Inspection on 24/06/04 for Magenta

Care Homes For Adults (18 ­ 65)Magenta31 St John`s Church Road Folkestone Kent CT19 5BHAnnounced Inspection24th June 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Magenta Address 31 St John`s Church Road, Folkestone, Kent, CT19 5BH Email address Tel No: 01303 254904 Fax No:Name of registered provider(s)/company (if applicable) Blythson Limited Name of Registered Manager (if applicable) Mr Paul Ellenworth Farquhar Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number H050000397 Date first registeredDate of latest registration certificate 31st March 2003Was the Home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionNO 04/11/03If Yes refer to Part CMagentaPage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 324th June 2004 09:30 am Wendy MillsID Code100453Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMagentaPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementMagentaPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Magenta. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.MagentaPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Magenta is a residential Home providing care and proactive support for three people with a learning disability and challenging behaviour. It is a large, late Victorian town house situated close to Folkestone town centre and local amenities. The Service Users participate in a wide range of meaningful activities. The Home maintains a consistent approach to the management of challenging behaviour and has been inspected in accordance with the Care Standards Act 2000 for the past two years.MagentaPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The Inspector, Wendy Mills was accompanied on this inspection by Laura Culkin, Business Administrator, CSCI and was assisted by Kerri Castle, the newly appointed Manager for the Home. Ms Castles application for registration with the CSCI is currently in process. The Inspector found that the Home meets, and in some areas, exceeds the National Minimum Standards. One of the registered providers was also available to speak to the Inspector on the day of inspection. The Inspector was only able to talk to one Service User at this inspection. The environment is Homely and reflects the personalities of the Service Users. It is spacious, well furnished, and has recently been redecorated. The Inspector found that the Home continues to maintain good standards of care practice and to develop new ways in which to support the Service Users in maximising their abilities. There is a proactive staff training programme, an exemplary behaviour management programme, good integration within the local community and an effective communications structure. Since the last inspection plans are being made for a supported living project that will enable some Service Users to move on from the Home to a more independent environment. The Home and the Company are commended for the way in which they care for the Service Users and promote their independence.MagentaPage 6 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)MagentaPage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.MagentaPage 8 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with Service Users Individual discussion with Service Users Group discussion with staff Individual discussion with staff Discussion with management Service User survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of Service Users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding Managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO YES NA YES NO YES NO YES YES YES YES NO YES NO YES 1 3 0 NO NO YES YES 5 0 24/06/04 09.30 6MagentaPage 9 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.MagentaPage 10 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective Service Users have the information they need to make an informed choice about where to live. Prospective Service Users individual aspirations and needs are assessed. Prospective Service Users know that the Home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the Home, its services and facilities and terms and conditions; and provides each Service User with a Service Users guide to the Home. The statement of purpose should clearly set out the physical environmental standards met by the Home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the Service Users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The Home has a comprehensive statement of purpose that is linked to the companys business plan. The statement of purpose has recently been revised to reflect the changes in Manager. There is a Service User guide. Tracking from statement of purpose through policies, procedures, training records and care plans demonstrated the statement of purpose continues to be used as a working document for the Home.Standard 2 (2.1 ­ 2.8) New Service Users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective Service User, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Written policies, protocols are in place. There is a very thorough assessment and admissions procedure that the Inspector has considered in depth at previous inspections. No new Service Users have been admitted since the last inspection.MagentaPage 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. 3 Key findings/Evidence Standard met? There is an extensive staff-training programme. Inspection of care plans and other documentation confirmed that all appropriate professional advice is sought on behalf of the Service Users.Standard 4 (4.1 - 4.5) The Registered Manager invites prospective Service Users to visit the Home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? All the Service Users were thoroughly assessed prior to being offered a place in the Home. Appropriate trial periods were undertaken On the day of inspection the Inspector was able to meet with the family of a prospective Service User and the prospective Service User. They confirmed that they had been made welcome and were enjoying their visit.Standard 5 (5.1 - 5.5) The Registered Manager develops and agrees with each prospective Service User a written and costed contract/statement of terms and conditions between the Home and the Service User. 3 Key findings/Evidence Standard met? All the Service Users have a statement of terms and conditions to which they have indicated their approval and agreement.MagentaPage 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The Registered