Inspection on 18/09/07 for Peel Way

This inspection was carried out on 18th September 2007.

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

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

Other inspections for this house

Peel Way 15/12/06

Peel Way 05/10/05

Peel Way 14/06/05

Peel Way 15/05/05

Peel Way 24/02/05

Peel Way 26/08/04

Peel Way 19/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Peel Way 6 Peel Way Harold Wood Romford Essex RM3 0PD Lead Inspector Jackie Date Key Unannounced Inspection 18 – 24 September 2007 10:00 th th Peel Way DS0000015599.V351472.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 Peel Way DS0000015599.V351472.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. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peel Way Address 6 Peel Way Harold Wood Romford Essex RM3 0PD 01708 386 478 F/P 01708 345 478 peel.way6@theavenuestrust.co.uk www.theavenuestrust.co.uk The Avenues Trust Ltd 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) Karen Ann Jackson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2006 Brief Description of the Service: 6 Peel Way is a purpose built home for six adults with learning disabilities, situated in Harold Wood, Romford. It is a detached two-storey house with parking space to the side, and an enclosed garden to the rear. There is an open plan lounge/dining area, conservatory, kitchen, and utility room on the ground floor, as well as two bedrooms, both of which have ensuite toilet and bath. The remaining four bedrooms are on the upper floor, and each have an ensuite toilet, and share a bathroom. There is a ramp to both front and back entrance, but no lift to the upper floor. The Avenues Trust, a company that has similar homes, both locally and in Kent, runs the home. There are good local transport links, and the home has its own minibus. Personal care is provided on a 24-hour basis, with health care needs being met by visiting professionals, or staff accompanying residents to appointments. At the time of the visit there were 6 men living at the home. Some residents have profound disabilities and limited ability to communicate verbally, whilst others are more independent. The fee for the service is £1478-10 per week. The manager provided this information shortly after the visit. Information about the service provided is contained in the service users guide. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10 am. It took place over 7 hours. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Where possible residents were asked to give their views on the service and their experience of living in the home. All of the shared areas and 3 bedrooms were seen. Staff, care and other records were checked. Relatives, social workers and healthcare professionals were contacted and asked for their opinions of the service. At the time of writing this report feedback had been received from 3 relatives. Any feedback subsequently received will be taken into account for future inspections. Keyworkers supported 3 residents to complete feedback forms and feedback forms were received from 6 staff. Services are now required to complete an AQAA (Annual Quality Assurance Assessment) and the completed form was received on 21st September 2007. Information provided in this document also formed part of the overall inspection. The inspector would like to thank the residents and staff for their input during the inspection. What the service does well: Relatives said: “This is an excellent home for my brother. The care staff always care for his needs. They always provide facilities for my brother, who needs constant supervision and is always clean and tidy. I am pleased with the home and the care he receives.” “The care staff are very helpful and support my son in a great deal of what he does in the house or outside. My son was ill when he first went to Peel Way two years ago. The staff helped him to be more independent, and to make him feel very happy with his surroundings. When visiting the home the staff always make you feel very welcome. The home is very clean, and they keep the residents, very clean and smart. When I’m taking my son out he opens the door to me, and he is more often than not laughing with the care person. His medication is always ready for me to take with me, for however long we are out for.” Residents that are able said that they liked living and Peel Way and that the staff are okay. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 6 Staff are provided with regular training to enable them to provide a suitable service for residents. 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. Peel Way DS0000015599.V351472.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 Peel Way DS0000015599.V351472.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): 2, 3,4 & 5. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Appropriate information is gathered on a prospective resident prior to their moving into the home and this gives staff a picture of the individual’s needs and how to meet these. Prospective residents and their relatives can spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. Residents have contracts/statement of terms and conditions and therefore have detailed information about the service that they are entitled to. EVIDENCE: There have not been any new residents admitted since 2005. At that time the inspection found that in-depth reports were received from members of the specialist multidisciplinary team for people with learning disabilities. The manager had also carried out a pre admission assessment using the company standard format. Therefore sufficient information was gathered on a prospective resident to enable the staff team to identify their needs. Prospective residents are given the opportunity to visit the service and to meet Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 9 staff and residents before they decide if they want to live there. In addition the organisation has a development manager, who works with services to support them when people are moving in. The residents have individually written contracts between themselves and the provider. The contracts were available at the home and copies were seen in residents’ files. Therefore residents have details about the service that they are entitled to. Peel Way DS0000015599.V351472.