Inspection on 24/07/07 for Shaftsbury House Care Home

This inspection was carried out on 24th July 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

Shaftsbury House Care Home 02/08/06

Shaftsbury House Care Home 20/12/05

Shaftsbury House Care Home 15/06/05

Shaftsbury House Care Home 09/02/05

Shaftsbury House Care Home 16/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Shaftsbury House Care Home 53 Mount Vernon Road Barnsley S70 4DJ Lead Inspector Mrs Sue Stephens Key Unannounced Inspection 24th July 2007 09:15 DS0000056401.V337757.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 DS0000056401.V337757.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. DS0000056401.V337757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shaftsbury House Care Home Address 53 Mount Vernon Road Barnsley S70 4DJ 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) 01226 786611 01226 786622 inquiries@sunhealthcare.org Sun Healthcare Limited Mr Lee David Watson Care Home 10 Category(ies) of Learning disability (10) registration, with number of places DS0000056401.V337757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels are maintained at; at least the levels required by the Residential Forum `Care Staffing in Care Homes for Younger Adults` published April 2002. The manager is employed to work full time (40 hours a week) and these hours are over and above those required by the Residential Forum Guidance. 2nd August 2006 Date of last inspection Brief Description of the Service: Shaftsbury is a care home for younger adults with learning disabilities; it provides personal care and accommodation to 10 residents. Sunhealth Care Limited provides the care and accommodation. Shaftsbury House is within easy reach of Barnsley town centre. The home is close to a bus route and has its own transport. The home is set in its own grounds with gardens and parking space. There is ground floor and first floor accommodation and a passenger lift gives access to both floors. Shaftsbury house provides two of its beds for respite care. The manager provided the information about the homes fees and charges on 24 July 2007. The fees range from £1,250 to £1,880 per week. The manager said fees are based on individual’s needs and assessments. If there are any additional charges these are agreed in the contract of care. Enquiries about the homes fees can be discussed with the manager. Prospective residents and their families can get information about Shaftsbury house by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. DS0000056401.V337757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; it took place between 9:30 am and 16:00 pm on 24 July 2007. The inspector sought the views of people who live at the home, and spent time observing their care and support. She spoke to a relative, and members of staff during the visit. After the visit the inspector spoke to one visiting professional. Lee Watson, the registered manager, assisted with the inspection. During the visit the inspector looked at the environment, and made observations on the staffs’ manner and attitude towards people. She checked samples of documents that related to peoples’ care and safety. These included three assessments and care plans, medication records, and staff recruitment files. The inspector looked at other information before visiting the home, this included evidence from the last key inspection and the homes Annual Quality Assurance Assessment record (AQAA). The AQAA is information that the Commission for Social Care Inspection require all services to provide; it enables the home to demonstrate their standards of care and identify where they have noted areas for improvement. The commission received 5 surveys from relatives, whose family members use the service, and one visiting professional survey. This was a key inspection and the inspector checked all the key standards. The inspector would like to thank the people who live at the home, relatives, the manager and staff for their warm welcome, help and contribution to this inspection. What the service does well: People have good assessments so that they know the home will understand their needs and aspirations. People have support plans that tell staff how to support them. The support plans included people’s likes, dislikes and information about their personal care, health care and social needs. The home looked at people’s risks. They looked at how to support people and keep them safe while supporting them to follow the life style they prefer. DS0000056401.V337757.R01.S.doc Version 5.2 Page 6 People had very good opportunities to follow the daily routines they preferred. Most people had a lot of support to go on outings and attend colleges, day centres and social activities. Relatives and visiting professionals said staff were very good at supporting people to enjoy good social activities. People had good support to enjoy their hobbies, such as gardening. People were satisfied with their meals. They were involved in shopping and preparing meals if they wished. Staff said they had good feedback from environmental health and a dietician about the standards of hygiene and choice of healthy meals. People said they had good support from staff to help them with their personal and health care needs. Relatives made positive comments such as, “When we visit, people always seem content and happy” “The staff are pleasant and know each individual’s needs” The manager said they had good links with the G.Ps and other health and social care professionals. This helped them follow good advise about people’s needs. People who needed support