Inspection on 04/05/07 for Mallow Crescent (25-30)

This inspection was carried out on 4th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mallow Crescent (25-30) 19/10/05

Mallow Crescent (25-30) 09/06/05

Mallow Crescent (25-30) 15/12/04

Mallow Crescent (25-30) 05/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Mallow Crescent (25-30) 25-30 Mallow Crescent Guildford Surrey GU4 7BU Lead Inspector Christine Bowman Unannounced Inspection 4th May 2007 11:30 Mallow Crescent (25-30) DS0000034879.V336462.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 Mallow Crescent (25-30) DS0000034879.V336462.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. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mallow Crescent (25-30) Address 25-30 Mallow Crescent Guildford Surrey GU4 7BU 01483 455879 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) rosie.broomer@surreycc.gov.uk South West Surrey Adults & Community Care Services Rosemary Ellen Broomer Care Home 35 Category(ies) of Learning disability (35), Physical disability (1) registration, with number of places Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Accommodation and services may be provided to named persons aged 65 years and over with prior written agreement of the CSCI. Respite care may be provided to a maximum of 6 persons at any one time, these persons should be grouped into the same unit, House 28 To accommodate one service user with a Physical Disability. Date of last inspection 19th October 2005 Brief Description of the Service: 25-30 Mallow Crescent consists of six purpose built houses situated in Burpham. The houses are set at the end of a crescent in a quiet residential area, which is well kept. Each house has a front garden and a medium sized garden at the rear of the house. There is adequate car parking for several cars at the front or side of each house. Five of the houses are for long-term placements, with the sixth house offering respite care for five places. Each house has a large and airy lounge/dining room, appropriately furnished, with access to the rear garden. An open plan kitchen is adjacent to the dining room. All the bedrooms are single occupancy and are nicely decorated and meet the needs of the residents. The home is registered to accommodate thirty-five people with a learning disability. The fees are approximately £65 per week depending on the level of the resident’s savings. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 11.30 am and ending at 17.30 pm and was undertaken by Ms Christine Bowman, regulation inspector. Initially, the houses were very quiet as most residents were not home, but were out in the community, and house leaders and other support staff were completing administration duties. The Team Leader, who is also the registered manager of the site, Ms Rosie Broomer was not on duty but kindly came in to assist with the inspection process in the afternoon. An Assistant Team Manager, who oversees the organisation of three of the houses, was interviewed, two house leaders were interviewed and the accommodation was sampled by a complete tour of one house and a partial tour of a second house. A number of residents were spoken with and observed as they prepared for tea and one resident spoke to the inspector at length and allowed their bedroom to be viewed. Seven residents completed comment cards and three care managers, one health professional and one relative also returned completed comment cards. One relative was interviewed on the telephone and one resident spoke on the telephone to the inspector. All the key inspection standards for Younger Adults were assessed. The Statement of Purpose, the Service User Guide, assessment documentation, care plans, risk assessments, medication records, minutes of resident’s meetings and a sample of quality assurance questionnaires and other monitoring forms were viewed. Staff personnel files were sampled and recruitment documentation viewed Individual induction and training records were also sampled. Policies and procedures, menus and health and safety records were viewed. The inspector would like to thank the management, the staff and residents of Mallow Crescent for their assistance and hospitality on the day of the site visit and those who completed comment cards or spoke to the inspector on the telephone for their contribution to this report. What the service does well: The service is very good at ensuring that the information available to residents is in a format, which they are able to understand. Important information such as the Service User Guide, the complaints procedure and the menu were available in a symbolic format to facilitate the resident’s understanding. Person-centred plans, which residents had been supported to compile, were well illustrated with photographs, symbols and drawings. The service is very good at supporting the residents to achieve their full potential, by enabling them to develop the life-skills necessary to become as Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 6 independent as their individual potential allows them to be. The home had a ‘person centred’ style of care planning, which meant that the care and support provided was based on what the service user wanted and needed rather than what was easier to deliver, and they were involved as fully as possible in the planning of their care. The home had strong links with the local community and made good use of the facilities and resources available. Residents had a full programme of activities based on their individual needs and choices. Internal complaints/concerns were responded to in a very appropriate way and the complaints procedure was very clear in encouraging residents to ‘speak out’. The Team manager of Mallow Crescent followed up complaints by sending a letter to the complainant to confirm they were happy with the result. The service is well organized and led by a manager, who is well qualified, experienced and empowering to the staff and the residents. A relative commented, ‘we consider the management of Mallow Crescent to be excellent. The staff are cheerful and loyal and the home is consistently staffed by a familiar team, which is reassuring for users and carers.’ Some comments from care and health care professional, when asked what they thought the service was good at, included, ‘effective communication – they look towards the development of services and individuals,’ and ‘They promote independence and have a multi-disciplinary approach’. A resident asked to speak to the inspector and the only thing they wanted to say was, ‘ I really love it here’ What has improved since the last inspection? License agreements were in place for residents whose records were sampled in order to protect their rights. A fire risk assessment had been undertaken on each house to protect the residents from the possibility of the outbreak of fire. The water had been tested for Legionella in the houses sampled to protect the residents from the possibility of contracting the disease. Shelving had been put in place in the cupboards under the stairs of the houses sampled to prevent health and safety hazards to the residents and staff. Hygiene practices had been improved by the provision of paper towel and liquid soap dispensers in bathrooms and toilet areas. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 8 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. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 9 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 Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 10 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): Standard 1,2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Sufficient information is available in appropriate formats to enable residents to make choices about the suitability of the service to meet their needs. Prospective resident’s individual needs and aspirations are assessed to ensure the home is able to meet them. EVIDENCE: The Statement of Purpose and Service User Guide for 26 Mallow Crescent had been reviewed in July 2006 and was well illustrated with colourful photographs of the exterior and interior of the home, showing living and dining areas, bedrooms and examples of meal choices. There was a map of the area of Guildford in which Mallow Crescent is situated and a diagram showing the local community facilities in relation to the location of the homes including bus stops, the local shops, the post office, the video shop, the bank and the local leisure centre, pubs and restaurants. A colourful design of the estate by a resident had been included showing the location of the houses in relation to each other from numbers 25-30. ‘The six homes have this information displayed in the entrance hall’, a house leader stated, ‘and the information reflects the individuality of the houses.’ Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 11 In addition to the well-documented and illustrated Statement of Purpose and Service User Guide, a video had been professionally produced, which the residents had assisted with by taking the acting roles. The video portrays ‘a day in the life of a resident at Mallow Crescent’ and is used to introduce new residents and staff to the ethos of the home. ‘Care management assessments are always sought when a referral is made’, a house leader stated. Assessment documentation viewed on resident’s files was comprehensive. Medical history was explored, mobility, sensory needs, personal care preferences, religious and cultural needs, interests and likes and dislikes. Residents were also assessed with respect to independence skills covering communication, domestic skills, independence in the community, selfmotivation, personal care and behaviour. One house specialises in offering short breaks to residents and a very satisfied resident described his introduction to the home, ‘I went to tea there with my mum and dad and I had a look around and I liked it. I liked the staff too. They asked if I wanted to come in the evening for a meal with every one, I did. Then they invited me to stay the night. It was great, it’s my holiday home.’ Standard 5 was not fully assessed but a requirement had been made at a previous site visit that all residents must have a contract. The sample of resident’s files viewed on the day of the site visit included license agreements. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 12 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): Standards 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ needs and personal goals are reflected in their individual plans, they are able to make decisions about their lives and are consulted with respect to all aspects of life in the home and participate in the running of the home. EVIDENCE: Resident’s files sampled contained person-centred plans, which had been compiled with them. They were illustrated with photographs and drawings of their favourite activities, and hobbies, holidays and important people in their lives. The resident’s aspirations and matters, which were important to them, were recorded. Lead workers were allocated to support the residents. Individual plans were written in the first person, were very detailed and included personal care, domestic skills, cooking, finances, communication, correspondence, safety in the community, shopping, leisure activities, group living, personal relationships, health, education, employment, choice/consent, spiritual needs, special wishes, keys, risk assessments and self-medication. