Inspection on 29/01/07 for Rachel Mazzier House

This inspection was carried out on 29th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Rachel Mazzier House 31/01/06

Rachel Mazzier House 31/08/05

Rachel Mazzier House 04/03/05

Rachel Mazzier House 01/09/04

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

CARE HOME ADULTS 18-65 Rachel Mazzier House 25 Chatsworth Road Brighton East Sussex BN1 5DB Lead Inspector Jane Jewell Key Unannounced Inspection 29th January 2007 10:15a Rachel Mazzier House DS0000014228.V325912.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 Rachel Mazzier House DS0000014228.V325912.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. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rachel Mazzier House Address 25 Chatsworth Road Brighton East Sussex BN1 5DB 01273 564021 01273 564021 mail@sussextikvah.org.uk 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) Sussex Tikvah Ms. Joanne Osbaldiston Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of services users to be accommodated must not exceed six (6). Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability only to be accommodated. Date of last inspection 31st January 2006 Brief Description of the Service: Rachel Mazzier, also known as Sussex Tikvah is a registered care home providing support for six people who have a learning disability. The home caters for people of the Jewish faith who have low to medium needs. The home provides only long term placements Brighton Housing Trust owns the building and the Jewish Charity, Sussex Tikvah, is responsible for the day to day running of the home and internal maintenance. The home is located on the outskirts of Brighton and within a fifteen-minutes walk of Brighton town centre, in addition there are local shops and amenities nearby. The home is a converted semi-detached domestic dwelling located in a residential street. Parking is restricted to pay and display bays. The home is presented across three floors with access to all floors via stairs. The stairs and other access arrangements mean that the home is suitable for residents who are mobile. Residents’ accommodation consists of six single bedrooms. Communal space consists of a lounge, dining room and small courtyard garden. The homes literature states that it aims to maximise independence by involving residents in all aspects of the running of the home and support residents in the practice of their religious beliefs. The fees for residential care are currently £483.00 to £ 583.05 per week, depending on the services and facilities provided. Extras such as: newspapers, holidays, cinema hairdressing, chiropody and massage are additional costs. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced inspection undertaken over six hours and information gathered about the home prior to the inspection. This includes: residents survey questionnaires, discussion with relatives and stakeholders involved in resident’s care and records submitted to the Commission for Social Care inspection (CSCI) including a Pre-inspection questionnaire. The inspection was facilitated by Joanne Osbaldiston (Registered manager) and Corrine Laurelut (Deputy manager). The inspection involved a tour of the premises, observation, examination of records and discussion with residents and staff. There were six residents living at the home at the time of the inspection. The focus of the inspection was to look at the experiences of life at the home for people living there. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: Residents live in a comfortable, homely environment which suites their needs and which is maintained and cleaned to a high standard. Residents benefit from a well supervised, experienced and stable staff team that know their needs. Comments about staff included: “life is excellent here”; “I like the home , I like everyone in the home” and “The staff and residents are nice and I feel it’s the right place for me”. Residents are supported to maintain relationships with their families and with the local community as they wish. A sample of comments made by relatives include: “The home is really quite exceptional”; “My son is extraordinary lucky to live at the home”; “wonderful place” “people are kind and caring” and “Staff extremely supportive and helpful” Residents are given support in order to have active social and leisure experiences. Integral to the ethos of the home is ensuring and respecting residents’ rights to make decisions about their daily lives. The home balances the rights of tenants to take reasonable risks as part of an active lifestyle against any unacceptable risk to themselves or others. Residents are offered a choice of well-balanced and wholesome meals. Rachel Mazzier House DS0000014228.V325912.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. Rachel Mazzier House DS0000014228.V325912.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 Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the homes services and facilities should the need arise for this to be shared with prospective residents and their representatives. Prospective residents would benefit from an admission process that ensures their individual needs and aspirations are assessed prior to moving in. The home is able to identify and meet the needs of the service users. EVIDENCE: There is information available about the home, to inform current and prospective residents about the services and facilities, this includes a statement of purpose and licence agreement. There have not been any new admissions to the home for a number of years. Therefore, this standard could only be assessed in respect of the admission procedure for prospective residents. The manager was aware of the admission criteria for the home and knowledgeable about admissions practices that would ensure a comprehensive range of information is gathered about prospective residents. This would then inform their decision whether a prospective Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 