Inspection on 18/06/07 for Netherlands

This inspection was carried out on 18th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Netherlands 19/06/06

Netherlands 03/10/05

Netherlands 25/04/05

Netherlands 17/01/05

Netherlands 16/08/04

Netherlands 22/03/04

Netherlands 05/12/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Netherlands Spilsby Road Horncastle Lincs LN9 6AL Lead Inspector Sue Hayward Unannounced Inspection 18th June 2007 2:30 X10029.doc Version 1.40 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 Netherlands DS0000002392.V343107.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 Older People and 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. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherlands Address Spilsby Road Horncastle Lincs LN9 6AL 01507 522009 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Miss Valerie Evans Care Home 11 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (11) of places Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Netherlands Care Home is registered to provide personal care to male and female service users who fall within the following categories :Learning Disability over the age of 65 years LD(E) 11 2. Learning Disability (LD) 11 The maximum number of persons to be accommodated at Netherlands Care Home is 11 19th June 2006 Date of last inspection Brief Description of the Service: Netherlands cares for up to eleven people who have learning disabilities from the age of 30 years upwards. It is a detached, two storey house situated on a main road in Horncastle. Horncastle is a small town, which has a variety of facilities and services. All bedrooms are for single occupancy with the exception of one, which can be shared if needed. Bedrooms are located both on the ground and first floors. A stair lift is available for people who are unable to manage stairs. Outside there is a large garden to the back and side of the property; there is also a decked area. There is car parking available to one side of the property. The home is part of Prime Life Limited and on the day of the visit care and accommodation was being provided for six people, as one resident was in hospital. Information provided prior to the inspection confirmed that the current weekly fee ranges from £407 - £750 depending on residents assessed needs. Additional charges are made for services such as chiropody, hairdressing, and reflexology, trips out and holidays. Information about the home, including the certificate confirming registration conditions and a copy of the last inspection report are available in the reception area and hall. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector made an unannounced visit to the home, which took place over 5 hours. It formed part of a “key” inspection. This is the checking of those standards considered to be “key” in terms of the health, safety and welfare of residents. The manager had completed a questionnaire giving important information about the service and this was used to contribute to the inspection process. Questionnaires had been returned from seven residents, who had been supported to complete them by a staff member. Information from these as well as that, which the Commission for Social Care Inspection (CSCI) holds about the service was used to plan the visit and produce this report. “Case tracking” was the main method of inspection used. This included looking at the care and support of three residents with differing needs, through discussion with two of them, a staff member on duty and checking a sample of the records held about them. There was also general discussion with some of the other residents who were present. Staff were observed for short periods of time whilst working with residents. Three bedrooms, the kitchen, sitting room, dining room, laundry and a bathroom were also seen on this occasion. The manager was present for part of the visit. General comments about outcomes were discussed with her at the end of the visit. What the service does well: Clean and comfortable accommodation is provided for residents who are able to make their rooms more homely with their own personal items and have choice as to how they are decorated and furnished. Residents’ health and care is well monitored. Residents said they liked their rooms and the staff and knew who to speak to if they had a problem. There is a range of social and leisure activities that residents can participate in. Residents are supported to be involved in decisions about the home and their lifestyles. Staff receive training to ensure that they have the knowledge and skills to provide the appropriate care for residents. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 3 (Older people) and Standards 2 (Adults 18 – 65). Standard 6 (Older People) is not applicable, as the service does not provide intermediate care. People who use the service experience good quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. There are good systems in place to introduce and assess residents to ensure their care needs are identified and can be met prior to admission. EVIDENCE: The statement of purpose giving important information about the home has been changed to reflect that the home is now registered to provide care and accommodation for younger and older people with learning disabilities. It is Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 9 not the current intention to admit people who are under 30 years of age in view of the age of other residents in the home and “only if their needs are able to be met and fit in with the existing client group”. The organisation has policies and procedures relating to admission and discharge. This includes visits to meet prospective residents, which the manager confirmed she undertakes, completion of relevant forms and consultation and obtaining information from other people such as social