Inspection on 24/11/07 for Mansfield Road Short Stay Unit

This inspection was carried out on 24th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mansfield Road Short Stay Unit 25/11/06

Mansfield Road Short Stay Unit 25/02/06

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Mansfield Road Short Stay Unit 29a Mansfield Road Blackpool Lancashire FY3 7HZ Lead Inspector Mrs Ruth Edgington Unannounced Inspection 24th November 2007 09:15a Mansfield Road Short Stay Unit DS0000064782.V350599.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 Mansfield Road Short Stay Unit DS0000064782.V350599.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. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansfield Road Short Stay Unit Address 29a Mansfield Road Blackpool Lancashire FY3 7HZ 01253 477666 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) Blackpool Borough Council Mrs Barbara Mary Crouch Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered to accommodate a maximum of 4 service users who fall within the following categories: LD (learning disability) PD (physical disability) 25th November 2006 Date of last inspection Brief Description of the Service: Mansfield Road is a purpose built home situated in a residential area and within reach of local amenities and shops. The home can provide accommodation for a maximum of 4 adults who have a learning disability and require respite care (short stay). The period of stay depends on the needs of the individual resident and their relatives. The accommodation consists of two single bedrooms on the first floor and a single bedroom on the ground floor, all of which have en-suite toilet and bathing. There is also a self-contained flat on the ground floor, which can be used for an emergency placement and also to build up skills of service users who wish to return to living independently in the community. In some cases the support given to the service user accommodated in the flat may be from the external agency used by that person. There is also a large lounge, kitchen-dining room and a separate toilet on the ground floor. The home does not have a passenger lift; therefore this is a consideration when assessing the suitability of possible service users. The information contained in the home’s Statement of Purpose/ Service User Guide is included in the information provided to prospective service users and their families. This written information explains the care service that is offered, the management and staff and what the service user can expect if he or she decides to stay at the home. Information received prior to the visit (24/11/07) showed that the fees for an over night stay were £9.55. Mansfield Road Short Stay Unit DS0000064782.V350599.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 undertaken as part of the home’s key Inspection. The visit started at on a Saturday morning and took place over 7.15 hours. This included a visit to the home in Coopers Way, which operates in conjunction with Mansfield Road. Service users are able to stay at either home depending on their needs and the availability of accommodation at that time. The homes are managed by the same manager, deputy and the staff group work between the two homes, depending on which service users are staying at the time. Every year the registered person is asked to provide us with written information about the quality of the service they provide and to make an assessment of the quality of their service. This information, in part, has been used to focus our inspection activity and is included in this report. Comment cards were sent out prior to the visit to a number of service users and their representatives. In total two service users, three relatives and two health care professional, and three members of staff returned these to express their views about the service. On the day of the visit there were two service users being accommodated in the home. As part of the visit a random selection of the service user records, staff records and other relevant documentation were looked at and a tour of the home took place. Discussions took place with the manager, deputy. two staff and two service users. From observations made, comments received and written documentation examined, the information has been put together to produce this report. What the service does well: The registered manager, deputy and the staff group are very committed and work well together to provide a high quality service, which ensures that those using the service enjoy their stay and have all their needs met. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 6 The manager is very responsive when areas for improvement are brought to her attention and works to resolve matters that are within her responsibilities in order that the needs of the service users are met. The relaxed atmosphere in the home provides the environment in which the needs of those using the service can be easily identified and met, individually and as a group. A member of staff commented, “It is lovely atmosphere to work in, relaxed and friendly which ensures the guests have a happy stay”. Evidence was gained that the service users and their families are involved in all aspects of the individuals care and are encouraged to voice their opinions in order that the service continues to be one of quality. One relative spoken to confirmed that they had been able to voice their opinions in relation to diet and this had resulted in menus being produced in order to ensure a healthy, balanced diet, whilst still giving the service users choice. Comments received from a care professional confirmed that the service users and their relatives that they had spoken to were all positive about the service. Both of the service users spoken to during the visit were full of praise for the managers and staff, one said that the staff “Are lovely”. Through observations made and comments received it was evident that the principals of equality and diversity are followed in the care and support given to service users by the managers and staff. One person commented that their relative’s diverse needs were met by staff and that they were assisted to attend activities relating to these needs. Staff spoken to confirmed that they enjoyed their work and felt supported by the manager. One staff member said, “The staff team is very stable and consistent, which means we all get to know our guests well”. Staff training is given priority to ensure that the people who use the service are cared for by an experienced, qualified and competent work force, who can meet the different and changing needs of the service users. What has improved since the last inspection? Improvements have been made in regard to the policies and procedures in the home for the administration of medication. The records have been re-designed and all the required information is now included in one document to ensure an efficient audit throughout the time that service users’ medication is in the home to ensure that their needs have been met. Lockable facilities have been provided for service users who may wish to keep their own medication in order to ensure the safety of the individual and other service users in the home. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 7 All documentation used in the home is continually reviewed and amended where necessary to ensure that the needs of service users continue to be identified and met. A new document named the ‘Transitional Action Plan’ had been devised by the deputy manager to improve the information gained in order to make the service users introduction into the home as smooth as possible. The provision and promotion of a healthy balanced diet has been further developed for the benefit of those using the service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mansfield Road Short Stay Unit DS0000064782.V350599.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 Mansfield Road Short Stay Unit DS0000064782.V350599.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. The admission and assessment procedures are clear to ensure that the prospective service user’s individual needs and aspirations are assessed and can be met. EVIDENCE: The admission procedure for any prospective service user includes a home visit carried out by the manager or deputy and their allocated Link Worker, during which the relevent documentation is completed in order to assess their individual needs and ensure that these can be met. During the individual’s transition every effort is made to arrange introductory visits to the service when their friends and acquaintences are staying at either of the homes. This process enables the managers and staff to look at the needs of the individual and those of the other service users to ensure that everyones needs can be met. The care file belonging to a service user who was in the home at the time of the visit was looked at in detail and was found to contain very comprehensive assessment information, which had been obtained before an admission had taken place. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 10 The deputy manager has devised a new document ‘Transitional Action plan’, which is to be used for all prospective service users. The use of this document is another way in which information can be obtained to ensure that the assessed needs of the service user can be met fully by the service provided. From comments received from staff, both prior and during the visit evidence was gained that they receive sufficient information about individual service users to ensure that the needs of the service users accommodated at any time can be met. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All individuals have a comprehensive plan of care ensuring that staff have clear guidance regarding their needs and aspirations. EVIDENCE: The care file of one service user was looked at in detail with the service user and it was found to contain detailed information in the Guest Profile document and care plan. Information was recorded about their personal, social, and emotional and health needs. The care plan also contained all the relevant information in relation to their individual goals and aspirations, likes and dislikes and help with decision making as required. The level of support and assistance being provided to service user with their decision-making was also recorded. The file also contained risk assessments, which enables the staff to give support in encouraging the service user to maintain their independence. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 12 The service user had an individual Essential Lifestyle Plan compiled with the assistance of the staff member who is their Link Worker and who has the responsibility for liaising with the individual service user and their family once a month to update their file to ensure that their needs continue to be met. Confirmation was gained through talking to the service user that they were involved in all decisions that affected them and were consulted at all times. Evidence was gained that the managers had assessed the very diverse needs of this particular service user and were able to meet these needs. Following each service users stay the staff complete an ‘Information Sharing Booklet’, which gives the family feedback on what sort of a stay the service user had. The document also gives the family the opportunity to make any comments that they have about the service provided. Comments received from a heath care professional confirmed that the service was meeting the needs of the individuals that they had contact with. These comments included; “In my experience the managers and staff have the skills and experience to care for individuals with complex social and health care needs. I have found the service to be person centred and flexible and responsive to a wide variety of care needs”. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16&17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Opportunities for development and community participation are addressed in the care plans, ensuring that people have a lifestyle that meets their individual needs and expectations. EVIDENCE: During the visit discussions took place with the managers and staff on duty and it was very clear that they understood their role in encouraging independence and promoting the residents’ personal development. They recognised the importance of working very closely with the relatives in order that the needs and wishes of the residents are met appropriately. Service users are encouraged to carry on with any pre-arranged activities and to maintain relationships with their family and friends during their stay. This was confirmed through comments made by a relative prior to the visit. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 14 The service users have a range of activities available to them, which included television, music, videos and board games. Staff and service users have compiled an “Out and About” resource file, identifying facilities available within a three-mile radius of the home, which service users can visit and become involved in if they wished to. The service has its own transport, which enabled the service users to get to the different venues much easier. From observations and discussions during the visit evidence was gained that the management team and staff have a clear understanding of equality and diversity and actively promote these principles for the wellbeing of the service users. During the visit a discussion took place between the manager and one service user in regard to a future stay,which coincided with an activity that this individual would not wish to undertake and therefore they were asked what they would prefer to do so that arrangements could be made that would meet their wishes. The two homes in the service operate together and service users can choose which to use depending on availability of rooms. Their choice often is dependent on who is in the home at that time, as they develop friendships with other service users. The relative of one service user commented that the person looked forward to their short stay at Mansfield Road. “They really enjoy being there and the staff are great and helpful” The managers and staff recognised that additional staff would be beneficial to ensure that there was greater flexibility to meet individual needs in relation to activities. In order to ensure that the needs of everyone staying in either