9 residents’ needs could be met at the home. There are also policies to ensure an effective pre-admissions process and moving in plans. A relative said that they were actively involved in the admission process of their relative. This had involved visits to the home, meeting staff, residents and the committee members. The manager said that prospective residents would be encouraged to visit the home prior to admission, along with any placing care manager, family or representative. The type and length of visits would depend upon the individual need. In the past a resident also visited local collages whilst staying at the home to see if the courses they offered would be suitable for them. A resident recalled that they were invited to stay for a trial period to determine whether they wished to stay permanently and were encouraged to make their own decision and said that they liked it so much that they never wanted to leave. Residents are aged between 31yrs and 76yrs with the majority of residents having lived at the home since it opened in the early 1990’s. Residents were a close cohesive group who clearly cared about one another’s welfare. Residents are assessed as having low to medium needs. In addition some residents have mental health needs. There is a wide range of evidence that the home is able to meet the range of residents needs. Staff consulted with, demonstrated a clear knowledge and understanding of the needs of each resident and also how those needs are consistently met. All residents consulted spoke positively about their experiences of the home and a sample of their comments include: “life is excellent here”; “I like the home , I like everyone in the home” and “The staff and residents are nice and I feel it’s the right place for me”. A sample of comments made by relatives include: “The home is really quite exceptional”; “My son is extraordinary lucky to live at the home”; “wonderful place” and “people are kind and caring” Licence agreements are used to inform residents and their representatives of their rights and responsibilities whilst staying at the home. This agreement is in a pictorial format for ease of understanding. The manager reported that resident’s signed copies are retained at the home and updated yearly. Rachel Mazzier House DS0000014228.V325912.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 and 9 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents’ benefit from support plans which detail information about how to support them safely and appropriately. Services are designed to provide appropriate care and support, in ways which maximise independence and choice for residents. The home balances well the rights of residents to take reasonable risks against any unacceptable risk to themselves or others. EVIDENCE: Each resident has a comprehensive care plan, which includes background information, health details, daily routines and personal care support. These provided clear guidance for staff on how to support resident’s needs. To further improve these it was discussed that residents individual aspirations and the targets leading to their attainment should be identified and included in care plans. Residents are involved, within the range of their strengths and tolerances, to participate in devising and maintaining their care plan. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 11 The manager and staff had a good working knowledge of the contents of care plans ensuring that residents received consistent support. Care plans were being updated regularly to reflect changes in resident’s needs and preferences. It was reported that a formal care plan review is undertaken six monthly with residents encouraged to invited people who are involved in their care. This has included relatives, placement authorities and day care services. The standard of daily recording in care plans was good with a clear account of actions and events that had occurred, these were written in a style that was respectful and non judgmental. The home has a developed system for enabling residents to take reasonable risks towards achieving an enhanced lifestyle. Written risk assessments are used to identify any risks faced or posed by residents and the control measures needed to help manage or reduce any risks. For example road safety and selfmedication. Some areas of residents’ lifestyles had not yet been assessed for any potential risk. This included diabetes and personal relationships. The manager agreed to promptly address this. It was evident that integral to the ethos of the home is ensuring and respecting residents rights to make decisions about their daily lives. One resident said ‘he was able to do what he wanted’ another spoke of choosing the décor for their bedroom and deciding what they wanted to do each day. Staff consulted were knowledgeable regarding the individual support needs of residents for them to make informed choices. Although no resident currently has an independent advocate, many have family members who undertake this role. One resident who does not have a next of kin felt that they could seek the support of members of the committee and that information about advocacy services was displayed at the home should they need this. Residents participate in the day to day running of the home in accordance with the range of their strengths and tolerances. For example some residents help to clean their bedrooms, undertake their own laundry and assist in the food shopping. One resident particularly enjoyed assisting with meal preparation while another went out independently to do some food shopping. A resident said that weekly meeting are used to discuss and identify any communal living issues, agree chores and discuss outings and menus. Rachel Mazzier House DS0000014228.V325912.