workers and relatives. A resident who had recently been admitted to the home confirmed that she had visited with her social worker and met other residents before making the decision to move in and had been able to choose her room. Another resident told us that a person was coming to look around the home, demonstrating that people who live in the home are kept informed about any possible admissions. All records checked contained assessment information from which a care plan had been drawn up. Comments from residents confirmed that they were aware of their care plans. Information about the home is on display for anyone to refer to. It is also available in larger print. The manager said residents are given a welcome pack of information, which is always discussed with them. Individual contractual information was not seen on the files of the two recent admissions checked. It was understood from the manager that this information is obtainable from the organisations head office and she agreed to address this matter. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 (Older People) and 6, 9, 16 and 18 – 21 (Adults 18 – 65). People who use the service experience good quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. The care planning system in operation provides satisfactory information and contributes to making sure that the health care needs of residents and their preferred lifestyles are met in a way which respects privacy and dignity. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 11 EVIDENCE: All three records checked of residents with a range of needs, two who had been admitted within the past twelve months had had care plans developed. Those residents spoken to were aware of their care plans and of the specific staff member, their “key” worker, who is responsible for ensuring they are kept up to date and reviewed regularly. Staff had a good knowledge of the needs of the residents asked about. Care plans reflected assessment information and residents wishes. There were instances noted were some risk assessments were more detailed than others. For example a care plan demonstrated that a resident liked to lock her door at night however there was no record to demonstrate what risk assessments had been done to enable the resident to have her privacy whilst ensuring her safety should her room need to be accessed in an emergency. The manager has since forwarded information demonstrating that this matter has been addressed. Records, residents and staff comments confirmed that the health of residents is well monitored and met. Records showed when visits to or from other health professionals such as district nurses, doctors and chiropodists had occurred. The majority of questionnaires received indicated that residents “always” received the medical support they needed. There are policies and procedures in place concerning the receipt, storage, administration and disposal of medications. Senior members of staff are responsible for administering medications and records and a staff members comments demonstrated they had had training to do so. Medication records checked were well maintained. A staff member was observed whilst giving out medications to two people. It was noticed that she followed a safe process. This included ensuring the residents had taken their medication before completing any record confirming this. She also had a good understanding of how to dispose of any unwanted medications safely and what to do in the event that medication was not administered correctly. A community pharmacist visits periodically to check and offer advice about medication systems in place. The most recent report dated 16th march 2007 demonstrated that there were no problems with record keeping, storage arrangements and stock control. Resident’s said they were satisfied with the care and accommodation provided. Staff were observed to be polite, courteous and respected residents privacy. Comments from residents were positive about their relationships with staff. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 (Older People) and standards 12, 13, 15, 16 and 17 (Adults 18 - 65) People who use the service experience good quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. Residents are supported to make decisions about their day-to-day lives and to participate in a range of social and leisure activities, which meets their individual preferences both within the home and community. Visitors are made welcome. The meals provided are well balanced and offer variety and choice for residents. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 13 EVIDENCE: Comments from residents were positive about the social and leisure activities they participate in. For example, comments indicated how much they had enjoyed an outing to “Natureland”. The home shares the use of a minibus with another home and outings are arranged on a monthly basis. A range of opportunities are available for residents to participate in should they wish. One resident said she attended a local club, participated in reflexology sessions in the home and enjoyed playing bingo. Information was on display about events. Staff confirmed other opportunities that are available for residents to participate in on a daily basis such as craft activities, dominoes and skittles. Residents said they had visited a local country fair the day prior to the visit and had called in at a local pub for a drink. In addition entertainers visit the home periodically and one of the residents runs a disco in the home. Records checked made reference to any specific cultural or spiritual needs of residents. Staff comments confirmed that a vicar visits the home and holds Holy Communion for those residents who wish to participate. The brochure makes reference to making arrangements for people who may wish to practice other religions. Comments contained in residents