home at any one time, staff liaise with each other to arrange suitable activities that will accommodate the needs and wishes of everyone. One staff member stated “ The service offers an excellent home from home service to all the guests. Everyone is treated with respect”. Comments received form a care professional confirmed that they had found that individual service users they had spoken to were very positive about their experience and relatives had also been very positive in the comments. Sample menus were looked at and these confirmed that service users were provided with a varied and healthy diet and a degree of choice. Details of individual preferences and dietary needs were recorded on the service users care plan. Evidence was seen of the information gained to ensure that individual needs are met. One staff member is also the parent of a service user and their input in regard to the provision of health, balanced dietary needs has proved beneficial for all service users. This member of staff was spoken to during the visit to Coopers Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 15 Way and they confirmed that the manager took on board their concerns in regard to their relatives diet and now they felt that the meal provision had improved whilst still enabling choice. Meals times are flexible to meet individual needs and what activities the individual is involved in. At weekends the service users usually have ‘Brunch’ as this enables them to have a lie in if they wish. Both service users spoken to confirmed that they had chosen what they wanted for their tea, which was different in each case. The manager and deputy had previously attended a series of training on diets etc and they are looking into all the staff team undertaking the ‘Essence of Care Nutritional’ training, which looks at healthy lifestyles healthy balanced diets. Routines in the home are very flexible to meet the needs of those accommodated at the time. During the week the time service users get up is in the main dictated by the activities for the day such as attendance at college or day centre, however at weekend the service users dictate their own routine. At the time of the visit there were only two service users staying in the home, one said that they had been up since about 8am and the other said that they had not got up until about 11am. They confirmed that they had told the staff what they wanted to do that evening, which was to watch their favourite programmes on the television. Mansfield Road Short Stay Unit DS0000064782.V350599.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): 18,19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans give clear guidance for the best way to support people so that staff assist in a manner that meets individual need and ensures their protection. EVIDENCE: The service user’s file, which was looked at contained very comprehensive information in regard to their physical and emotional needs and the amount of support that they required. Throughout the visit observation were made of the support that was given to the service users to maximize their privacy, dignity and independence. Evidence was seen to confirm that service users health care needs were met through the continuity of care within their health action plans that have been compiled and agreed by all professionals involved with their package of care. A relative commented ,”Everything is ok keep up the good work”. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 17 At the time of the previous inspection shortfalls in the medication procedures were identified. The policy for administration of medication has been updated and the medication records have been redesigned ensuring that there is a clear audit of all medication brought into the home. A designated member of staff on each shift is responsible for administering medication and all staff undertaking this role have received appropriate training. A monthly audit is undertaken to ensure that the procedures are being followed correctly for the protection of the service users. Facilities for the safe keeping of medication have also been provided for any service users who wishes and is capable of self administering their medication. Evidence of this was seen during the visit and the service user involved indicated that they were very happy with the arrangements in place. Mansfield Road Short Stay Unit DS0000064782.V350599.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): 22&23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to and taken seriously. EVIDENCE: Evidence was seen that the complaints policy and procedure was clear, accessible and met the requirements of the standards. It is very unlikely that the majority of service users would be able to make a formal complaint, but from comments made by the relatives it was clear that they were aware of the procedure and would do so on their behalf. Staff were able to demonstrate that they were aware of individual behaviour changes and gestures that may indicate if a person was not happy and not able to communicate verbally. Staff are given guidance around “ Awareness of Abuse” through the NVQ (National Vocational Qualification) in care and the Learning Disabilities Award Framework (LDAF). There have been no complaints received by us or referrals to POVA (Protection of Vulnerable Adults) in the past twelve months. However information was received prior to the visit in regard to an incident that had occurred and which had been referred to the relevant person in Social Services to look into and the manager was waiting to be notified of the outcome. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 19 Staff spoken to said that they would have no hesitation to pass on information to the managers if they had any concerns. Comments received from relatives were very positive and confirmed that the staff acted upon any concerns that they brought to their attention. Mansfield Road Short Stay Unit DS0000064782.V350599.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): 24 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable, homely and safe environment. EVIDENCE: This home was purpose built and opened in 2005 and met all the requirements of the National Minimum Standards and other relevant agencies. A great deal of time and effort was put into ensuring that the needs of those using the service could be met by the facilities in the home. All bedrooms are for single occupation and have their own bathing and toilet facilities. Aids are provided throughout the home especially in relation to meeting the needs of service users with more complex physical needs. This home does not have a passenger lift, which restricts some service users from using this home and therefore they would in the main use Coopers Way. One service user spoken to said that they preferred Mansfield Road as it was “Cosier”. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 21 A tour of the home found it to be warm, clean and free from any obvious hazards ensuring that the service users had a homely and comfortable environment which to stay. Since the last visit the garden area has been landscaped by a team of volunteers, which included varies service users. This was very much a community project and the home has just been awarded the ‘Environmental Garden Award 2007’ of which everyone is very proud. Mansfield Road Short Stay Unit DS0000064782.V350599.