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 and 17 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Residents’ lives are enriched by the home providing various opportunities for occupation and leisure and by residents being supported to make decisions about their daily lives. Resident’s benefit by being supported to maintain relationships with their families. The meals are good offering both choice and variety and catering for individual preferences. EVIDENCE: It was clear from reading documents, speaking with staff and from direct observations that residents are given the opportunities to maintain and develop social independence communication and living skills, as far as is possible within the constraints of their individual needs, likes and dislikes. A relative spoke of how their son was thriving and how he now goes out independently following intensive support from staff. One resident has just Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 13 completed a formal qualification in a foreign language that they were studying at college. Residents follow their own individual varied daily programmes. Some residents attend day care services for part of the week, where there is an opportunity to participate in structured curriculum based activities. Many residents have voluntary employment for a couple of hours per week. One resident preferred to be based at home and organise their own occupation and this was respected. A relative said that their daughter had gained in confidence and experience due to the variety of daily activities residents are supported to undertake. Records showed that use is made of the many local amenities in the area including shops, cafes and cinemas. Many residents go out independently and access these resources on their own. Two residents spoke of the synagogues they attend and the various outings and events that they enjoy going to and the friends that they visit and have made there. Residents spoke of the variety of leisure activities they undertake, which included cinema, bowling, art work, swimming and evening clubs. Residents have access to a computer, which they said they use for research, emailing friends and playing games on. In addition one resident also has their own computer. There was a range of equipment suitable for in-house entertainment, including books, audio equipment and, popular with some residents, free-view television. There is a leisure budget, which the manager said they use to fund one monthly group outing, the remainder being used to pay for staff when accompanying residents on outings. A relative felt that although residents are very active during the week, “weekends were not so full”. The home had identified that the wide age range of residents ages meant that it was often difficult to organise group activities and as a result now employs an additional member of staff on a Sunday in order to facilitate different activities. A resident said that the home has its own transport, which enables access to a wide range of leisure and recreational facilities. Care plans describe the significant others for each resident with the majority of residents relatives and friends taking an active role in their lives. Staff supported residents to maintain contact through the use of emails, visits and telephone calls. One resident is supported to visit friends regularly in other parts of the country and also has friends to stay at the home. A relative said that they are always made to feel welcome when they visit and have been invited to stay for meals in the past. All residents consulted mentioned flexibility in the daily routines and respect for their personal freedom and lifestyles. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 14 The home operates a kosher kitchen with alternating weeks of vegetarian and meat menus. One resident has a diabetic diet and who said received varied and interesting food. Another resident is on a weight reduction diet with their relative saying that their diet was healthy and balanced. No records were however maintained of any alternative meals /food provided. The manager agreed to undertake this in line with food safety guidance and the National Minimum Standards. The inspector had lunch with staff and two residents. The meal was relaxed with residents choosing what they wanted to eat. In addition to the main meals residents said that they could make themselves drinks and have their own snacks. Some residents are involved in the preparation of meals with one resident saying how much they enjoyed this. A sample of comments about the food included: “food is fabulous”; “high quality” and “spot on” Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 and 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive flexible, consistent, dignified and sensitive support to meet their personal, emotional and health care needs and are protected by the systems in place to manage medication. EVIDENCE: Staff were observed providing dignified and sensitive support in a relaxed and friendly manner. Care plans viewed contained information to guide staff in the delivery of personal care and health care needs. This helped to ensure that support was provided in a consistent manner. There was documentary evidence that residents are supported to access a range of health services, to meet their individual needs. This included: opticians, dentists, chiropodists and community health care teams. Residents are registered with a variety of local GP’s with prompt medical intervention being sought for any concerns. A resident said that when they felt unwell recently staff were very caring and called a Doctor straight away. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 16 As previously noted the manager agreed to undertake a risk assessment on a resident’s diabetes. The District nurse team currently supports the resident with managing their diabetes and it was discussed that staff could further increase their awareness of diabetes by undergoing training in this area. There is an established system for the administration of medication, which provides good, clear and comprehensive arrangements for the management of medication. The home encourages residents to administer and control their own medication where possible. It was previously recommended that stock medicines be regularly counted and that a self-medication risk assessment be reviewed. These have now been undertaken. As a matter of good practice it is recommended that hand written Medication Administration Records are checked and countersigned for accuracy by a second member of staff. Mood pictures are used to help a resident and staff determine when a resident needs additional medication, this practice is to be commended. Staff showed much understanding and sensitivity towards the needs of older residents. This included ensuring that appropriate occupation and activities are available. A resident had written a booklet about their life with the support from a volunteer, which they clearly enjoyed writing and sharing. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. An effective complaints procedure and appropriate adult protection policies and training for staff protect the rights and interests of residents. EVIDENCE: There is an accessible complaints procedure for residents, their representative and staff to follow should they be unhappy with any aspect of the service. The Manager stated in information submitted both before and during the inspection, that there have not been any complaints about the service in the last twelve months. All residents consulted felt confident to approach any member of staff with any concerns and felt that it would be dealt with promptly. The home has written policies covering adult protection and whistle blowing. These make clear the vulnerability of people in residential care, and the duty of staff to report any concerns they may have to a responsible authority for investigation. Staff consulted confirmed that they had attended training in the protection of vulnerable adults and demonstrated that they had a clear understanding of their roles and responsibilities in this area. The home had made an adult protection referral in the last twelve months which social services had asked the manager to investigate. The manager reported that social services were happy with the outcome of their investigation and no further action had been necessary. The paper work relating to this investigation could not be located at the time of inspection. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 18 Residents are encouraged to manage their own personal finances. Where the manager holds personal monies on behalf of residents, there was a transparent system for the handling of this money. The system had an easy audit trail from receiving benefit monies to cash transactions. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 27 28 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, homely environment which suites their needs and which is maintained and cleaned to a high standard. EVIDENCE: The home is located in a residential street on the outskirts of Brighton near to many local amenities including day care services, local shops, pubs and cafes. Several residents said that one of the best bits about living at the home is its location being near to so many amenities and transport links. The home is maintained and decorated to a high standard. The external maintenance of the building is the responsibility of Brighton Housing Trust. The manager was happy with the quality of the work undertaken by them and maintenance issues being undertaken in a timely manner. . Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 20 Communal space consists of a lounge, dining room and small courtyard garden. This shared space was well used and decorated and furnished in a homely manner. Residents consulted said how they liked their bedrooms. Resident’s bedrooms were highly individualised reflecting their tastes and preferences. A resident said that they had requested that there bedroom be redecorated and this was undertaken. They spoke of being supported to choose the colours and new furnishings. Bedroom doors are fitted with locks. The manager reported that keys are available should a residents request them, but to date no residents have done so. One bedroom is below 10sq metres, with innovative use of the space to maximise the living area. There are sufficient number of toilets and bathing facilities located around the building, including the redecoration and installation of a new bath and shower. The home is not designed to offer a service to people with physical disabilities and the stairs and other access arrangements would make it unsuitable for residents with significantly restricted mobility. Residents are ambulant and currently do not require specialist equipment, however, the manager is mindful of the aging process for some residents. Laundry facilities have been created in a converted down stairs toilet. Residents undertake some of their own laundry and ironing with some supervision from staff. A cleaner is employed weekdays, with residents also expected to be involved in keeping their bedrooms clean. The standard of cleanliness and hygiene in the home was noted to be very high Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 and 36 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a stable, well-supervised, experienced and enthusiastic staff team that know them and who are employed in sufficient numbers as is necessary to safely meet the needs of residents. EVIDENCE: It was observed throughout the inspection that staff understood their roles and had good planning skills. Staff had a clear understanding of the purpose of the service and how their role contributed to the achievement of this. Staff consulted with spoke respectfully and professionally regarding residents and demonstrated much commitment towards the home and enthusiasm towards supporting residents. Most of the staff have worked at the home for a number of years which enabled residents to be provided with stable and consistent support. All persons consulted regarding the home spoke positively about the staff. A sample of comments regarding staff include: Staff very nice and helpful”; “excellent” and “Staff extremely supportive and helpful”. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 22 The minimum staffing level is for one staff to be on duty throughout the waking day, this is excluding the manager and cleaner. Additional staff are employed at the weekend to enable for a range of activities to be undertaken. The manager reported that there is some flexibility in staffing levels and when the need has arisen in the past additional staff have been rostered. Staff felt that the staffing ratio was sufficient for them to undertake their duties in a timely manner and spend individual time with residents. All residents consulted with felt that there was always staff around to support them if they needed them. There is historically little turnover of staff. New staff recently recruited had previously worked at the home as relief staff and were therefore already familiar with the needs and preferences of residents. Recruitment files were examined these showed that the recruitment process followed included the use of an application form, interviews, CRB checks and written references prior to employment commencing. The home has teamed up with a Human Resources service in order to gain additional support for staff and to assist the manager in such issues. The manager reported that training is valued by the committee, who oversee the running of the home. Staff were found to have compulsory training such as Moving and Handling, medication, First Aid, food hygiene and Fire safety. With additional training in mental health, Judaism and autism also undertaken. The deputy manager oversees the induction of new staff and has developed an induction process for staff to follow. Staff said that they receive regular supervision with the manager regarding their performance, conduct and training needs. Staff consulted said that they felt well supported by the manager to undertake their roles and felt able to approach them for advice and guidance. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 42 and 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents continue to benefit from an experienced and established manager who ensures a clear ethos and values of the home enables staff to provide good quality care to residents. A range of regular health and safety checks helps to ensure the health and safety of residents and staff. EVIDENCE: There was clear evidence available that the home is managed effectively with a strong sense of leadership and direction being provided. The registered manager has managed the home for a number of years and is well qualified for the role. The manager reported that they undertake regular training in order to keep themselves updated in the care of people who have learning Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 24 disabilities. The manager said that they received supervision from an experienced member of the committee. A sample of comments regarding the manager includes: “ we have a great manager who is hard working and honest”; “gets things done and takes on board other people ideas” “excellent” and “pretty good”. There is an established management on call system, as staff work largely by themselves in the evening and at night. A staff member said that they have confidence in this system and can call the duty manager at any time. It was previously required that the home provides the Commission with a copy of the quality assurance report, this requirement is now been assessed as met. The manager reported that a yearly quality assurance review is undertaken. This is undertaken in two parts, residents satisfaction surveys and review of services and facilities. The deputy manager and the committee undertake this task and produce a report of the audit outcome. It was clear that action is taken to address any areas of shortfall identified during the quality review. A range of ways were seen of how well residents are fully involved in the running of the home with weekly meetings and informal consultation. Two residents are also members of the committee that oversee the running of the home. Written guidance is available for staff on issues related to health and safety. Records submitted by the manager prior to the inspection stated that all of the necessary servicing and testing of health and safety equipment had been undertaken. The manager reported that systems to support fire safety were in place. This included: fire risk assessment, staff training, testing and servicing of fire safety equipment and regular fire drills. The manager acts as the home’s budget manager and the committee manages the financial viability of the home. There are clear lines of accountability between the home and the committee. A member of the committee visits monthly and undertakes the required monthly audit of services and facilities and completes a written report on their visit. This is in accordance with their responsibilities under the National Minimum Standards. Much evident was apparent in how supportive the committee members are to staff and residents and in the homes aims and objectives. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 4 STAFFING Standard No Score 31 3 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 4 3 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 x x 3 3 Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA20 Good Practice Recommendations That care plans include residents individual aspirations and the targets leading to their attainment. That hand written Medication Administration Records are checked and countersigned for accuracy by a second member of staff. Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Rachel Mazzier House DS0000014228.V325912.R01.S.doc Version 5.2 Page 28 - 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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