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 13 All the self-help, life and social skills, which a person might need to live an independent life, were set out in relation to what the resident had already achieved, what they needed support with in order to achieve, what they would like to learn, the risks involved, positive outcomes to the individual of taking the risk and action taken to minimise the risk. Each section of the plan was signed and dated by the resident to confirm their involvement and the lead worker and the assistant team manager had also signed them. All the care plans viewed had been reviewed within the last six months, which confirmed the resident’s changing needs had been addressed and that plans were in place to address them. Specific targets taken from the goals recorded on the person-centred plan, the health action plan and the individual plan were recorded on a separate sheet to clarify what the resident was working on between reviews and to inform the staff. Minutes of residents’ meetings were viewed confirming that they were consulted with respect to the running of the homes. Resident were enabled to participate in the meetings, which records confirmed, took place monthly and put forward ideas for improving the service by adding items to a ‘wish list’, which was then discussed in the team meetings. In this way residents made choices about activities, holidays, menus and purchasing new items for the house. One resident had put on the wish list that he would like to go to a circus. Records confirmed that tickets were purchased and the resident was accompanied by two friends to see the ‘Moscow State Circus.’ Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in a wide range of activities in the community, are supported to maintain personal relationships, and have their rights and responsibilities recognised in their daily lives. EVIDENCE: The crescent in which the homes were located was like any other small estate, each of the six houses having their own front door, garden and parking areas. It was very quiet in the late morning when the inspector arrived because almost all the residents were engaged in various daily activities, including work and classes at a local adult education and day centres. Some residents were able to access the community independently, but the majority travelled to the day centre by bus. One resident was at home in the house designated for short breaks. They were happily relaxing in their bedroom and pleased that arriving at the home on Thursday meant having some time to listen to music and make plans for the weekend. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 15 Other residents started to return home between 3.30 and 4.30 pm and the atmosphere changed and became lively and purposeful as residents chatted to the staff about the events of the day and preparations for tea began. Twenty of the thirty permanent residents maintained their own benefits books, the Team Leader stated, and five handle their own financial affairs with support. Surrey County Council at County Hall collected benefits on behalf of residents and credited their accounts weekly, the manager did not act as appointee for handling financial affairs. Care plans showed that every effort was made to support residents to handle money safely. Residents were supported to maintain relationships with family and friends. The houses were all equipped with pay telephones for resident’s use and many residents had regular contact with their families a staff member informed the inspector. The parent of a resident who stays for short breaks stated, ‘the care home always helps my son to keep in touch with me. He is assisted with the pay phone –calling home when he wants to. He is usually so involved that he rarely ’phones. His first question when we collect him is, ‘when can I come here again?’ Holidays were arranged for individual residents and small groups. Photographs were viewed of previous trips displayed in frames on the walls of the homes and in the resident’s person-centred plans. Leisure activities engaged in by the residents were listed in the pre-inspection data and the number of separate trips was in excess on 70, including trips out on public transport including trains to many various destinations. Visits included were to garden centres and coffee shops, country walks, sports events, the cinema, the theatre, discos, nightclubs, karaoke night at the pub, seaside trips and visits to conventional entertainment centres such as Chessington World of Adventure, The Bluebell Steam Railway, Blue Reef Aquarium, Bockett’s Farm and Buckingham Palace. As the inspector was leaving, tea was being prepared and some residents were setting the table and assisting with the food preparation, others were relaxing and enjoying a television programme. Quiche and new potatoes with peas or beans were on the menu. Pictorial menus were provided to help residents to make choices. The house leader stated that, ‘special dietary needs were catered for and also the needs of ethnic minority groups could be catered for when the need arose.’ Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 16 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): Standards 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 support according to their needs and wishes and positive action is taken with regard to health issues. EVIDENCE: A house leader confirmed that residents could choose to be escorted by a male or female member of staff when keeping personal appointments in the community and that the practise was always to ensure a female staff member administered personal care to female residents, especially if this was of an intimate nature. All residents had a lead worker to provide consistency and continuity of support. Comment from a visiting care manager, ‘I observe the staff treating all the residents with respect and kindness.’ All the residents, whose files were inspected, had health action plans in place, which stated clearly what their health issues were and what action was required to ensure their health needs were met. All permanent residents were registered with a local General Practitioner and specialist health professionals based at Greenlaws were accessed through the GP practice including psychologists, community nurses and therapists. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 17 Health care appointments were recorded. A parent commented, ‘my son’s disabilities require close monitoring and a professional response. We have found the staff make an excellent and caring response.’ A clear medication policy was in place to instruct the staff. Risk assessments had been carried out with respect to the self-administration of medication and a locked drawer in the resident’s bedroom was provided to store medication safely. However, the majority of residents required support with their medication administration. The medication was blister-packed at the local pharmacy. For homely remedies, there was a letter from the GP to confirm their agreement to their administration to individual residents. The storage of medication was satisfactory. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 18 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): Standards 22,23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clear guidance in an appropriate format and a good support system encourage residents to express their views. Well-informed staff protect residents from harm. EVIDENCE: Residents’ meetings take place in the houses every month and minutes of the meetings confirmed that the views of residents were listened to and acted upon. Examples viewed showed that residents offered ideas in meetings about activities they wished to be involved in, trips they would like to make, holidays they would like to take and of improvements to the home. All suggestions were included on a ‘wish list’, which was discussed in team meetings when resources were allocated. Records confirmed that suggestions put forward were acted upon. The resident’s complaints procedure was in symbolic format with words to facilitate understanding for everyone. It was very clear in encouraging residents to ‘speak out’. The complaints form was easy to complete and contained tick boxes with a range of choices and symbols to describe them. Widget symbols encouraged residents to ask for help in writing on the form if there was something they wished to add. Confirmation that the system worked had resulted in some concerns, which had been taken seriously and resolved to the satisfaction of the complainants. One incident had taken place at the Lockwood Day centre and the letter confirming the action taken had been sent from the team manager to the resident in widget and words to reassure them. The Team manager of Mallow Crescent had followed up Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 19 complaints by sending a second letter to the complainant to confirm they were happy with the result, which gives the choice of circling, ‘I am happy’, or ‘I am sad please help me’. A care professional commented, ‘The care service has always responded appropriately if I or the person using the service has raised concerns’. 100 of the residents who completed comment cards knew who to speak to if they were not happy, they comment that they would speak to the, ‘staff at home or Lockwood or to their key worker. Five complaints/concerns had been recorded and dealt with appropriately by the team leader and these had been forwarded to the CSCI. No complaints concerning the home had been received independently. Compliments were also included in the log, a care manager had commented, ‘I have often visited Mallow to see my client, and noted the care and affection she received,’ and the service manager had passed on a commendation from a parent who had appreciated support at a time of crisis and sent her thanks to the team for helping them to remain together. Staff confirmed they were aware of the local authority Safeguarding Adults Procedure, a copy of which was available in the office. Each house had a copy the local procedure based on the local authority guidance. Training had been regularly up-dated to ensure the residents were protected from harm. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 20 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): Standards 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable, clean and safe environment, which meets their needs. EVIDENCE: The six homes were purpose built and fulfilled the collective needs of the residents in a homely, comfortable and safe way. A full tour of one house and a partial tour of a second house were undertaken. The shared accommodation consisted of a through kitchen/ dining room / sitting room and either one or two quiet rooms. One house had a conservatory and all had good-sized gardens, which were well kept. A house leader stated that some of the residents enjoyed gardening and herbs were grown and used for cooking. All the houses were equipped with an office and a fold-down bed was provided for the staff for sleeping-in purposes. One house was specifically for short-term breaks. The homes accommodated five/six residents in single rooms, some of Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 21 the bedrooms were on the ground floor and suitable for wheel-chair users. The accommodation was well furnished, comfortable, clean and bright. There were separate laundry rooms with impermeable floors and hand washing facilities. Infection control and HIV awareness was one of the mandatory training courses for the staff, which had been regularly updated. The homes clean and smelt fresh. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 22 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): Standards 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Safe recruitment practices, which residents contribute to, and appropriate induction, mandatory and specialist training prepare the staff for the supportive role. EVIDENCE: A comment made by a resident with respect to the staff stated, ‘the staff are lovely to me and very kind. They are helpful. They always try to take me where I want to go.’ Observations of the staff working with the residents throughout the site visit confirmed that relationships were respectful and that residents were listened to and their wishes acted upon. There was a strong commitment to training at Mallow Crescent. Training records showed that many staff had completed National Vocational Qualifications at level 2 and 3 in care, and that new staff were encouraged and supported to complete the qualification, a house leader stated and an NVQ assessor was employed for 18 hours per week to facilitate the process. The Learning Disability Award Framework was followed with respect to induction and foundation units. Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 23 Comment cards completed by care management and health care professionals confirmed the home had formed good relationships with them and one commented, ‘there is very good interaction between the Health team and Mallow,’ and ‘what the care service does well is that it supports each person as an individual – the care is tailored to individual needs very well.’ Staff personnel files sampled confirmed that all the recruitment checks had been completed prior to the offer of a post and the team leader followed the Criminal Record Bureau Guidance with respect to Criminal Record Bureau checks. The team leader informed the inspector that that residents were involved in the recruitment process and an interview form was viewed which had been developed specifically for the residents in picture/symbol format. The residents were invited to attend the interviews and were able to ask the applicants questions. Equal opportunities legislation was adhered to and completed forms retained on file to confirm that the process was fair to all applicants. In addition to the mandatory training, which records confirmed, was regularly updated, the staff were encouraged to access a variety of courses to assist them with the caring role and to meet the needs of the residents. Some of the courses accessed included, Disability Equality, Makaton training, Supporting Adults with Learning Disabilities, Social Care Values and Equality, Autism –the Triad of Impairments and Dementia. A parent commented, ‘the staff are welcoming and always ready to listen and to exchange information. ‘They are cheerful and loyal and the home is consistently staffed by a familiar team, which is reassuring for users and carers.’ Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 24 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): Standards 37,39,42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Enthusiastic, qualified, experienced and efficient management and good internal quality assurance systems, which take into account the views of the residents and inform continuous improvement ensure this service is run in the best interests of those who use it. Policies, procedures and regular monitoring promote the health, safety and welfare of those who use the service and the staff who care for them. EVIDENCE: The Team Leader had completed the Registered Manager’s Award and received her certificate since the previous site visit. From conversations with staff and residents, it was clear that she was highly regarded, and empowering in her role. Feedback was actively sought from the residents and acted upon, as records of residents meetings confirmed. There was a clear management Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 25 structure in place with two Assistant Team Managers each responsible for three of the houses and supporting the staff with regular team meetings and supervision. The house leaders completed a quality assurance monitoring system on all areas each month to ensure that the systems in place were being adhered to for the smooth running of the organisation and the benefit of the residents. Quality assurance questionnaires were sent out annually to relatives, health and care professional and to residents to obtain feedback on the service, to inform future developments and to ensure the best interests of the residents were considered. The home had policies and procedures in place for health and safety. All the necessary safety checks had been undertaken and recorded and copies of safety certificates were held on file. Staff had received training in Health and Safety, Control of Substances Hazardous to Health, Moving and Handling, First Aid, Fire Safety, Food Hygiene and the Protection of Vulnerable Adults Procedures. There was an ongoing programme of maintenance and repair. A relative commented, ‘We consider the management of Mallow Crescent to be excellent.’ Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 26 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 4 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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Mallow Crescent (25-30) DS0000034879.V336462.R01.S.doc Version 5.2 Page 29 - 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. 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