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): 32,34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new staff recruited to the service since the previous inspection visit. However an issue raised during that visit was the lack of evidence in the home to confirm that robust recruitment procedures were being followed. The manager confirmed that this matter had been resolved and now all staff files contained the relevant information in relation to recruitment and selection. The files of three staff members were looked at during the visit to Coopers Way and were found to contain all the information required therefore ensuring the protection of the service users. The staff working in the respite service have been recruited specifically and have specific job descriptions. All new staff undertake a six week induction process during which time they commence their LDAF training and mandatory training courses. Evidence was seen of the training undertaken and training which was planned for the future. All of which ensures that the staff employed by the home are competent and well trained to meet the needs of the residents. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 23 The staff spoken to said that they enjoyed the training that was provided, which they felt benefited them in meeting the needs of the service users. The staff work in both homes in the scheme and staff records are kept at Coopers Way. Evidence was provided to show that over 50 of staff had achieved level 2 NVQ (National Vocational Qualification) or above. Comments received from staff spoken to confirmed that they felt supported and included in all aspects of the service users care. One staff member commented that “It is a lovely atmosphere to work in , relaxed and friendly, which helps the guests have a happy stay with us”. Another commented that “I am happy with the training I receive, I could not be better supported by the managers”. Other comments received from staff prior to the visit indicated that they felt that more staff were required to ensure that individual needs continued to be met appropriately. Evidence was found to confirm that every effort is made to ensure that the staffing levels provided at any one time meet the care needs and support required by any individual service user. A relative commented they the service users looked forward to their stay, enjoyed being there and that the staff were great and helpful. A health care professional stated that in their experience the managers and staff had shown that they had the skills and experience to care for the individuals and they showed a willingness to undertake further training if the identified any gaps in their knowledge. Mansfield Road Short Stay Unit DS0000064782.V350599.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): 37,39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users. EVIDENCE: The registered manager is very experienced and has worked in a caring environment for many years. She has achieved the required qualifications to ensure that the service is managed by a competent and qualified person for the benefit of the service users and staff. Mansfield Road operates in conjunction with Coopers Way and the manager is supported by an experienced and competent deputy, which ensures the smooth running of both homes in order that the needs of all service users are met. Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 25 The leadership from the managers is very good and staff confirmed that they felt valued in their role. The manager confirmed that she had a very committed team, who work well together and support each other all of which provides the service users with a quality service that meets the needs and expectations of everyone using the service. The health and safety of the service users was protected by the policies and procedures in place in the home. Evidence was seen that confirmed that staff receive mandatory training in relation to these issues. Information received confirmed that services and equipment were maintained in line with health and safety legislation to provide a safe environment for the service users and staff. The quality of the service being provided is assessed in a number of ways. The feedback from the link workers provides a quality check on how service users and their carers rate the service. Staff meetings are held on a regular basis and waking watch staff are seen regularly for their input. Coffee mornings and open days enable relatives and others to have a say and see how the service operates. A service user attends that learning disabilities committee forum which gives the opportunity for service users to have a say in the service. A copy of the Team Plan for June to December 07 was provided and this clearly showed the objectives of the service and how these were to be met and by whom. Comments received prior and during the visit indicated that the manager and deputy were excellent and that they offer as much support as they can. The home is visited on a very regular basis by a senior manager of the local authority and they also keep in regular contact via email and supervision with the manager. However there was no evidence to confirm that they complete a monthly report following these visits. This was discussed with the person concerned following the visit and they confirmed that they would ensure that this matter was complied with in the future. The manager was reminded of her obligation under Regulation 37 of the Care Homes Regulations to inform us without delay of any incident that affects the welfare of the service users. We had not been informed of this incident at the time it occurred and had only received information just prior to the visit by telephone. The manager confirmed that she would ensure that this requirement was complied with in the future. A written report was subsequently sent to us. Mansfield Road Short Stay Unit DS0000064782.V350599.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 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 4 25 x 26 x 27 x 28 x 29 x 30 4 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 3 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 3 x x 3 x Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 27 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 YA42 Regulation Requirement Timescale for action 31/12/07 2. YA43 37(1)(g)(2) Written information in relation to any incident that affects the health and welfare of service users must be sent to the Commission without delay. 26 The representative of the 31/12/07 registered provider must complete a report following their monthly unannounced visit to the home and ensure that a copy is provided to the manager for retention in the home. 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 Mansfield Road Short Stay Unit DS0000064782.V350599.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Mansfield Road Short Stay Unit DS0000064782.V350599.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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