Inspection on 09/07/07 for Naimo Care Home

This inspection was carried out on 9th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Naimo Care Home 15/07/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Naimo Care Home 31 Nanaimo Way Kingswinford West Midlands DY6 8TY Lead Inspector Ms Linda Elsaleh Unannounced Inspection 9th July 2007 11:00 Naimo Care Home DS0000069614.V340069.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 Naimo Care Home DS0000069614.V340069.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. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Naimo Care Home Address 31 Nanaimo Way Kingswinford West Midlands DY6 8TY 01384 835001 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) Select Health Care (2006) Limited vacant post Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Learning disabilities (LD 3). The maximum number of service users to be accommodated is 3. 2. Date of last inspection 17th January 2007 Brief Description of the Service: Naimo is a three-bedded home registered to provide personal care for younger adults set in a residential area of Kingswinford. The home is approached via the road, down a number of steps, and therefore may not be suitable for a service user with mobility problems. Parking is available on the road. A small block of shops is within easy walking distance and there is a good public transport system. The design and location of the home blends in well with the local community. There are three single bedrooms, none of which are en-suite, located on the first floor and are accessed by service users via stairs. There is no lift available. There is a garden at the rear of the premises. The current weekly fee for this service is £645.00 to £710.00. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 9th July 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults and report on the progress made to address previous requirements. The inspector’s findings are based on the information received by the Commission for Social Care Inspection, examination of relevant records and documents kept at the home and discussions with the newly appointed manager, staff on duty and service users. The atmosphere within the home was relaxed and friendly. A tour of the premises found it to be suitably furnished, clean and tidy. Service users expressed satisfaction with the environment, the planned re-decoration of the home and the care being provided. The majority of requirements made at the previous inspection have been met. What the service does well: What has improved since the last inspection? The current providers have carried out an environmental assessment on the home and are in the process of carrying out re-decoration of the premises and refurbishment of the kitchen. A Statement of Purpose and Service User Guide has been produced. Service users have been provided with the Service User Guide, Contract/Terms & Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 6 Conditions and the Complaints procedure in pictorial form and other documents are also provided in a similar format. House meetings and individual sessions are being held with service users to discuss the day-to-day running of the home and issues relevant to individuals. Service users care needs have been assessed and reviewed. Where applicable, staff are working closely with relevant healthcare specialists to address issues specific to individual service users. The manager has started to a implement planned staff meetings and individual supervision sessions. A training programme has been identified. 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. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 7 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 Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 8 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): 1, 2 & 5 Quality in this outcome area is good. Information about the home is well presented. However, service users would benefit further from more clarity about the home’s staffing complement. Each service user is provided with a written contract. Assessments of the needs and aspirations of the current service users have been carried out by staff who know them well. Training for staff in this area would improve the quality of the assessment process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection there have been no admissions to home. A Statement of Purpose and Service User Guide has been produced. The Statement of Purpose states “”Naimo is a home for life, …for as long as possible, regardless of age and disability.” The Statement of Purpose and Service User Guide also states there are 4 care staff (days & nights). This information needs to be clarified. At the time of this visit the staff complement for the home was a full-time manager, three care staff (2 x 30 hours and 1 x 25 hours) and a bank worker. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 9 The manager has been in post since May this year and is in the process of applying for registration with the Commission for Social Care Inspection (CSCI). On successful completion of this process the manager’s details should be included in these documents. Staff carried out a needs assessment for each service in April this year and, where applicable, produced risk assessments for the safe management of risks and support for appropriate risk-taking as part of promoting their independence. The format includes assessment of personal care, health, communication, individual choice & preferences. The quality of the information is adequate. The process would be improved by providing staff with training in this area. Each service user is provided with a written contract/statement of terms & conditions provided in user-friendly, pictorial formats. Both documents are signed and dated by the service user and representative of the home. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is adequate. Care plans need to reflect more fully service users assessed and changing needs, how these are to be met. Risk assessments produced to ensure service users are protected and supported to take appropriate risks need to be kept updated. Staff respect service users’ right to confidentiality and provide advice and support to assist service users in making their own decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Recent reviews have been held on the needs of each service user with relevant professionals. Staff provide support to service users to enable them to participate in their individual review meetings. Care plans are produced in written and pictorial formats. The pictorial formats contain very limited Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 11 information, for example; one plan examined identifies a service user’s personal goals as being “…in her day to day living as independently as possible….needs support from staff doing most things.”