questionnaires indicated that 4 people were of the opinion that activities were “always” arranged which they could participate in, 1 said “usually” and 2 said “sometimes”. Meetings are held where residents can participate to air their views and be involved in decisions about what happens in their home. For example notes of the meeting of 23rd May 2007 showed that residents had discussed where they would like to go on holiday, whether their next-door neighbour should be invited to play the organ and that they would like to arrange a coffee morning. Residents said they are able to have visitors when they wish and records are kept of any visitors. Questionnaires received indicated that the majority of residents always liked the meals provided. One additional comment made was “I like the cake, fruit and biscuits” all which were seen available to residents on the day of the visit. Menus demonstrated that residents do have a choice of a hot meal, sandwiches or salad daily although the menus did not demonstrate all the options that staff confirmed were available. The manager agreed to ensure that staff was aware that any variation needs to be documented. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 (Older People) and standards 22 and 23 (Adults 18 - 65) People who use the service experience good quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. Residents are protected by satisfactory procedures in place for handling complaints and allegations of abuse. EVIDENCE: Prime Life Limited has a complaints procedure, which tells residents and relatives how to make a complaint and how it will be handled. This was on display on the notice board. It is also included in the information pack that is given to prospective residents. There is a system for recording any complaints that are raised and a comments book is available in the reception hall for people to record any concerns or compliments. The Commission has received no complaints about the service since the last inspection. Comments from residents indicated that they knew who was in charge and would feel comfortable to talk over any problems with staff. Questionnaires included comments which indicated that staff listen and act on what they say and all except one said they knew how to make a complaint. Records kept of residents meetings demonstrated that residents also have the Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 15 opportunity to raise any issues they may have at these as well as individually with staff. Staff spoken to had a good knowledge of the procedures in place and of what action they should take to ensure residents were well protected should any adult protection issue be raised. Records and discussion demonstrated staff have training about dealing with challenging behaviour and procedures are in place, which include Lincolnshire County Councils adult protection procedure for them to refer to if needed. Records are kept of any complaints or adult protection issues raised although none had occurred in the past 12 months. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 (Older People) and 24 and 30 (Adults 18 – 65). People who use the service experience good quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. The home is well maintained and provides comfortable and clean accommodation for residents, which meets their needs. EVIDENCE: Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 17 The bedrooms of three residents were seen on this occasion. Residents’ comments indicated that they had been able to choose the décor and bed linen and had made their rooms more homely with their own personal effects. Bedroom doors are lockable. All parts of the home seen including bedrooms, the lounge, dining room and bathrooms were clean and tidy. Some areas have been redecorated since the last visit. A downstairs bathroom has been converted into a shower room, which has improved the facilities for people who have difficulties getting in and out of the bath, although there are hoists provided for people who prefer to have a bath. Residents said that they were very happy with the home’s facilities and their own rooms. Questionnaires also confirmed this. There is an on-going programme of maintenance with records being kept to report any issues that need attention. Residents are supported to be involved in domestic duties around the home such as the cleaning of their rooms and helping in the kitchen, which helps to promote their independence. Risk assessments in relation to any potential hazards the home may pose are in place. The manager confirmed that she is currently reviewing the fire risk assessment of the home. A fire safety officer last visited the home on 22nd December 2006 when fire precautions were considered to be satisfactory. A visit from environmental health services occurred on 13th October 2006, 5 matters were raised at that time which the manager confirmed had all been rectified. There are satisfactory policies and procedures relating to good hygiene practices and staff confirmed that stocks of equipment such as gloves and aprons were available for them to use if needed. Discussion with the manager indicated there is not currently a procedure in place for continence promotion however she agreed to develop this. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 (Older People) and 34 and 35 (Adults 18 – 65). People who use the service experience poor quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. There are sufficient staff on duty that have training to ensure that residents are well cared for, however residents are not sufficiently protected by the recruitment procedures in place. EVIDENCE: Discussion with staff and the manager confirmed that there have been changes to the staff team. Two staff have been appointed as seniors to deputise for the manager in her absence. Other managers within the organisation can be contacted for advice if needed when the manager is off duty. There are currently 6 residents at the home and discussions with staff indicated that as the home is not fully occupied staffing levels in the morning Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 19 have reduced. There are 2 care staff on duty throughout the day that also have catering duties. At night there is one wakeful staff member and one on “sleep-in” duty who is on-call. A staff member is also employed to carry out domestic tasks. Staffing shortfalls are covered by “bank” staff which assists with ensuring continuity of care is provided. Residents’ comments about staff were positive. They knew who their “key” worker was and comments indicated that the majority felt that they “always” or “usually” received the support they needed. Records and discussion with staff confirmed that there is an on-going training programme, which includes an induction programme for new employees as well as regular updates on training such as fire and moving and handling training. Some staff have participated in Learning Disability Award Framework training and 2 staff have achieved a recognised vocational award in care. Discussion with the manager and staff confirmed that staff need their First Aid certificates renewing and training for this has been planned for 2nd July 2007. The staff recruitment process was checked. Records were not in place in one instance to show that a recently employed staff member had had the necessary police and criminal records bureau check undertaken prior to employment. The commission have since this visit received a telephone call confirming that a criminal record bureau check has been applied for. Records also demonstrated that some staff were appointed and commenced work after a satisfactory protection of vulnerable adults register check but pending the receipt of a criminal records bureau check without there being any exceptional reasons for this. Discussion with the manager confirmed that in such circumstances staff do not undertake personal care for residents and are supervised although additional staff are not rostered on duty during this time. It was discussed that the appointment of staff pending a satisfactory criminals record check should only take place in exceptional circumstances. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 (Older People) and standards 37, 39 and 42 (Adults 18 - 65) People who use the service experience good quality outcomes in this area. We have made a judgement using a range of evidence, including a visit to this service. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 21 The home is well managed and there are satisfactory arrangements in place to obtain the views of residents and staff to ensure the quality of the service is maintained. EVIDENCE: There has been no change to the management arrangements in place. The manager has a recognised vocational qualification in care and management and has been in this role for over 3 years. Comments from residents indicated that they knew who was in charge and that staff would listen to any concerns they had. Staff said they felt supported and valued by the manager. This happens both formally through supervision sessions and staff meetings and informally through the manager being available and approachable as needed. There are various systems in place to check on the quality of the service provided. This includes monthly visits by a representative of the organisation who completes a report. Comment cards and a comment book was on display for anyone to complete. This showed that in the past twelve months 6 people had made comments about the service all of which were positive. A quality review carried out by the organisation in November 2006 included the views of residents and the production of a report, which was on display. There are well-managed systems in place for the safekeeping of valuables. The arrangements for those residents who have money held in the company account are satisfactory but could be improved by ensuring that individual accounts can accrue interest. There are a range of policies and procedures regarding health and safety available to guide and instruct staff. There is also a programme in place to service and maintain the equipment in the home on a regular basis. A random check of the service certificate for the fixed electrical wiring of the home was satisfactory. Staff comments and records confirmed that new employees receive training to induct them into the work. This has recently altered to include a mentoring process. A staff member within the home has been given specific responsibility for supporting new employees through a process of completing a range of work books giving information about key areas such as manual handling. This is in order that new employees obtain the knowledge and skills to provide appropriate care for residents. A staff member confirmed she had received training from the company’s training department to do so and that continued support and guidance would be provided as needed. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 3 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation Reg. 19 1 Requirement It must be demonstrated that all staff have had a protection of vulnerable adults and a criminal records bureau check as part of their recruitment process, which is deemed to be satisfactory. This will help to ensure that people who use the service are well protected. Timescale for action 09/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincolnshire Area Office Unity House The Point Off Whisby Road Lincoln LN6 3QN 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. Netherlands DS0000002392.V343107.R01.S.doc Version 5.2 Page 25 - 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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