Manager develops and agrees with each Service User an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the Home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? There is an excellent system of assessment and care planning that fully involves the Service Users, their relatives and supporters and key members of staff. Appropriate risk assessments are in placeStandard 7 (7.1 ­ 7.7) Staff respect Service Users right to make decisions, and that right is limited only through the assessment process, involving the Service User, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Documentation confirms that the Service Users have been involved in the care planning process. In addition, the regular reports that the Inspector receives from the Home confirms that the decision making process is structured and integrated into the care plans and daily life of the Service Users.MagentaPage 13 Standard 8 (8.1 ­ 8.5) The Registered Manager ensures that Service Users are offered opportunities to participate in the day to day running of the Home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The Service Users are encouraged to participate in the day-to-day running of the Home, making choices and agreements about the household chores they undertake. Regular house meetings are held.Standard 9 (9.1 ­ 9.4) Staff enable Service Users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the Service Users individual Plan and of the Homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? There is a risk management policy. Comprehensive and user-friendly risk assessments are in place. There are regular reviews. Documentation confirms that good explanation and information is given to the Service Users about the risks they may wish to take.Standard 10 (10.1 ­ 10.6). Staff respect information given by Service Users in confidence, and handle information about Service Users in accordance with the Homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the Service User. 3 Key findings/Evidence Standard met? There is a confidentiality policy and all staff sign a confidentiality agreement. The need for confidentiality features prominently on the induction programme and staff confirmed that they understand the meaning and implication of confidentiality requirements. All documentation was stored appropriately.MagentaPage 14 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable Service Users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 4 Key findings/Evidence Standard met? The Service Users are encouraged to participate in the life of the local community and access various clubs, swimming and leisure facilities amongst other activities. The Manager has developed a computer-generated chart that gives immediate visual feedback to the Service Users about the level of their participation in activities. All the Service Users have work and/or college placements. The Home has its own transport but also encourages the Service Users to use public transport to promote independence. Relatives and friends are encouraged to visit the Home. Currently the Company is developing an independent living facility and it is hoped that some of the Service Users may soon move on to live more independently. The Company and the Home are commended for their foresight in planning the next stage of the Service Users progress towards full independence. The Manager is commended for her innovative work in developing a means of visual feedback for the Service Users. Standard 12 (12.1 ­ 12.6) Staff help Service Users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? The Home makes use of all available opportunities. It continues to actively seek out possible college and work placements.MagentaPage 15 Standard 13 (13.1 ­ 13.5) Staff support Service Users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The Service Users are encouraged to participate in the local community. There is a nearby church and club for young people that some Service Users attend.Standard 14 (14.1 ­ 14.6) Staff ensure that Service Users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? There is a wide range of leisure activities on offer and this is reflected in the care plans.Standard 15 (15.1 ­ 15.5) Staff support Service Users to maintain family links and friendships inside and outside the Home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The maintenance of family links is both encouraged and supported. There is a risk management structure for this and the way in which communication with families is noted in the care plans. Records are kept in respect of all family contact.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The Service Users are encouraged to become as independent as possible and the Inspector noted that considerable progress has been made in the way in which the Service Users take responsibility for their own lives. They contribute to the household chores, make meals and help with the shopping.MagentaPage 16 Standard 17 (17.1 ­ 17.9) The registered person promotes Service Users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The Service Users are involved in menu planning and are encouraged to make healthy choices about the food they prepare and eat. Mealtimes are flexible to fit in with the various activities of the Service Users. There was an ample supply of fresh fruit and vegetables on the day of inspection. The Home has a spacious and well-furnished dining room.MagentaPage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 Homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise Service Users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? There are clear policies and procedures in respect of privacy and dignity. Training in this aspect of care is given on induction and frequent reminders are given both at formal training sessions and at staff meetings. The Manager told the Inspector that any encouragement required for the maintenance of personal hygiene is given in a discreet and sensitive manner. Service Users can have keys to their rooms and lockable cash boxes if they so choose. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of Service Users are assessed and recognised and that procedures are in place to address them. No. of incidents where Service Users have been taken to Accident & Emergency during last 12 months No. of Service Users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? The Service Users are all registered with a local GP and dentist. Other health services are accessed as required.MagentaPage 18 Standard 20 (20.1 ­ 20.14) The Registered Manager and staff encourage and support Service Users to retain, administer and control their own medication, within a risk management framework, and comply with the Homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? There is a comprehensive policy and procedure for the administration of medication. All medication was seen to be stored appropriately and records were seen to be in order.Standard 21 (21.1 ­ 21.8) The Registered Manager and staff deal with the ageing, illness and death of a Service User with sensitivity and respect. 3 Key findings/Evidence Standard met? The Home has a policy in respect of the illness and death of a Service User. The Registered Manager stated that extra staff would be used, if necessary, in the event of a Service User suffering a terminal illness. Arrangements would be made to support staff should this situation arise.MagentaPage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service Users feel their views are listened to and acted on. Service Users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that Service Users know how and to whom to complain. No. of complaints made to the Home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3 Key findings/Evidence Standard met? The Home has a comprehensive complaints policy. There is also a simplified induction pack that contains information about dealing with complaints. Induction training includes the policies and procedures for dealing with complaints. Day to day concerns are noted and dealt with as they arise.MagentaPage 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that Service Users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The Home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX0 Key findings/Evidence Standard met? The Home has an adult protection procedure and has developed a specific information file for adult protection. The company is proactive in its approach to staff training in this area. Recruitment processes are rigorous and there is a staffing structure that provides good levels of on-the-job supervision. There is a six-month probationary period for all staff.MagentaPage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The Homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet Service Users individual and collective needs in a comfortable and Homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The Home is spacious, well decorated and comfortable. All areas were clean and hygienic on the day of inspection. There are weekly and monthly safety check schedules that are signed off as per the health and safety policy for the Home. The owner makes visits in accordance with Regulation 26 and the CSCI receives regular written reports.MagentaPage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each Service User with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing Homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Standard met. YES NO NO 3 0 0 0 Standard met? 3 3 00 0 0 0MagentaPage 23 Standard 26 (26.1 ­ 26.4) The registered person provides each Service User with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? All bedrooms are spacious, light and airy. All bedrooms are personalised to reflect the taste of each Service User. The bedrooms are well decorated and furnished. The Service Users are encouraged to personalise their own rooms and can have keys to their rooms, subject to risk assessment.Standard 27 (27.1 ­ 27.6) The registered person provides Service Users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? There is a large bathroom and a downstairs toilet. All toilet and bathroom facilities were clean and hygienic and offered ample privacy.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is a large lounge, spacious dining room, comfortable breakfast room and small kitchen. All areas were well maintained and decorated. Outside there is a small courtyard garden that is safe and enclosed.MagentaPage 24 Standard 29 (29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the Homes stated purpose and the individually assessed needs of all Service Users. 9 Key findings/Evidence Standard met? No environmental adaptations are necessary within the Home at present.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the Home. 3 Key findings/Evidence Standard met? All areas of the Home were very clean on the day of inspection. The Home was free from any offensive odours.MagentaPage 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 Homes 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.Standard 31 (31.1 ­ 31.7) The Registered Manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? There are clear definitions of job roles and interviews with staff showed that they understand their individual roles and responsibilities. Job descriptions are comprehensive and up to date. Staff supervision and appraisal take place on a regular basis with training needs being identified through this process. There is a rigorous recruitment process and procedure. The company has registered for the Investors in People Award; in addition, it operates a bonus scheme for staff that encourages innovation and good practice.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet Service Users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? There is a high level of staffing and a structure that ensures the necessary level of supervision.MagentaPage 26 Standard 33 (33.1 ­ 33.11) The Home has an effective staff team with sufficient numbers and complementary skills to support Service Users assessed needs at all times. Staff numbers/hours relating to the needs of Service Users are based on guidance recommended by the Department of Health. Personal Care No. Service Users High needs No. Service Users Medium needs No. Service Users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 1 2 0 170 3 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 210 Nursing 0 0 0103 Key findings/Evidence Standard met? There is a high level of staffing that reflects the needs of the Service Users. As the level of need for support can vary considerably from day to day staffing levels allow for flexibility. In addition there is a good mix of skills amongst the staff. Staffing level calculations are based on the assessed needs of the individual Service Users and are adjusted when additional need indicates. The Home already achieves the target of fifty percent or above of all staff qualified to NVQ level II or above. In addition, one member of staff is currently undertaking NVQ level III. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. 3 Key findings/Evidence Standard met? There is a rigorous recruitment policy and procedure. Inspection of staff files confirmed that these policies and procedures are followed and that the required checks are made on all new staff.MagentaPage 27 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the Home and meet the changing needs of Service Users. 3 Key findings/Evidence Standard met? The Home has a training and development plan and a structured induction programme. The staff training and development programme was tracked through from the statement of purpose, to the policies and procedures, appraisal, supervision and training records. A good level of appropriate training was noted. Staff confirmed that they are given the information, training and support necessary to carry out their jobs effectively. Training programmes and courses are linked to the needs of the Service Users. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? There are regular staff meetings, one-to-one supervision, appraisals and on-the job supervision. Staff providing supervision have received appropriate training. Supervision records are maintained to an agreed format. Staff are encouraged to put forward new ideas to improve the service and to record any concerns in an open and non-discriminatory way.MagentaPage 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 Homes policies and procedures. Service Users rights and best interests are safeguarded by the Homes 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.Standard 37 (37.1 ­ 37.4) The Registered Manager is qualified, competent and experienced to run the Home and meet its stated purpose, aims and objectives. Registered Manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The Manager has several years experience in care and is currently undertaking the NVQ level IV. In addition, she has maintained a continuing professional development portfolio. She has worked at the Home as deputy Manager for some time and has a clear understanding of the needs of the Service Users. Staff confirmed that she is approachable and that they have confidence in her ability. Her application for registration with the CSCI is currently in progress. Conversation with the Manager confirmed that she has a good understanding of the Care Standards Act 2000 and its implications. In addition, she is conversant in the management of challenging behaviour. Standard 38 (38.1 ­ 38.6) The management approach of the Home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Manager was observed to demonstrate good leadership skills and to communicate well with staff. There are good written and verbal communications systems in place. Regular meetings take place at all levels and the ethos, policies and procedures of the Home encourage staff to speak out if they have any concerns. There is a bonus scheme that rewards commitment and good practice. The Home has an equal opportunities policy and all staff are aware of its implications. Staff were observed to speak to Service Users with respect and to include them in conversations about their lives and aspirationsMagentaPage 29 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users, are in place to measure success in achieving the aims, objectives and statement of purpose of the Home. 3 Key findings/Evidence Standard met? There are excellent quality-monitoring systems in place both for environmental and practice issues. Views of the Service Users are sought via house meetings and questionnaires. Regular contact is maintained with relatives, seeking their views on the progress of the Home. All policies are reviewed regularly and the Inspector noted that the Manager has undertaken a policy review since taking up her new post.Standards 40 (40.1 ­ 40.6) The Homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The Home has a comprehensive range of policies and procedures that are reviewed regularly. The Manager and the registered providers keep up-to-date with current legislation and codes of practice and ensure that any change or innovation is included in the documents. Staff and management meetings, in which the views of those present are sought, also inform these policies and procedures.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of Service Users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records are stored securely and appropriately and the Service Users (and/or their advocates) understand their rights in connection with access to their records and are involved in the care planning and review process.MagentaPage 30 Standard 42 (42.1 ­ 42.9) The Registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. 3 Key findings/Evidence Standard met? There is a comprehensive range of health and safety policies. There is a regular monitoring process for all health and safety issues. Records inspected confirmed that all required checks have been carried out and signed off. Appropriate risk assessments are in place. No health and safety hazards were noted on this inspection.Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the Home) ensures the effectiveness, financial viability and accountability of the Home. 3 Key findings/Evidence Standard met? The registered provider stated that the company is financially viable.MagentaPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorWendy MillsSignature Wendy Mills Signature SignatureRegulation Manager Suzie Burden Date 22/09/04MagentaPage 32 Public reports It should be noted that all CSCI inspection reports are public documents.MagentaPage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 24th June 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Magenta Page 34 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by n/a, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: No response received at point of publicationYESMagentaPage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Magenta confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Magenta am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.MagentaPage 36 Magenta / 24th June 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000023236.V154173.R01© This report may only be used in its entirety. 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