Inspection on 13/09/06 for Sabre Court

This inspection was carried out on 13th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sabre Court 29/08/07

Sabre Court 24/01/06

Sabre Court 21/04/05

Sabre Court 19/10/04

Sabre Court 29/04/04

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

CARE HOME ADULTS 18-65 Sabre Court 4 Lonsdale Road Scarborough North Yorkshire YO11 2QY Lead Inspector Mr M. A. Tomlinson Key Unannounced Inspection 13th September 2006 09:30 Sabre Court DS0000007730.V310877.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 Sabre Court DS0000007730.V310877.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. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sabre Court Address 4 Lonsdale Road Scarborough North Yorkshire YO11 2QY 01723 361256 01723 361256 Jantaitt@connect.com 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) Mr Andrew Maurice Tait Mrs Janet Tait Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (12) Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One Service User with a dementia and aged under 65 years of age may be accommodated. This condition will terminate when the named Service User ceases to be accommodated at Sabre Court. Service Users under 65 years of age whose primary need for care derives from a mental health disorder, but who have an associated dementia may be accommodated in the home. 24th January 2006 Date of last inspection Brief Description of the Service: Sabre Court is a large semi-detached house situated in a residential area of the town. It is convenient for local amenities and facilities. Public transport to and from the town centre passes the door. Accommodation and facilities are provided on three of the floors. The ground floor houses the communal areas while the upper two floors provide the bedroom accommodation. The top floor is used for storage purposes and night staff accommodation. The property does not have a passenger lift and is consequently only considered suitable for service users who are fully ambulant. Sufficient numbers of bathrooms and toilets are conveniently located throughout the building. The home provides accommodation for residents who have or who are recovering from mental illness. The staff provide personal care as and when required, help, advice and guidance on daily living skills and activities, a catering service, laundry facilities and a domestic and cleaning service. All these services are offered in conjunction with input from the residents. Leisure and recreational facilities are offered in-house by staff and at a number of locations in the town. Most residents are able to leave the premises unaided and can take advantage of the many attractions in the town. All residents are registered with local medical practitioners who will make arrangements for the provision of more specialised health services. Residents have direct access to community psychiatric nursing services. The current fees for the service users are £317 a week. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit formed an integral part of the annual ‘key inspection’ process for the home undertaken by the Commission for Social Care Inspection (C.S.C.I.). Information contained in this report was obtained through discussions with the home’s management, the staff, discussions with five service users, and telephone discussions with relatives of four the service users. A telephone conversation was held with a Macmillan Nurse who recently attended a service user. The report also reflects comments made in three Comment Cards returned from health and social care professionals and the information provided by the registered manager in the pre-inspection questionnaire. The service users were also provided with an opportunity to complete Comment Cards but they declined to do so. The report also includes information obtained by the C.S.C.I. prior to and subsequent to the inspection visit. A number of statutory records were examined. What the service does well: What has improved since the last inspection? The registered manager has continued to review, modify and update the policies and procedures of the home. The staff have continued to look at ways of overcoming the service users’ apathy and lack of motivation by endeavouring to get them involved in the daily routines of the home. Since Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 6 the last inspection the staff have been provided with the opportunity to attend a range of training courses covering statutory as well as professional subjects. A programme of redecoration and refurbishment of the premises continues. 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. Sabre Court DS0000007730.V310877.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 Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. Prospective service users are fully assessed prior to their admission into the home so that the manager can make a considered decision as to the appropriateness of the proposed placement. EVIDENCE: The three care records examined contained a pre-admission assessment of the respective service user. This was in addition to any assessment provided by a service user’s placing authority. The pre-admission assessments were clear and comprehensive and provided a good basis on which an initial care plan could be developed. In addition to a service user’s needs they also identified their strengths and abilities. The care records also contained individualised risk assessments thereby underpinning the service users’ safety. One of the more recently admitted service users confirmed that they had received adequate information on the home prior to their admission so that they could make a considered decision as to whether they wished to live there on a permanent basis. They went on to say that the home ‘exceeded their expectations’. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 9 All of the service users had been provided with a statement of the conditions of residence and were consequently aware of the service to be provided before their admission into the home. This was in addition to the contract agreed with the service users placing authority. From an examination of the records and discussions with the staff and service users, it was apparent that the home had the capacity and the staff the skills to meet the needs of the current service users. Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. All of the service users have comprehensive care plans that clearly identify their needs and abilities along with the actions required to be undertaken by the staff to meet those needs. EVIDENCE: All of the service users had a care plan developed and implemented by the home. This was in addition to any care plan provided by a placing authority thereby ensuring a multi-agency approach. The care plans were clear and meaningful and therefore took into account the literacy abilities of the staff. They were also well organised and laid out in a logical manner that enabled the staff to easily access information. The objectives both short and long-term were achievable and consequently the staff saw the care plans as a practical tool on which they could base the care required. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 11 The staff on duty had good access to the care plans and confirmed that they used them on a regular basis. Each service user was allocated a key worker who had the responsibility to ensure that the service user’s needs were being met as identified in the appropriate care plan. There was evidence that the care plans had been regularly reviewed and updated as necessary thereby ensuring that they remained current and relevant. The staff maintained daily records of the service users that were linked into the care plans. The care plans also incorporated ‘agreements’ with specific service users particularly with regard to the administration of the medication and rationing of their cigarettes. These agreements had been signed by the service user concerned thereby indicating their agreement. There was some recorded evidence that the service users had direct input into the development and implementation of their care plans. Several had signed their care plan indicating their agreement with it. One of the more able service users said, however, “We have a care plan as far as I know but I don’t know what’s written in it. I’d like to have a read. If they’re written about you then you ought to know what’s in them”. It was apparent from discussion with several service users that they are able to make individual choices and decisions particularly as to how they wished to spend their time thereby promoting their independence. It was observed that some of the more able service users assisted the staff with the daily domestic routines in the home. As previously stated risk assessments had been undertaken on the service users so that they could be enabled by the staff to lead active and meaningful lives whilst not undermining their safety. The comment cards received from Social Services’ Care Managers indicated their total satisfaction with the standard of the service provided by the home. Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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”. The service users are enabled to follow a lifestyle best suited to their needs and wishes. EVIDENCE: The service users presented as having a range of needs thereby presenting a possible challenge for the staff in order to successfully meet those needs. It was, however, apparent from discussions with them that they were satisfied with the service provided by the home and in particular the support provided by the staff. They felt that the home was meeting their needs. It was evident that they had established a close but professional relationship with the staff and were not reluctant to voice their views and opinions. They presented as being relaxed and at home in their environment. The majority of the service users had a natural sense of humour and were very talkative. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 13 There was not a formal programme of social activities for, according to the more able service users, it was not necessary. One service user stated, “ Things here are not programmed – I wouldn’t like that. It was like that where I lived before and you were ordered around” and another said, “ I can do what I like here. I just come and go as I please”. The service users were enabled and encouraged to make maximum use of the local community facilities thereby promoting their independence and their integration within the community. One of the service users had a part-time job and another owned a motorcycle. Another service user was staying with his parents for a few days. Some of the service users had minimal or no contact with members of their family either through choice or because there were no known relatives. Overall the home presented as being more like a supported living establishment in which the service users could live their lives at their own pace. One of the biggest problems faced by the home was the apathy and lack of motivation displayed by the majority of the service users. Considerable efforts had been made by the staff to overcome this by, for example, encouraging the service users to become involved in the daily routines of the home and arranging social activities, but this had only been partially successful. The menus indicated that the service users were provided with a reasonably varied and nutritious diet that was generally based on their preferences. The staff for reasons of hygiene and safety prepared the meals. The staff said that a balance had to be maintained between healthy eating and the service users preferences. The manager had endeavoured to introduce menu meetings for the service users but there was little support from them for this. There were facilities in the dining room for the service users to make a hot drink when they wished. This again promoted their independence. The service users generally ate their meals together in the dining room thereby encouraging a degree of social interaction. Those service users spoken to expressed their satisfaction with the quality of the meals. The dining room was multifunctional and had new chairs, tables and non-slip flooring that met the needs of the service users. Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. 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”. Good support is provided for the service users by the home’s staff and external health care professionals thereby ensuring that their health and personal care needs are met. EVIDENCE: The service users’ care records provided recorded evidence that their health care needs were being met. A practical example of this was the care provided for a service user who was terminally ill and died in July 2006. From discussions with the staff it was apparent that he was provided with good support both from them and from external healthcare professionals. A Macmillan Nurse who was directly involved in the care of this service user described the efforts of the staff as, ‘amazing, outstanding and admirable’. A record was maintained of medical referrals. All of the service users were registered with a local medical practice and the staff confirmed that the practice provided a good standard of service. On the day of the inspection visit the service users presented as being appropriately dressed and well groomed. The staff said that emphasis was Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 15 placed on ensuring that the service users maintained a good standard of personal appearance and hygiene. The majority of the service users had a Care Manager or Community Psychiatric Nurse allocated by their placing authority and consequently their health needs were also monitored by external agencies. A problem encountered by the registered manager was the apparent lack of input from some Care Managers and the reliance placed by the local authority on the use of a ‘Virtual Care Manager’ system. Routines in the home were reasonably flexible to take into account the service users daily activities. At the start of the inspection, for example, one service user had just got up and was having breakfast. Some of the service users displayed behavioural problems. For example, one would stay awake for most of the night if they had run out of money for cigarettes. In these circumstances the staff used patience and discretion and did not put this service user under any additional pressure. The majority of the service users smoked cigarettes and some had ‘agreed’ to have their cigarettes rationed by the staff to ensure that they did not run out. These ‘agreements’ were incorporated in the relevant care plans. The home was a fully non-smoking environment and the only designated area that was considered suitable for smoking was at the front of the property. The drawback to this was that the service users had to smoke whilst in full view of the general public thereby undermining their privacy. The registered provider was fully aware of this problem and had looked at possible solutions. He had endeavoured to get the service users to pick up discarded cigarette ends but with only limited success. From burn marks in the carpet of one service user it was apparent that the non-smoking policy had not been adhered to by all of the service users. The registered provider had sought continence advice and support for one service user. The health authority had apparently declined to provide support as it was assessed that his needs were due to a ‘behavioural problem’ and consequently did not satisfy the criteria for continence support or any associated aids. One of the problems faced by the home’s management and staff was the apathy and lack of motivation displayed by the majority of the service users. The staff provided examples on ways they had endeavoured to overcome this. They had, however, only achieved limited success. Some of the service users were over the age of 65. Over the recent years there had been a number of service user deaths from natural causes the most recent being since the previous inspection. There was an appropriate policy and procedure in place on this subject and from discussions with the staff it was apparent that they dealt with the illness and death of a service user in a sensitive and caring manner. For some of the staff, however, it had been the Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 16 first time that they experienced the death of a person and said that they had found it very traumatic. The home continued to use a monitored dosage system for the administration of the service users’ medication. This was appropriately secured and only authorised and trained staff had access to it. No controlled drugs were in use at the time of the visit. From a description of the administration process provided by a member of staff, it was apparent that action had been taken to minimise the chance of error. The medication records were complete and up to date. The staff acknowledged, however, that it would be difficult to audit the medication, as the records did not readily reflect the ongoing situation of the stock. Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. 