Inspection on 10/02/09 for Marlborough Lodge

This inspection was carried out on 10th February 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Marlborough Lodge 253 Wishing Tree St Leonards-on-Sea East Sussex TN38 9LA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Rebecca Shewan     Date: 1 0 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Marlborough Lodge 253 Wishing Tree St Leonards-on-Sea East Sussex TN38 9LA 01424854103 01424854103 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Trustcare Management Ltd Name of registered manager (if applicable) Mr Stephen Andrew Shelley Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 6. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home Marlborough Lodge is owned and operated by Trustcare Management Ltd and is located in St Leonards on Sea. The home is registered to provide care and accommodation for up to six younger adults with a learning disability. The home is arranged over three floors consisting of six single occupancy bedrooms with en-suite shower rooms, a large lounge, dining room, kitchen and conservatory. Additonally there is a jacuzzi bathroom, a downstairs WC and a kitchenette for service users to use independently (where able). There are well maintained gardens, that are easily accessible to service users. There is parking to the front of the house. Care Homes for Adults (18-65 years) Page 4 of 31 care home 6 Over 65 0 6 Brief description of the care home The town centre with its shops and access to bus and rail travel is approximately two miles away. Other local amenities are also within a short distance to the service. The range of fees charged is from £1000 to £1950 per week. Additional charges are made for chiropody and aromatherapy sessions. Potential new service users can obtain information relating to the home via the internet on the CSCI website, from Care Managers, Placing Authorities, by word of mouth or by contacting the home directly. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection took place during the morning and afternoon of the 15th February 2009. The inspection was conducted by a CSCI Inspector and an Expert By Experience and his Personal Assistant, from the organisation My Life My Choice. Incident reports, and the homes Annual Quality Assurance Assessment (AQAA), held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took six hours. A tour of the whole home was undertaken and the Registered Manager, two staff and two service users, were spoken with. Records such as care plans, staff files and medication records were also viewed. Three service users were accommodated at the home at the time of the inspection. Responses to CSCI staff and service user surveys were positive in all areas of care and provisions Care Homes for Adults (18-65 years) Page 6 of 31 provided by the service. What the care home does well: What has improved since the last inspection? What they could do better: The contract between the home and service users is in need of being updated to include all items required under the National Minimum Standards and associated Regulations. Updating the contract will further enable service users to make an informed choice about their rights and responsibilities on admission to the home. Further recommendations for good practice were also made in that two signatures should obtained for all monies entered and discharged from service users Personal Allowance accounts. A menu in pictures and in an easy read format should be implemented and displayed on the kitchen wall to assist service users with meal choices. The complaints procedure should be updated to include a 28 day response time to all complaints made. Policies and procedures should be amended to include an annual review date. All documentation prepared by the home should refer to service user by one term of Care Homes for Adults (18-65 years) Page 8 of 31 address. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides detailed information to prospective service users and their family/representative. There are appropriate processes in place for assessing potential new service users, with services being offered to only those service users whose needs can be met. Improvements are required to ensure that Contracts include all items specified by the standards and associated Regulations to ensure that service users and/or their representatives are enabled to make an informed choice about their rights and responsibilities on admission to the home. Evidence: The Service User Guide and Statement of Purpose are provided to all new and existing service users. These documents were found to be comprehensive in detail. Pictorial and large print formats are available upon request. The homes Registered Manager and/or Deputy Manager carry out pre- admission assessments. Records inspected showed that Pre admission assessments are carried out on all new and potential service users. The home also obtains a copy of a care Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: management assessment from a placing authority where these exist. There is a clear Admissions procedure/policy in place. The Registered Manager confirmed that potential service users would be declined if necessary, if it were deemed that the home could not meet their needs. Trial visits are arranged as a matter of course and generally consist of a number of visits to the home during the day and to enable potential service users to obtain a flavour of the home, have a meal and meet with other service users. A further trial period of twelve weeks is offered following admission, a review is then held and all parties agree whether the placement is suitable for the individual service user. Of the three service user files viewed it was evidenced that service users have individual Contracts in place, which are signed by the home, the individual and/or the placing authority. Contracts viewed were found to be in need of amending, in that they do not currently detail the room to be occupied, the fees charged for extras and that the fee is subject to an annual review. Therefore a Requirement has been made. Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that this requirement has now been actioned. Care Homes for Adults (18-65 years) Page 12 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service user care plans are comprehensive in detail and are suitable for meeting service users needs. Service users are encouraged to have control over their lives and to exercise choice and be independent in their decision-making. The home has good processes in place for recording and handling of monies that they hold for service users. Risk assessments are satisfactory and encourage service user independence. Evidence: Service users individual care plans were viewed and it was noted that these were comprehensive, detailed in content and covered all aspects of service users needs and allows the assessor to gain a good overview of individuals medical, social and personal care needs. Care plans are devised with service users involvement and in a format that is service user friendly. Monthly care plan reviews were also evidenced. Care plans viewed reflected service users wishes and detailed how the home assist service users to make decisions about their lives. The staff of the home work with Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: service users in order to assist them to meet their physical/medical needs, as well as personal aspirations and goals that are within their limitations. Advocacy services are available for those who require them. Personal allowance accounts are maintained by the home. Records of all accounts were found to be well maintained, separate wallets were utilised for storage of individual accounts in the homes safe. It is recommended good practice that two signatures are obtained for all monies entered and discharged from service users Personal Allowance accounts. Current practice is one staff signature, by obtaining two signatures both service users and staff will be further safeguarded when dealing with monetary matters. Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that this recommendation has now been actioned. The Registered Manager reported that the home does not take any responsibility for any of the service users other finances and that most service users have family, friends or representatives who protect their financial affairs. Service users are encouraged to participate in the day to day running of the home. Monthly formal service user meetings are held. Each service user is aware of their responsibility to maintain their home environment and staff assist service users, where necessary, to conduct their activities/chores/rest periods/skills learning at an agreed time. Suitable risk assessments were noted to be in place. On occasions due to the nature of the service users limitations, it becomes necessary to restrict/limit choices and decisions. The need to balance rights against health and safety is kept under constant review. Behavioural charts are also maintained and any limitations that behaviours may have on an individual service user are recorded and actioned. Information that is held by the home, in relation to service users, is well maintained and stored in a locked cupboard. Service user may have access to their records upon request. The home has a Confidentiality Policy in place. Care Homes for Adults (18-65 years) Page 14 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users participate in an activities programme that is rewarding and stimulating. Service users individual programmes are varied and provide ample opportunities for personal development. The home provides good social, cultural and recreational facilities, including specialist diets to service users, with service users choice and wishes being respected. Evidence: Each of the service users has a programme of the activities that they participate in. Service users are encouraged to attend college courses. Service users attend Christchurch - Pulse School of Movement. Activities that service users participate in include, gym, swimming, bowling, external activities such as shopping, walks, day trips and life skills. Programmes are designed to keep service users active through the day but there is ample leisure time in the evenings and weekends. Service users Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: spoken with stated that I am busy doing activities from Monday to Friday: I go out shopping, horse riding, swimming, bowling, fitness class and do college courses, learning sewing, custom design, introduction to the internet, photography, living independently, looking after yourself, speaking for yourself and dealing with common problems. and I also go to the day centre, shopping and swimming. At the present time there are no service users in active employment. The Registered Manager reported that staff are accessing the local resources available, in order to provide service users with the opportunity to gain employment. Service users are able to access the local community. Service users religious wishes are observed and arrangements are made to allow service users to attend places of worship. Discussions with the Registered Manager highlighted that although the current service users fell into a specific age group and had similar religious beliefs, the home would welcome any potential new service user who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home believes in promoting an equal and diverse culture among staff and service users. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the service users wishes. Service users have access to all areas of the home to ensure that they have freedom of movement. Service users are called by their preferred choice of address. Service users, with or without assistance, conduct household chores/tasks. Such tasks are appropriately assessed and agreed in the service users individual care plan. The promotion of independence is an essential element of the homes ethos, therefore responsibility for housekeeping tasks is positively encouraged. Both service users spoken with confirmed that they do their own food shopping. Staff use the training kitchen for service users who are ready to move into supported living. One service users spoken with stated that I go out on my own. I use the bus and train. I keep my mobile phone with me. if I get stuck, I ring staff who come to help me. The homes menus are devised on a weekly basis. The Registered Manager confirmed that service users are asked to choose their favourite meals from a menu book. The menu book was viewed and it was noted that this was handwritten, difficult to read and it was not in easy read with pictures. Therefore a Recommendation has been made. Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that this recommendation has now been actioned. Service users are active helping with the cooking. Mealtimes can be varied upon request and service users guests are also welcome to have meals at the home. Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. Mealtimes were observed to be unhurried and a time for social interaction amongst staff and service users. Care Homes for Adults (18-65 years) Page 17 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are offered a good provision of health care and personal support by the home. Medication procedures ensure that all necessary precautions are taken to ensure errors do not occur and that medications are stored and administered safely. Evidence: Personal support that is offered is given in such a way as to promote and protect service users privacy and dignity, whilst promoting their independence. Discussions with the Registered Manager highlighted that personal care for current service users is minimal. There is a Key Worker system in place, each service user has two designated Key Workers. It was observed that staff had good relationship with service users and were respectful of their privacy. From the records sampled and from discussions with staff, it was evidenced that the health needs of service users are well met with evidence of good multi disciplinary working taking place. The Registered Manager said that service users could be registered with a GP of their own choice or with one from the local surgery. Service users are encouraged to attend the GP surgery were able and home visits are Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: conducted when necessary. The home has access to a Psychiatrist, Speech and Language Therapist and Occupational Therapists. Dietician and Audiologist appointments are made via the GP or the hospital. Local dental and optician practices are utilised. District Nurses would be sourced via the GP practice as required. All service users have attended well woman or well man clinics. The home has established strong links with both the Community Learning Disability Team and the Community Mental Health Team. The home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. There were no Controlled Drugs being held by the home at the time of the inspection. Some unexplained handwritten entries were noted on the Medication Administration Record (MAR) sheets viewed. Therefore an immediate Requirement was made, which was addressed prior to the conclusion of the inspection. From the service user files sampled it was evidenced that service users death, dying and critical illness wishes had not been recorded. Discussions with the Registered Manager highlighted that such discussions with current service users would have a detrimental effect on their well being, therefore a judgement has been made not to discuss this with service users. The Registered Manager reported that all service users would be encouraged to remain at the home during ageing and dying processes and that all measures would be taken to ensure that service users wishes would be respected at such times. Care Homes for Adults (18-65 years) Page 19 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect service users in the event of an allegation of abuse. Evidence: The home has a comprehensive complaints procedure in place. The current complaints policy in place will need amending to include a 28 day response period to any complaints made. Therefore a Recommendation has been made. Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that this recommendation has now been actioned. The home has not received any complaints since it was registered in September 2008. Advocacy services are sourced from Mencap or IMCA, as and when required. Both Criminal record Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults. This was evident from the staff files that were viewed. The home has obtained a copy of the East Sussex County Council Safeguarding Adults procedures. There has been one Safeguarding Alert raised in the last six months, which is currently being investigated. The Registered Manager is aware of the POVA register referral system. Care Homes for Adults (18-65 years) Page 20 of 31 Care Homes for Adults (18-65 years) Page 21 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides accommodation for service users that is appropriate, well equipped, safe, hygienic and odour free, whilst infection control procedures are adhered to at all times. Evidence: The location and layout of the home are suitable for their stated purpose. The home and was refurbished prior to being commissioned and registered in August 2008. The home has a friendly, relaxed atmosphere. All areas of the house, including the garden, are accessible to service users. All bedrooms are single occupancy and have en- suite facilities. Bedrooms are spacious and have been designed to accommodate service users who may require the use of specialist equipment. Bedrooms also have the necessary fixtures and fittings in place, including a television and a telephone point. Service users are encouraged to bring in their own furniture and may personalise their rooms, in accordance with Fire and Safety requirements. Each bedroom is lockable and service users can have a key to their room if risk assessed as safe to do so. All six bedrooms have bathroom facilities that consist of a walk-in shower, WC and Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: hand washbasin. Additionally there is a Jacuzzi bathroom (with hand wash basin and WC) and a downstairs WC. The house has a number of shared spaces that include one large lounge, a large dining area, kitchen, conservatory and a kitchenette for service users to maintain independence in cooking and for life skill training. From the tour of the premises it was evident that environmental adaptations are in place. No adaptations have been made, though these would be arranged as required by service users needs. There is no lift, to enable access to the first and second floors. All areas of the premises are accessible to service users. There is an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records. Staff were observed adhering to infection control procedures. The