Inspection on 12/03/04 for Priory Road

Care Homes For Adults (18 ­ 65)Priory Road9 Priory Road Nether Edge Sheffield South Yorkshire S7 1LWUnannounced Inspection12th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Priory Road Address 9 Priory Road, Nether Edge, Sheffield, South Yorkshire, S7 1LW Email Address Tel No: 0114 281 3183 Fax No: 0114 281 3183Name of registered Company Sheffield Alcohol Advisory Service Name of registered manager Mr Stuart Hawkshaw Type of registration Care Home No. of places registered 6Category of registration, with (number of places) Past or present alcohol dependence (6) Registration number C060000173 Date First registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 30th July 2002 YES YES 15.7.04 If Yes Refer to Part CPriory RoadPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector 1 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspection20th January 2004 09:00 am ­ 200 pm Rob CurrID Code099576None None Stuart Hawkshaw - ManagerPriory RoadPage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementPriory RoadPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Priory Road. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Priory RoadPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Sheffield Alcohol Advisory Service at Priory Road project is a residential unit with facilities to care for up to six men and women with alcohol related problems. Priory Road is a detached house with 4 single rooms and 1 double room. One to one and group counselling is provided, with the aim of reshaping lifestyles and learning to enjoy life without drink.Priory RoadPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors SummaryThis was an announced inspection that took place over one day in March 2004. Six service users were spoken to during the course of the inspection. Due to the nature of this unannounced inspection the majority of standards were not checked. There was a positive atmosphere at the home. Choice of home. Service users were able to visit the home prior to planned admission and there was an agreed trial period. The inspector had met one service user before when the service offers an `open house to prospective service users. This is when prospective service users and other relevant professionals come to visit the home and meet with current users. Contracts were issued and the service users and staff undertook assessments of need. The home had a Statement of Purpose and Service User Guide. Health and Personal Care The service user plans seen were written by the service users and staff. Health care records were complete. Staff had respect for service users. All of the service users had control of their own medication. Daily Life and Social Activities A range of recreational pursuits were available within the home and outings and trips were organised on a regular basis. All service users undertook their own food preparation and cooking. Complaints and Protection The homes complaints procedure was displayed and all service users were aware of this. No formal complaints had been made since the last inspection. A service user explained the homes `group contract to the inspector. This is built on the basis of respect for oneself and others. One service user said that no matter how small a concern was, the management would do all they could to rectify it. Environment The home met the required standards both for individual and communal space. The home was pleasantly decorated throughout and service users bedrooms were highly individual. The service users dining room was used for a variety of activities. The manager and staff had worked hard to complete a project that would enable service users to have private and group meetings in a detached meeting room in the grounds of the home. Staffing Levels of staff were being maintained as agreed with the registering authority. Recruitment procedures were in place and the home had a staff-training plan. Staff received formal supervision and undertook an induction on commencing work. Staff had received training in food hygiene, fire procedures and health and safety. Management and Administration. The homes manager audited the day-to-day running of the home. All service users controlled their own monies. The home had a maintenance programme. Priory Road Page 6 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 2 12 3 12 CSA 28(1) YA1 YA6 YA41 YA16 YA17 YA28 4 Appendix 3 YA40 The home must produce copies of all policies and procedures and documents as outlined in the National Minimum Standards 1.9.04 Service users must have a dedicated dining room for their sole use. The Certificate of Registration must be on display in a conspicuous place. 1.6.04The care plan must contain a section to identify 1.6.04 the preferred gender of the person to offer support/counselling to the service user. 1.8.04Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 YA25 YA27 Double bedrooms must be phased out by 1st April 2004 unless two service users currently living there choose to continue sharing. In existing homes en suite toilets and wash basins should be provided where possible; toilets must be shared by no more than three people (by the 1st April 2004) 50 of the staff must achieve the NVQ level 2 by 2005 The registered manager must hold qualifications at level 4 NVQ in both management and care by 2005 Page 73 4YA32 YA37Priory Road CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMET (YES/NO)Priory RoadPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 12,13 YA21 The manager must develop a policy specifically related to the ageing process and dealing with the death of a service user The toilet seat in the ground floor toilet must be replaced. A risk assessment must be put in place for the identified worker without two written references. The responsible individual must provide the NCSC with a report of their monthly visits. A risk assessment must be put in place for the use of aromatherapy candles in the house. 