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”. The service users are provided with a good network of internal and external support thereby ensuring that any problem or concern should be quickly identified and acted upon. EVIDENCE: An appropriate complaints procedure was in place and was readily available to the service users. The current service users had the ability to understand and use the procedure. From discussions with the service users it was apparent that they would not hesitate to discuss any problem or concern with the staff or manager. The staff were of the opinion that by having an open and honest environment any prospective complaint should be addressed before it becomes formalised. This was also supported by relatives of the service users who felt able to discuss any concerns directly with the staff or the home’s management. The staff records provided evidence that they had undertaken a certificated course on Adult Abuse. The staff on duty demonstrated a sound understanding of the subject and were aware of the action they would take in the event of alleged abuse of a service user. A policy and procedure was available with to the Adult Protection procedure. It was evident from the internal and external support network provided for the service users that any concern should be quickly identified and acted upon. Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The service users are provided with a good standard of accommodation that meets their needs and provides them with pleasant environment in which to live. EVIDENCE: The premises continued to be maintained and decorated to a good standard. The main lounge in particular was decorated to a high standard with the outcome being that the service users had developed a degree of pride in their accommodation. It was non-smoking environment and there were discreet notices displayed around the home reminding staff, service users and visitors of this. As previously stated in the report, the downside to this was that the service users and the staff had to smoke cigarettes at the front of the house in full view of the public thereby reducing their level of privacy. The manager had endeavoured to reduce the effect of this by providing the service users with containers in which to put discarded cigarette ends but this was generally ignored. The front garden was in the process of being refurbished and had Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 19 appropriate seating for the service users. There was also a patio area at the rear of the property but this had been assessed as not being suitable as a smoking area as it was used for drying clothes and was also adjacent to the kitchen and could result in hygiene problems. The dining room was adjacent to the kitchen separated by a ‘swing door’. The dining room had been upgraded by having new non-slip flooring and matching tables and chairs. The service users also had access to drink making facilities in the dining room thereby further promoting their independence. The home did not have a passenger lift and consequently the service users accommodated on the upper floors had to be reasonably ambulant. The service users bedrooms were all decorated to an acceptable standard and the majority had been personalised by the occupants. This indicated that the service users’ had a degree of ownership over their environment. The home was subjected to a higher than normal level of wear and tear and consequently the management of the home had developed an ongoing programme of maintenance and renewal to ensure that the premises were maintained to a good standard. There were sufficient numbers of toilets, baths and showers for use by the service users and emphasis was, according to the staff, placed on maintaining the service users personal hygiene standards. On the day of the inspection visit the home was very clean and free from any offensive odours. According to a service user’s relative, this was the norm. Those service users spoken to expressed complete satisfaction with the quality of their accommodation. As far as could be ascertained from the records, the home satisfied the requirements of the Fire and Environmental Health departments. Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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”. The service users are supported by a well trained and enthusiastic staff team that enables them retain their independence and live reasonably active and meaningful lives. EVIDENCE: The registered manager had provided the Commission for Social Care Inspection with a copy of the staff roster prior to the inspection visit. This, along with discussions with the staff, confirmed that there was generally three staff on duty during the day, two in the evening and one awake and one oncall in the building at night. It was apparent from discussions with the staff that the level of staffing had been based on the needs of the service users and was reasonably flexible to take into account any change in those needs. For example, there was increased staffing available during the terminal illness of a recently deceased service user. The service users primarily required guidance, support and advice from the staff with only minimal physical care required. The staff team were a good balance in terms of gender and experience. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 21 The registered provider acknowledged that there had, until recently, been a considerable turnover of staff, which tended to undermine the continuity of the care provided. This was also reflected in the comments made by a relative of a service user. In recent weeks the staff team had become more stable and, according to the relative, was reflected in the service provided. The staff records verified that the staff had been provided with opportunities to participate in a range of training courses on statutory and professional subjects. They had not, however, had training specifically on mental health. Also in the light of the recent death of a service user which although being handled extremely well had a traumatic effect on some staff, it was recommended that training should be provided on care of the dying and bereavement. The registered