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, 8, 9 & 10. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents’ care plans and risk assessments contain sufficient information to enable staff to safely meet their needs. Residents are consulted about what happens in the home as far as they are able. EVIDENCE: Avenues Trust is committed to the concept of Person Centred Active Support (PCAS) and each resident has an individual person centred plan covering all of the necessary areas. These include communication, behaviour, environment, personal care and health, domestic, family and personal relationships, cultural, and social interaction. The plans give a good picture of who the person is, what he can do and what he likes. For example, my religion is Church of England, but I’m not interested in celebrations or going to church. I like snooker, greyhound racing, football and Manchester United. The degree to which some of the residents can be involved in the development of the plan is Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 11 very limited due to their profound learning and communication difficulties. Others are able to take an active part in this process. Two care plans were examined. These contained a lot of information about the individuals needs, likes and dislikes. They also had photographs and symbols throughout to make them more user friendly. The plans clearly described how to support the person and what good support would be like. There was sufficient information available for staff to work with the residents and both plans show that staff know the residents well and that they are working to meet individual needs and to provide a more person centred service. The plans seen had been reviewed and were up to date and planning meetings are held every six months with relevant people being invited. Daily recordings are made about what each person has done and support that they have been given. Separate night logs are also kept. This information is used as part of the review process and to identify ongoing and changing needs. Residents’ meetings are now held each month and a record is kept of these. Some of the residents can and do express their views about what they want to do and what they like. This shows that residents are consulted about what happens in the home and to them. There are risk assessments in place. These identify risks for the residents and staff and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. Risk assessments seen were detailed and had been reviewed to ensure that they are up-to-date. This means that risks can be reduced and that the residents’ needs can be met as safely as possible. In some cases restraint and/or restrictions form part of the resident’s care plan and these have all been reviewed and signed by the manager. For example one resident is offered low alcohol alternative drinks instead of alcoholic drinks, another has his cigarettes “managed” by the staff team. The reasons for this are recorded and have been agreed with the individuals concerned as far as is possible. Residents’ records and other information are stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. Staff awareness of confidentiality issues is checked as part of the monthly monitoring visits carried out by the service manager. Peel Way DS0000015599.V351472.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): 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents are encouraged to take part in activities and to be part of the local community and this is being developed further to ensure that they have as fulfilling a lifestyle as possible and that they are as independent as possible. Residents are supported to keep in contact with their relatives and relatives are welcomed at the home. Residents are given meals that meet their needs and individual preferences. EVIDENCE: Four of the residents are more independent than the other two and they assist with chores and with the cooking. The washing machine controls have been colour-coded to assist residents to do their own laundry. One of the residents Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 13 can travel independently but the others require support from staff. A relative said “my son was ill when he first went to Peel Way two years ago. The staff helped him to be more independent, and to make him feel very happy with his surroundings.” Residents go to a variety of activities and these include a computer club, bowling, pool, sauna and out for meals. One resident said that he has started to go to Havering College to do numeracy and literacy. Staff are escorting him at present but this will be reviewed once he has had time to settle in. Another resident has started to go to golf. One resident’s person centred plan said that his dream would be to watch Manchester United and recently this was organised. Two staff took two residents to Old Trafford to watch a match and they stayed in a hotel overnight. The residents have all been or are going on holiday. This was in small groups according to individual needs and preferences. Two residents went to Potters holiday camp, two went to Devon and another went to Derbyshire. Activities and opportunities continues to develop and the residents are having a more interesting lifestyle. Most residents have contact with their families in varying degrees. One resident’s mother visits regularly. She said, “when visiting the home the staff always make you feel very welcome”. Another resident’s file contains details of family birthdays and there is a note in his individual plan to remind him to send cards. Therefore the residents are supported to maintain their contact with their families. A record is kept of the food that is offered to residents and of what they choose. One of the residents said that the food was good. During the course of the visit some of the residents who were able to, were observed to be encouraged to make their own drinks. Some residents are able to indicate what they would like to eat and staff are aware of others preferences. Residents’ person centred plans contain information about the residents’ likes and dislikes in term of food. For example one plan said, “ I like a roast dinner, chocolate, sweets and cakes. I don’t like rice and salads and I don’t always like having breakfast” . The menu seen appeared to be appropriate and nutritious. Guidelines for different religions’ foods, for example Hindu, Sikh, Jewish are available should the need for these arise. At present none of the residents have any specific dietary requirements in relation to their religious or cultural needs. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 14 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 People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. Residents receive their prescribed medication appropriately and as safely as possible EVIDENCE: The residents require differing amounts of support with their personal care. Some are quite independent but others are dependent on staff to meet their personal care needs. Details of the help that they need and how they prefer to be supported are in their individual plans. All of the residents go to the local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 15 and these show that residents have checks from the optician, dentist and when needed the chiropodist. Residents have had “annual health checks”. Therefore residents’ health care needs are being met. None of the residents are able to self medicate and medication is administered by staff that have been trained and deemed capable to do this. This is usually a senior or a shift leader. Medication is stored in an appropriate lockable cabinet in the main office. Avenues Trust have developed a medication policy in consultation with one of the Commissions’ specialist pharmacist inspectors. The service had just changed their pharmacy and medication system as it was felt that the new system was more appropriate and complied with requirements. The new company carried out training for staff and staff will have workbooks, which will count towards NVQ. Examination of the MAR (Medication Administration Record) found that these had been appropriately completed. There was also descriptions of how their medication needed to be administered. For example “I take my medication in liquid form from a spoon”. It also showed how residents are supported to be a bit more independent by applying cream themselves with support rather than staff automatically doing this. Some residents receive PRN (as required) medication and protocols/guidelines have been developed for these to ensure that all staff know when to give this medication and for what purpose. The doctor has signed these guidelines. Overall, medication is appropriately stored and administered and residents are receiving their prescribed medication safely. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 16 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 People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a complaints procedure, available in a user-friendly format that would be followed in the event of any complaints being made. Residents can be supported to make any complaints by an independent advocacy service. All staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. Residents’ bank accounts need to be more tightly monitored to further safeguard them from financial abuse. EVIDENCE: Two of the residents are not able to realistically make a complaint due to their profound learning and communication difficulties but the other residents would be able to voice dissatisfaction. The organisation has an appropriate complaints procedure and is available in a user-friendly format. This is included in the service user guide. Residents have access to independent advocates who can raise any concerns or issues on their behalf. Staff are aware of what to do and how to facilitate a complaint. The Commission has not received any complaints or concerns about the service since the last inspection. A random selection of residents’ finances was checked and cash amounts held agreed with records. Receipts were on file. Residents’ monies are securely Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 17 stored and checks are made at each handover. During a previous inspection it was discovered that residents were routinely paying for staff meals and other staff expenses. This is no longer the case and residents have been compensated for any expenditure on staff expenses or for any items that should have been purchased by the organisation. The manager is now appointee for most of the residents and is in the process of arranging that those residents that are able will be able to sign to withdraw cash. The organisation carries out financial audits and the service manager checks residents’ monies as part of the monthly monitoring visits. Although a record is kept of withdrawals it was noted that bank accounts are not reconciled or checked. A system needs to be in place to reconcile and monitor residents’ bank accounts. This will offer further safeguards to residents in terms of their finances. Staff have received protection of vulnerable adults training. They are aware of what constitutes possible abuse and of the action that needs to be taken. This offers more protection to residents who are unlikely to be able to indicate that they have not been treated appropriately and are relying on other people to keep them safe. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents live in a purpose built home that is suitable for their needs. EVIDENCE: 6 Peel Way is a purpose built home for six adults with learning disabilities, situated in Harold Wood, Romford. It is a detached two-storey house with an enclosed garden to the rear. There is an open plan lounge/dining area, conservatory, kitchen, and utility room on the ground floor, as well as two bedrooms, both of which have ensuite toilet and bath. The remaining four bedrooms are on the upper floor, and each have an ensuite toilet, and share a bathroom. There is a ramp to both front and back entrances, but no lift to the upper floor. None of the residents require any specialist adaptations. The kitchen has started to look quite worn and there is a broken cupboard door. This will need to be refurbished or replaced before too long. The manager said that they are checking the budget and that they hope that this Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 19 will be done. They are also hoping that the building will be redecorated. Therefore at this stage no requirements have been made. Bedrooms are personalised according to individuals likes. One resident is a Manchester United supporter and his bedroom reflects this. Another resident likes sensory things and his room has been redecorated and sensory equipment has been purchased for it. At the time of the visit the home appeared to be clean and was free from offensive odours. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Staffing levels are sufficient, and staff receive the necessary training, supervision and support, in order to meet residents’ current needs and provide an appropriate service for them. Staff are properly recruited and the necessary checks carried out. This helps to protect service users and keep them safe. EVIDENCE: There is a minimum of three staff on duty during the daytime shifts and two staff during the night. Four staff are frequently on the shift and this is linked to residents’ activities. Staff spoken to said that that these staffing levels and arrangements are better and that there is more flexibility to work with residents both in the home and in the community. They also said that there had been occasions when there had only been two staff on duty in the morning instead of three but that this was not often and was getting better. From discussions with staff and from examining rotas it would appear that staffing arrangements and levels and are sufficient to meet residents’ assessed needs. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 21 The staff team all have experience of working with people with learning disabilities. Staff on duty said that they had received training since they started work in the home and that the training programme for the coming year was available and that they have been booked on other courses. A staff training record was available and this showed courses completed and those that staff were booked to attend in the coming months. One member of staff said that they had “a most enjoyable and very knowledgeable induction”. Another staff said “the training is very good and is open to permanent and bank staff which is excellent.” Staff training has included the Mental Capacity Act, challenging behaviour, de-escalating and defusing, Protection of Vulnerable Adults, health & safety and infection control. Some staff have NVQ level 2 &/or level3 but feedback from staff was that the availability of NVQ training was an area that needed to be improved. However overall the staff team are receiving the training that they need to meet residents’ needs The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. Staff records are held centrally at the organisations head office in line with an agreement made with the Commission. However copies of the necessary information was available in the file held at the home and two files were examined during the inspection. The files contained evidence that the necessary checks had been carried out. Therefore the recruitment procedure offers safeguards to residents. Staff are receiving regular supervision and staff meetings are being held each month. This gives staff the opportunity both collectively and individually to discuss work practice, any concerns and the development of the service. Feedback from staff was that they can raise issues or suggestions and that these are welcomed and listened to. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 22 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, 38, 39 & 42. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The home is well managed and provides a safe environment for the service users. The registered provider monitors the service appropriately to check the quality of the service provided to residents. The residents are benefiting from the management and development of the home. EVIDENCE: The manager has experience of working with people with learning disabilities and has completed NVQ 3. She has been a senior and an assistant manager at Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 23 a residential home and has also managed a supported living scheme. She is undertaking the Registered Managers Award. The manager has recently been registered by the Commission and deemed suitably qualified, experienced and fit for the position. Staff feedback was that the service has changed a lot. It was chaotic but is now more organised and structured. This has meant that residents have a lot more opportunities and are a lot more involved with the daily running of the home. One staff said “the manager and deputy are good and know what they are doing, this gives everyone more security.” Therefore the residents are benefiting from a well run home. A representative of the organisation carries out monthly unannounced monitoring visits to the home and a report on this visit is left at the home and a copy of this sent to the Commission. The reports cover the necessary areas and indicate any action that is needed. The service manager and the home manager review the progress of the service regularly and an action plan is agreed. Stakeholder questionnaires are sent to appropriate people to get feedback on the quality of the service provided. Therefore the quality of the service provided to the residents is monitored by the organisation. The staff team carries all of the necessary health and safety checks out regularly. For example fire call points are tested weekly, as are hot water temperatures. Fridge and freezer temperatures are tested daily. Appropriate servicing is carried out on the fire system and fire equipment. Fire drills have been held in March and in July. Appropriate service and checks are also carried out on equipment and services. For example gas safety and portable appliance testing. A safe environment is provided for the residents. Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13 Requirement A system must be in place to reconcile and monitor residents’ bank accounts and to more tightly safeguard their finances. Timescale for action 31/12/07 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 Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Peel Way DS0000015599.V351472.R01.S.doc Version 5.2 Page 27 - 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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