. However, it does not identify any specific areas or how/what level of support is to be provided. Similar findings were noted when examining pictorial care plans for the other service users. The care plans are also produced in written formats. Other information contained in service users files identifies how the needs of the service users have changed. All service users require varying levels of support when carrying out tasks in the home. Two require support when out in the community. It is evident these needs are not currently being fully met. One member of staff is on duty for the majority of each shift. One service user’s weekly activity programmes include two sessions at the day centre instead of the identified three sessions per week. The records show the service user does not always attends two sessions per week. This was said to be due at times due to the current staffing levels and the service user’s previous health. The manager stated action was being taken to try to address. The care plans for the current service users do not include any restrictions on their right to make their own decisions. The manager stated staff support service users in their decision-making by discussing the benefits and possible consequences. Concern had previously been identified about one service user choosing to leave the home alone when in a state of upset and the risk this posed to her safety. A risk assessment was carried out and strategies put in place to respond effectively when it was thought the service user was becoming upset. Staff stated this behaviour has reduced significantly. Risk assessments are also available on service users’ files for activities, outings and behaviour. Some risk assessments are no longer applicable and need to be removed or replaced. For example; individual risk assessments are in place for a service user who no longer travels independently and for a service user who no longer self-administers her own mid-day medication. Staff and service users were observed discussing the day’s events and choosing what to eat for their evening meal. At the previous visit the inspector expressed concern about the lack of confidentiality. During this visit the inspector did not observe any inappropriate discussions taking place. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. The home’s current staffing levels do not enable service users to be fully supported to participate in activities within the community. Service users are supported to maintain contact with relatives. Care plans should identify how this support is to be provided. Service users are able to follow their own routines and are provided with flexible mealtimes and nutritious meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users confirmed to the inspector that they are able to follow their own routines, such as choosing when to get up, mealtimes and what clothes to wear. They enjoy a good relationship with staff and value their advice and Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 13 support. The minutes of recent meetings with service users demonstrated that they are encouraged to be involved in the day-to-day running of the home. Holiday arrangements have been discussed at these meetings. The newly appointed manager has been familiarising herself with service users routines and interests and making contact with the different agencies involved each service user’s care. Two service users spend time outside the home without staff. One is independent and spends time in the community shopping or playing bingo. The other service user has regular day services and is collected and returned by the day care staff. The third service user, as previous mentioned, is allocated three sessions a week at a local centre, 1 art class and 2 exercise classes. The records show her attendance is sporadic. The inspector was informed this was due to staffing levels and the service user’s previous ill health. Each service user has a weekly activity programme. One service user’s file identifies an interest in dance and music. This has not been included in her activity programme. The activity programme for the service user who spends the majority of her time at the home shows limited activities such as a walk or visit to the pub. The more independent service user records her events of the day on return to the home every afternoon/evening. The service user, who was at home during the day of this visit, was occupied in craft activities and was supported by staff to make lunch. The inspector was informed she is artistic and has good literary skills. Her weekly activity programme includes art and reading. However, more suitable arrangements should be considered to enable her to participate in these activities in a more stimulating environment and have contact with peers who have similar interests. Another service user spoke enthusiastically about how she spends her time outside the home. She also informed the inspector she has to take things more easy due to her not being able to walk the distances she use to. She recognises the support she needs in carrying out tasks within the home and enjoys the company of staff. The service user who attends day services has limited communication skills. A communication book is kept to relay information between the home and day services staff. The interaction observed between the service user and a member of staff was positive. The staff member referred to the communication book and observed the service user’s reaction to assess whether she had had an enjoyable day. The manager stated the home is in the process of reviewing activity and social programmes. She acknowledges the current staffing levels do not allow for service users to be fully supported without the staff’s dedication and willingness to work additional hours. The manager provides direct care to Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 14 service users three days per week. She is rota-ed to carry out management duties twice a week, on these days she is also involved in direct care or, where necessary, attending appointments with service users. Two service users have regular contact with relatives. The relative of one service user looks after her finances and is involved with the home in supporting her to look after her personal allowance. The other service users also have contact with relatives. Arrangements for supporting service users to maintain contact with family and friends are not included in care plans. The home does not employ ancillary staff. Staff are responsible for supporting service users to develop their cooking skills and for all other catering duties. Nutritional assessments have been carried out by the home on each service user. One service user is diabetic, for which she is prescribed medication. The assessment carried out by the home identifies her dietary requirements. However, this information is not reflected in her care plan. Staff would benefit from training in monitoring and managing diabetes. One member of staff has received basic food hygiene training during the last three years. Arrangements should be made for the two other staff to receive training updates. Service users are provided with the meal of their choice. Pictorial menus and records of meals taken are kept in the kitchen. The main meal of the day was taken in the conservatory/dining room. The three service users were present for the evening meal. Service users who expressed an opinion stated they were satisfied with the arrangements for mealtimes and with the quality of the food. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. Service users personal and healthcare needs are met appropriately. The home procedures and practices for managing service users’ medication ensure they are fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff was able to demonstrate they are familiar with service users personal care needs, individual preferences and the support provided to them. Since the last inspection discussions have take place with one service user about when she chooses to bathe. With the agreement of the service user the routine has changed. The service user is pleased with the new routine as it suits her lifestyle better. Service users records show regular arrangements are made for general and specialist healthcare checks to be carried out. One service user’s hearing is Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 16 being monitored closely. Information leaflets are available to staff about medical conditions that affect individual service users. The home has developed relationships with relevant healthcare specialists. Regular meetings are held with one service user’s consultant to discuss her progress and how she can be best supported. However, records kept by the home needs to sufficiently detailed to ensure accurate information is taken to these meetings. Service users’ medication is managed by the home on their behalf. A written record of the service users’ consent to this is available on their individual files. All staff have received training in the safe handling and administration of medication and two have recently undertaken update training. A written policy and procedure is available in the home and has been signed by staff. The inspector was informed the home does not administer homely remedies. The manager is advised to include this statement in its medication policy. She is also advised to record the implementation date of the current policy and review it periodically to ensure it remains relevant and continues to meet the needs of the service users. The inspector observed the mid-day medication being administered to one service user. This was done in accordance with the home’s procedures and a drink was provided. The local pharmacist recently carried out an audit of the medication. No issues or problems were identified during this visit. Medication Administration Record Sheets (MARS) are completed to a satisfactory standard. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. Service users feel their views are listened to and concerns are appropriately addressed. The home’s procedures and practices protect the service users from abuse and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has not received any complaints since the last inspection and none have been reported to the Commission for Social Care Inspection (CSCI). Service users expressed no concerns and two service users informed the inspector that any issues raised are addressed appropriately. Each service user is provided with a pictorial copy of the home’s complaints procedures. Information is also included in the Statement of Purpose and Service User Guide. Adult protection policies and procedures are available and contain a flow chart providing staff with easy-to-read guidance on action to be taken by staff. Staff received adult abuse training two years ago. Arrangements are being made for them to receive training in the Protection of Vulnerable Adults later this year. There have been no reported adult protection issues and no concerns were identified during this visit. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 18 Dudley Appointee-ship Unit manages the finances on behalf of two service users and the home manages their personal allowance. The other service user does give the home some money to keep safe for her. Satisfactory records are kept of all monies received by the home, transactions made on the service users behalf and monies returned to them. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 19 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 good. Service users live in a clean, tidy and safe home. They living environment will be further enhanced once the refurbishment and redecoration programme has been completed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have a well-kept garden at the rear of the premises that is enjoyed by service users during fine weather. One service user has taken responsibility for putting out food on the bird table. The service users have unrestricted access to all communal areas and their own bedroom. The communal areas consist of front and rear lounges and conservatory/dining room. Supervision is provided in high-risk areas such as the bathroom and kitchen. As reported in the previous inspection, fittings in Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 20 the kitchen are worn and need to be replaced. The inspector was informed arrangements have been made to re-furbish the kitchen in September, while the service users are on holiday, and plans have been made for all rooms in the house to be re-decorated this year. One service user said she had been involved in selecting new dining furniture for the conservatory and was waiting for it to be delivered. The temperature of the conservatory was found to be very warm. The manager stated consideration was being given to replacing the roof covering to give more control over managing the temperature. The service users have their own bedrooms and these are situated on the first floor. All have been personalised by the occupant and reflects their individual personalities and interests. They told the inspector they are looking forward to selecting the colour scheme and soft furnishings for their individual bedrooms. The wash hand basin removed from one of the bedrooms before the previous inspection has been re-fitted. A small office/staff sleep-in room is also located on this floor. There is a small bathroom and separate toilet. The home is exploring how these facilities might be improved with particular consideration being given to meeting the needs of service users, as they grow older. One service user is unsteady on her feet. Handrails are fitted to the staircase and rails are sited in the front garden. The home has suitable laundry facilities. Staff are aware of the home’s infection control procedures. There was an unpleasant odour in the conservatory area at the time of this visit. The inspector was informed this had already been noted and arrangements made for the drains to be looked at. Overall the premises are kept clean, tidy and homely. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is poor. A small team of dedicated, experience and qualified staff provide care to the service users. However, the care needs of the service users are not being fully met as only one member of staff is on duty for the majority of the day. The home has recruitment policies and procedures designed to protect the service users wellbeing and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a small stable staff team who work the majority of the time on their own. They are familiar with the service users preferred routines, likes and dislikes. Staff need to be supported by their managers to ensure service users wellbeing and safety is fully protected at all times. Two staff hold the National Vocational Qualification (NVQ) Level 2 in Care and one has also achieved NVQ Level 3. The current providers have carried out an audit of staff training. The manager has produced a training programme for Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 22 2007/08 and is waiting for approval from her manager before confirming the bookings. The programme is for Manual Handling, Protection of Vulnerable Adults, Introduction to Learning Disability, Autism, the Mental Capacity Act and Holistic Assessment courses. The home has policies and procedures for the recruitment of staff. The new provider has carried out an audit on the recruitment records for the current staff team. They have obtained POVA First (Protection of Vulnerable Adults) checks on all staff and applications have been made for updated Criminal Record Bureau checks. Staff have been issued with new contracts of employment and with a copy of General Social Care Council’s (GSCC) Codes of Practice. The manager has recently implemented a planned programme for staff meetings and individual supervision. Supervision records examined show discussions are taking place about training and practice issues. Individual training and development programmes have yet to be produced. Annual appraisals have yet to be carried out with all staff on their individual performance. The home’s Statement of Terms & Conditions for service users states “Sufficient staff will be available at all times to accommodate Service User’s requirements.” However, the findings of this inspection supports previous inspection findings that having one member of staff on duty means the needs and aspirations of the service users are not being fully met. This inspection also identifies the needs of the service users are beginning to change, as they becoming older and one service user has experienced a period of psychological poor health. Comments made by staff about staffing levels indicate they are “just managing” and are supported by other homes. For example; on occasions when the member of staff on duty has been called out, a service user has been taken to another home within the group. The issue of staffing has been discussed in with the current providers and, at this inspection, with the manager and area manager. The provider has contacted the relevant authorities with regards to additional funding for specific aspects of individual’s care. However, it is unacceptable that the needs of the service users are still not being fully met. The home needs to demonstrate that positive action is being taken to assess its staffing ratios against the service users overall needs and lifestyles. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 23 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 & 42 Quality in this outcome area is adequate. Service users are becoming more confident in the newly appointed manager’s running of the home. Suitable health and safety procedures are available for the premises and implemented by staff. Monthly visits to report on the conduct of the home should be carried out in accordance with regulations in order for service users to be assured the home is being suitably monitored by the provider. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 24 The manager has been in post since May this year. She has the relevant experience required for working in a residential setting with this client group. She is supported by a stable staff team and by regular visits from her area manager. Her application for registration as manager is being process by the Commission for Social Care Inspection (CSCI). The manager has been spending time developing relationships with service users and becoming familiar with their care needs and routines. When she has not been involved in providing direct care, she has been consulting with staff and observing practice. The home’s quality assurance system was not assessed during this visit. Suitable records are kept of inspections and servicing of appliances and equipment. Accident records are appropriately maintained and, where applicable, the relevant agencies are notified. Monthly visits are made by the area manager to monitor the home’s performance. The inspector was informed the majority of these visits are announced. Regulation 26 of the Care Home Regulations 2001 require these visits to be unannounced by an employee who is not directly concerned with the conduct of the home. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 25 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 3 2 2 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 1 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X X X X 3 2 Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must contain detailed information about service users’ needs and how these will be met. Risk assessments must be kept up to date to ensure service users are fully protected. Activity programmes must be produced that reflects service users interests and identifies how they will be supported by the home to regularly participate in these. Service users must be provided with more opportunities to engage in community based activities and outings (based on their needs and preferences) in groups and as individuals. Sufficient staff must be deployed to assist this process. (This is an outstanding requirement from previous inspections.) Timescale for action 01/10/07 2. 3. YA9 YA12 12 16 01/10/07 29/10/07 4. YA13 16 29/10/07 5. YA24 23 Suitable arrangements must be made to ensure the temperature in the conservatory/dining room can be maintained at level that is comfortable for service users at all times. DS0000069614.V340069.R01.S.doc 29/10/07 Naimo Care Home Version 5.2 Page 27 6. YA33 18 The registered person must ensure that a re-assessment of staffing ratios and service users’ dependency levels is undertaken. The care hours, ancillary hours and hours spent outside the home by service users attending day centres must be clearly identified. Sufficient staff must be allocated to provide all service users with opportunities for social inclusion. (This is an outstanding requirement from previous inspections). 29/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations Service users and their representatives would benefit from more clarity being provided in the Statement of Purpose and Service User Guide in respect of the home’s staffing complement. Staff should be provided with training to ensure all service users needs and aspirations are fully assessed. Care plans should detail arrangements for supporting service users to maintain contact with family and develop friendships to ensure a consistent approach is given. A service user’s dietary needs should be detailed in her care plan to demonstrate how this need is being met appropriately. Staff should receive up date training in basic food hygiene and monitoring and managing diabetes. An individual training and development programme needs to be produced for all staff to ensure they have relevant and up to date knowledge and skills to meet the service users needs. DS0000069614.V340069.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA2 YA15 YA17 5. YA35 Naimo Care Home 6. YA43 Staff should be provided with annual appraisals on their performance. Monthly visits should be unannounced and by an employee who is not directly concerned with the conduct of the home. Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Office Ground Floor, West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA 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 Naimo Care Home DS0000069614.V340069.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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