provider had offered the staff the opportunity to take a National Vocational Qualification in care but for a variety of reasons several were reluctant to do so. The staff spoken to at the time of the inspection visit had a clear understanding of their role with one stating, “ Our aim is to support the residents to enable them to safely achieve a maximum level of independence and an active and meaningful lifestyle”. The inspection visit was conducted with the cooperation of the staff on duty as the registered provider and manager were on holiday. Whilst these staff were keen to assist the inspector and were not reluctant to answer any questions, they were unable on grounds of confidentiality to access the staff records. Confirmation was provided both by the staff and in the pre-inspection questionnaire that all staff had been fully vetted before taking up employment in the home. The staff also confirmed that they were provided with good support from the registered manager and that they were provided with regular supervision and appraisals. As stated the night staff consisted on one person awake and another on-call on the top floor of the building. From discussions with the staff, however, it was evident that in the case of an accident or incident the waking member of staff had to physically go to the top floor of the property to contact the on-call person. This would therefore necessitate the waking member of staff leaving the scene of an accident or incident which, it is suggested, may not always be possible or advisable. It was apparent that the staff had established a positive relationship with the service users with conversations and banter being natural and spontaneous. Praise for the staff and their efforts to deliver a good standard of service was provided by several relatives of service users and a health care professional. Comments included, “The staff are excellent and very helpful. We are always made to feel welcome. They never talk down to the residents but treat them as adults” and in reference to the support provided for a dying service user, “They were amazing and outstanding in the way they provided care for A.” Sabre Court DS0000007730.V310877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 42 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The service users and staff are provided with good management support that enables the staff to provide a quality service tailored to the assessed needs of the service users. EVIDENCE: The registered manager and the registered provider are well qualified and have amassed considerable experience working with people who have a mental health problem. From comments made during the inspection visit it was apparent that the service users, staff and the relatives of service users, respected them. These comments included, “J. (manager) is very approachable and will discuss any problem” and “I can always discuss things with J. (manager) and A. (registered provider)”. It was also evident from Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 23 discussions with a healthcare professional that the home’s management ‘would go the extra mile’ to ensure that their service users receive a good service. The registered providers had developed a basic quality assurance process that included actively seeking the views and opinions of the service users, their relatives and health and social care professionals. Through this process they were able to identify the strengths and weaknesses in the service provided and take appropriate action as necessary. A number of policies, procedures and records were examined during the inspection visit. These were maintained to commendable standard, had been regularly reviewed and amended and were readily accessible to the staff. From an inspection of the premises and an examination of the maintenance and servicing records, it was apparent that the manager had taken appropriate action to ensure a safe environment for the service users and the staff. This included training for staff on health and safety matters. As identified during the previous inspection, several of the hot water outlets were not regulated and radiators not guarded. These had all been risk assessed based on the abilities and understanding of the service users thereby minimising any potential risk. As previously mentioned in the report a ‘swing door’ separated the dining room and the kitchen but there was uncertainty as to whether it was an approved fire door, as it did not appear to satisfy the fire safety requirements. The doors at either end of the dining room/kitchen met the fire safety standards and were fitted with automatic closers. The registered provider is to clarify the fire safety aspects of this door with the Fire Department. Sabre Court DS0000007730.V310877.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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 4 3 4 3 3 X 2 X Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 25 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. 3. 4. Refer to Standard YA6 YA20 YA35 YA42 Good Practice Recommendations All of the service users should have ready access to their personal records and be aware of, and agree to, the contents of their care plans The medication records should contain a procedure for ongoing stock checking. The staff should be provided with training on mental health, the care of the dying and handling bereavement. Consideration should be given to providing the waking member of night staff with the means of contacting the on-call person without having to leave the scene of an incident/accident. Sabre Court DS0000007730.V310877.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 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 Sabre Court DS0000007730.V310877.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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