house was clean and odour free throughout. There is a daily cleaning schedule in place. Laundry facilities were also noted. Care Homes for Adults (18-65 years) Page 23 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current service users. Staff are appropriately trained and supported to conduct their jobs effectively. Evidence: There is a clearly defined staff team and service users are aware of staff roles and responsibilities. From the three staff files viewed, it was evident that staff have clearly defined job descriptions in place. Staff spoken with knew the aims and values of the home. A competent staff team meets the service users needs. There is a staff rota in place, which details staff designations and hours of working. The home has a permanent staff team the Registered Manager, Deputy Manager, four Senior Support Workers and seven Support Workers (additionally there is a Bank Support Worker and a Voluntary Support Worker). Four Support Workers are trained in National Vocational Qualification (NVQ) level 3 in care. Two Senior Support Workers have completed the NVQ level 4 in care training. A further two Senior Support Workers are undertaking NVQ level 3 training and two Support Workers undertaking the NVQ level 2 in care training. The Deputy Manager is undertaking an NVQ 4 in Learning and Management Course. This Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: was confirmed in the homes AQAA and from the staff training records viewed. Three staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Discussions with the Registered Manager highlighted that one Support Worker is under the age of 18 years. This person does not administer personal care and works whilst supervised by another staff member. The Registered Manager reported that voluntary staff employed are recruited in line with the Care Home Regulations. Three individual staff training files were viewed and it was evident that staff have received training in Induction, Health & Safety, Food Hygiene, First Aid, Protection of Vulnerable Adults, Infection Control, Fire Safety, Moving and Handling and Medication. Additional training is also provided for: Diabetes, challenging behaviour, Risk Assessing, Epilepsy, Report Writing, Makaton, Supervision Skills, Multiple Sclerosis and Sexuality. The staff induction-training package was viewed and this was found to be comprehensive in content. Staff spoken with stated that they are regularly supervised, both formally and informally. Records viewed confirmed this. Care Homes for Adults (18-65 years) Page 25 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion, whilst the health, safety and welfare of service users and staff is protected at all times. Evidence: The Registered Manager has many years experience of working with younger adults, has a Management Diploma in Health and Safety, NVQ level 4, the Registered Managers Award and is a qualified Paramedic. Staff spoken with said that the Manager was always friendly and approachable. The Registered Manager operates an open door policy and promotes and open and inclusive atmosphere to staff, service users and their relatives/representatives. The home has a Quality Assurance Procedure in place. The Registered Manager reported that a Quality Assurance audit was due to take place within the near future, as the home will be operating at full capacity and that it is hoped that the audit will Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: convey how the home is meeting its aims and values. Regulation 26 visits are carried out by the Registered Providers. Records of monthly staff and service users meetings were viewed and there was evidence of actions taken to address any issues raised. Policies and procedures are in place and are accessible to both staff and service users. These were evidenced as having been dated as October 2007 and were signed by the Registered Manager in August 2008. It is recommended good practice that an annual review date is entered onto all policies and procedures in place. It was also noted that these documents refer to service users as residents, service users and clients. Therefore a recommendation has been made. Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that these recommendations have now been actioned. Service users may have access to their records upon request. All records are stored and maintained in accordance with the Data Protection Act 1998. From the AQAA provided by the home and from discussions with the Registered Manager it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (where applicable) had been carried out within the last six months. During the inspection the Jacuzzi bathroom with a shower and also a training kitchen were both locked and not accessible to the rservice users for safety reasons, until a risk assessment could be completed. This showed that staff were aware of the importance of health and safety. The financial viability of the home was assessed prior to its registration in August 2008, therefore such documentation and records were not assessed during this inspection. Care Homes for Adults (18-65 years) Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 5 5A That the contract is updated 10/03/2009 to include the room occupied, the fees charged for extras and that the fee is subject to annual review. In that the current contract does not include this information. Updating the contract will further enable service users to make an informed choice about their rights and responsibilities on admission to the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 7 17 That two signatures are obtained for all monies entered and discharged from service users Personal Allowance accounts. That a menu in pictures and in easy read format should be displayed on the kitchen wall so service users can choose their meals by looking and pointing at the photo of the displayed meals. Page 29 of 31 Care Homes for Adults (18-65 years) 3 4 5 22 40 40 That the complaints procedure is updated to include a 28 day response time to all complaints made. That an annual review date is entered onto all policies and procedures in place. That one term of address is utilised for service users in all documentation prepared by the home. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. 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