to manage their behaviours had good support from staff. All staff had training so that they followed safe procedures. This included what to do to help keep people who are distressed keep calm and in control. Staff followed good medication procedures so that people had safe support to take their medication. People knew how to complain, relatives also said they felt confident they could do this and the managers and staff listen and take positive action. Staff had training so that they could recognise bad practice and help keep people safe from harm and abuse. People said they were happy with their environment. They could personalise their bedrooms as they wished. And the home was clean and furnished in a way that was homely, comfortable and inviting. People and relatives spoke very highly about the staff team. They made comments that included, “The staff are great.” “They have the right skills and experience to look after people properly.” Staff had good training, the deputy manager managed this and made sure staff had access to safe practice training (such as fire and first aid) they had training that helped staff understand people’s complex needs. All staff had LDAF (Learning Disability Award Framework) training when they started work at the home; and then staff completed National Vocational DS0000056401.V337757.R01.S.doc Version 5.2 Page 7 Qualifications in care. This meant the home had staff with good skills and knowledge about how to support people in a safe and consistent way. The home followed good recruitment procedures to make sure they employed the right staff to support people. The manager and deputy manager ran the home well. They were in touch with the people the home supports, and their relatives. They gave staff good support and they had good systems in place to monitor the quality of the home. They had good systems in place to monitor health and safety and make sure the home was safe for people to live in. What has improved since the last inspection? What they could do better: The home has only one new requirement. This is about looking at how to improve communication with visiting professionals. The responsible individual is looking at ways to improve transport access to give people who use wheelchairs better opportunities to go out. This was not a requirement because the RI had already identified the problem and had taken action to address it. This included talking to the people involved and their relatives. The manager and deputy manager identify areas for improvement through their audits and the monthly provider visits. DS0000056401.V337757.R01.S.doc Version 5.2 Page 8 The managers recognise that the person centred approach used in care plans can improve. This is not a requirement but the inspector encourages this improvement as good practice and a good way to help make sure people lead the lives they want. 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. DS0000056401.V337757.R01.S.doc Version 5.2 Page 9 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 DS0000056401.V337757.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People who live at the home have their needs assessed before they move in. This helps make sure Shaftsbury is the right place for them to meet their needs and aspirations. EVIDENCE: People have full assessments before they come to live at the home. The manager and deputy manager look at people’s needs to assess if Shaftsbury can offer individuals the support they need. This includes the homes own assessment. The manager confirmed that they always include the person in their assessments and also consult with relatives and involved professionals. The manager said they have good relationships with local authority and health care teams and this enables them to get good information about people’s support needs and what they might want from the home. People’s assessments formed the basis for their care plans. And the manager and deputy manager reviewed these after people move in to make sure their identified care needs were up-to-date. DS0000056401.V337757.R01.S.doc Version 5.2 Page 11 The homes assessments include looking at restrictions on people’s freedom and choice, for example managing behaviours and access to the local community. DS0000056401.V337757.R01.S.doc Version 5.2 Page 12 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have good support plans; they make decision about their own lives and have good support to take risks that enable them to be independent. EVIDENCE: The inspector looked at four support plans. These had good information about how to support each person. The home had done some work to introduce a person centred approach to the plans. This means that the information always put the person’s needs and preferences first. The manager acknowledged that they could improve the person centred focus further and this could include better symbols and pictures, and in some places better descriptions. The plans did meet the National Minimum Standards, but the inspector encourages the home to develop the plans further, in a person centred way, so that they help people to express and lead the lives they prefer. DS0000056401.V337757.R01.S.doc Version 5.2 Page 13 The plans had guidance for staff about how to support people’s health care, personal care and behavioural needs. Each plan included the person’s preference about each aspect of their support. And it included good profiles about the person and what they liked and disliked. This was good practice because it encouraged people to voice how they wished to lead their lives. The plans included risk assessments that