptable system for recording any accidents and the fire logbook was inspected and all required testing had been carried out. Certificates were available for annual testing of equipment and services. Fire equipment was last tested in Mat 2007, Gas equipment tested in August 2007, hoists and safety equipment was tested in September 2007 and Private electrical equipment was tested in August 2007 John Darling Mall DS0000040678.V347425.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 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X John Darling Mall DS0000040678.V347425.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. 1. Standard YA6 Regulation 15 2 (b) Requirement The registered manager must ensure that care plans are kept under review to ensure that service users needs in respect of their health and welfare are met by the home. Timescale for action 31/12/07 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. 2 Refer to Standard YA13 YA39 Good Practice Recommendations It was recommended that the home investigate the possibility of employing a dedicated activities co-ordinator to improve the recreational opportunities for residents. At present the home does not hold residents meetings and it would be beneficial to both the home and residents if these were implemented to help residents to be more involved in the day to day running of the service. John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 John Darling Mall DS0000040678.V347425.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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