1.8.04216,23YA271.6.04318YA341.6.04426YA391.6.04523YA421.6.04Priory RoadPage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * YA16 YA261The development of the `meeting room in the grounds should continue.Priory RoadPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES YES NO NO YES YES YES NO YES YES NO NO NO YES YES YES 6 0 X YES YES NO NA 2 0 12/3/04 9.00 4.5Priory RoadPage 11 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Priory RoadPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 340 340 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? The inspector checked one service user plan. This plan had recently been reviewed to include a planned discharge from the home. This plan set out in detail the service users needs and the action required by staff to ensure all these were met. This included current and anticipated specialist requirements being met, any restrictions on choice and freedom (agreed with the service user) imposed by a specialist programme. There was no a section in the care plan for the service user to identify their need to be supported/counselled by staff of a specific gender. A previous requirement was made in relation to this issue. This has been carried forward. Individual procedures were also seen for service users who may be likely to be aggressive or cause harm or self-harm, these focused on positive behaviour, ability and willingness. Service users and staff interviewed confirmed they were responsible for drawing up and developing their own care plans. From speaking to the service users it was clear that they have control over the `house rules. One service user explained the `group contract to the inspector. This focused on cooperation, consideration, honesty and respect for self and others. A key worker system was in place within the home, service users interviewed confirmed this.Priory RoadPage 15 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and exceeded at the last inspection.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 18 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? It was clear from the inspectors observation that daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in individual care plans. Service users were seen having responsibility for housekeeping tasks. (e.g. making a sandwich, cleaning and laundry). There was full access to the garden at the rear of the home. The inspector acknowledged that that space was limited within the home. However, the inspector observed that that the service users dining room was used for a variety of meetings, activities and administration. The service users had no private meeting room for counselling sessions or group meetings. Some service users were concerned that their conversations could be `over heard due to the lack of private facilities. A previous requirement was made in relation to this issue. This has been carried forward. Since the last inspection the manager has obtained funding for a detached meeting room in the grounds. This work was well underway and both the manager and service users were involved in its development. The manager is to be commended for his commitment to this project. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The issues round taking meals in a congenial setting are discussed in standard 16.Priory RoadPage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Service users healthcare needs were clearly identified in the care plans. They were supported and encouraged to take up appointments with GPs, CPNs, psychiatrists, social workers, dentists, opticians and other identified professionals. Service users health was monitored as part of the care plan review and service users told the inspector that they had complete responsibility for their own health e.g. giving up smoking or losing weight. Specialist advice had been sought for service users who needed it. Service users told the inspector that they were able to see visiting professionals in private.Priory RoadPage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? All the service users retained and administered their own medication; records were kept in the home of medication prescribed to each service user. Facilities were provided for service users to store medication securely in their bedroom. The home had a medication policy, which allowed for the safe management of medication.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 1 Key findings/Evidence Standard met? The home did not have a specific policy to assist the staff deal with service users ageing process.Priory RoadPage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 X X X X X X 3 Key findings/Evidence Standard met? The inspector checked the records of complaints. There had been no complaints. This standard was only partially checked. This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES00 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO NO X X X X X XX X X X0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 2 Key findings/Evidence Standard met? The home had a sufficient number of baths, showers and toilets. These were close to bedrooms, lounges and dining areas. Privacy locks were in place. The toilet on the ground floor had a worn and damaged toilet seat.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 2 Key findings/Evidence Standard met? The home provided sufficient space for communal use, this included: outdoor space with seating, domestic kitchen and laundry, and a lounge, which was the agreed smoking area. The inspector observed the dining room being used for a variety of uses. This at times prevented the service users from using for dining. Staff had adequate facilities to store their personal belongings.Priory RoadPage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 9 Key findings/Evidence Standard met? The home did not have any service users who required any adaptations to be made to the building or specialist equipment provided.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? There were job descriptions for each post in the home; these explained the role of the employee and what they would be expected to do to meet the needs of the service users. It was clear to the inspector from staff and service users spoken to and from examination of the care plans that staff were encouraged to develop strong professional relationships with service users. Staff were encouraged to take part in training activities. The manager stated that they did inform staff about the General Social Care Council code of conduct. Staff interviewed were aware of the need to seek support from within and outside the home for the service users. The home did not use volunteers.Priory RoadPage 28 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X002 Key findings/Evidence Standard met? Staff were aware of other services available for the service users and maintained good contact with other professionals (this was evident in care plans). Staff have had training on maintaining a safe environment and managing potentially aggressive behaviour. The entire staff group were registered on NVQ training at both level 2 and 4. This standard was only partially checked.Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Staff files were available to be checked. The manager stated that there was a thorough recruitment process which included obtaining two written references, obtaining full employment histories, a criminal records check, medical checks, obtaining proof of ID and any qualifications. The staff interviewed confirmed these processes had occurred and that they had received statements of terms and conditions. One file did not contain two written references. This staff member had worked at the home for number of years. A previous requirement was made in relation to this issue. This requirement has been changed. All staff including the manager had an enhanced Criminal Records Bureau disclosure. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The manager had created a thorough training and development plan. Each staff member also had a development plan. From records checked there was evidence that the staff had all received a structured induction. The plan was up-to-date and the manager was on target to meting the staffs training needs.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. NO 2Key findings/Evidence Standard met? The manager was now registered on the NVQ level 4 in management. This standard was only partially checked.A previous recommendation was made in relation to this issue. This has been carried forward.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was assessed during the last inspection. The standard was checked and met at the last inspection.Priory RoadPage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The manager had developed a clear annual development plan, based on a systemic cycle of planning ­ action ­ and review. The National Care Standards Commission have not been receiving the monthly reports required by regulation. This standard was only partially checked.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 1 Key findings/Evidence Standard met? The home had some policy documents which were appropriate to the setting and staff and service users had access to these. Staff were involved in developing policies and service users had opportunities to assist in their development. The manager stated that he had developed the majority of the policies required. The ispector checked all the policies and could see that the manager had further developed them. This work was on-going. A previous requirement was made in relation to this issue. This has been carried forward. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 1 Key findings/Evidence Standard met ? The inspector checked a sample of records that the home was required to keep. These were in the main appropriately completed and up to date. Records were stored securely. The service users spoken to were aware they had access to their own records. Issues relating to incomplete records are mentioned elsewhere in this report.Priory RoadPage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The home did have a health and safety policy. The records did show that staff had received training in health and safety. Fire safety, first aid and food hygiene. Hazardous substances were securely stored. In the bathroom it was noted that the service users enjoy the use of aromatherapy candles. This issue was discussed with the manager. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The manager stated that the company had a business and financial plan. He takes part in the wider management group meetings. There is a finance management group where all the running costs are discussed. The manager does have control over the finances. The manager then receives the published audited accounts. Insurance, including public liability was in place.Priory RoadPage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition None CommentsComplianceLead Inspector Locality Manager DateRob Curr Joanne Knight 2.4.03Signature SignaturePriory RoadPage 34 PART D(where applicable) NoneLAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Priory RoadPage 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12th March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible NoneAction taken by the NCSC in response to provider comments: Priory Road Page 36 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan within 28 days, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOPriory RoadPage 37 E.3PROVIDERS AGREEMENT ­ Unannounced Inspection 12.03.04 Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Nicola Smith of Priory Road confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Nicola Smith of Priory Road am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Priory RoadPage 38 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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