allowed people to take reasonable risks, and identified events in people’s lives that may present risks to them. This included people who may be vulnerable or whose behaviours and emotions may put them in unsafe situations. People could be involved in their plans and reviews as much as they wished. The inspector spoke to people who confirmed this. For people who were unable to express their views staff had made careful profiles about what the person liked and dislike, based on staff and family knowledge about the individuals. For people who needed support to manage their behaviours and emotions the care plans covered these in a dignified way. However one record made by a member of staff about someone’s behaviour did not describe what the behaviour was. This makes it difficult to monitor progress and change, and to make sure all staff understand about the individual. The manager agreed to follow this up and make sure all staff give clear descriptions on behalf of the people they support. DS0000056401.V337757.R01.S.doc Version 5.2 Page 14 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): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have good access to education, occupation and leisure opportunities. They have good nutrition and healthy meals; they have good choices about food, drinks and mealtimes. EVIDENCE: People had varied routines depending on their assessed needs and choice of life style. People had support plans that reflected this. Some people attended day centres, college and voluntary work, whilst others chose to spend more time at home. Staff supported people depending on their needs, this included full support on outings and transport to destinations. DS0000056401.V337757.R01.S.doc Version 5.2 Page 15 Two people told the inspector they were happy with their daily routines. They said they could choose to alter these if they wished. Two visiting professionals said Shaftsbury House does well with encouraging people to enjoy a community presence, outings and social and leisure activities. A relative expressed some concern that the homes transport was not suitable for some people who use wheelchairs. This affected how often they could visit the local community and go on outings. The responsible individual said he was aware of this and was looking into alternative transport options that would suit people better. A relative said staff respect what their family member chooses to do during the day. And said the staff encouraged the person to try new things. Comments in the surveys included, “ I think (people at the home) have a very good social life” “Staff are always organising social activities and outings” The deputy manager had put together an information file, this contained social events that people could go to. It included local facilities and trips further field. The file also contained information about days out and leaflets of places of interest. There was photos and information about past trips. And people could use the file to remember past outings or to choose new places of interest they wished to go to. An example of the leisure trips and activities people had done included, themed parties, trip to the seaside, local leisure activities such as swimming and super-bowl, outings to places such as Derbyshire gem mines, and outings related to peoples hobbies, such as gardening. People said they were satisfied with their meals. The kitchen was open for people to enter and make themselves drinks or snacks; staff were available to support people to do this. The mealtime arrangements were relaxed and people could generally choose when they wanted to eat their meals. The deputy manager had recently consulted with the local authority dietician and received good feedback on the choice and nutritional value of the meals people have. Staff supported people to make their own choices about following healthy diets, and the inspector noted that although staff encouraged healthy options they also respected people’s choice and preference. One relative commented that their family member always enjoys meals at the home. Staff also gave people the opportunity to cook if they wished. DS0000056401.V337757.R01.S.doc Version 5.2 Page 16 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are satisfied with their personal support. Staff support people to maintain good health care and they have safe support to help them with medication. EVIDENCE: People living at Shaftsbury House told the inspector they were happy with the way staff supported them. Staff were helpful, supportive and encouraged people to be independent. Relatives said in the surveys that their family members receive the support they need. And made the following comments, “Our daughter is happy to go to Shaftsbury House for respite care” “Staff do all they can to help our son” “When we visit, people always seem content and happy” “The staff are pleasant and know the needs of each individual” “We are quite happy with the service we are receiving” DS0000056401.V337757.R01.S.doc Version 5.2 Page 17 Another relative said they thought the staff were good at watching out for changes in people’s health and staff took quick action. People could follow their own preferred routines, for example the time they go to bed and get up, when they have baths and showers and when they have their meals. This encouraged people to have independent lifestyles and encouraged people to make personal choices. A relative said their family member preferred support from male staff and on the whole the home could accommodate this. Other people spoke about their key workers and said they got on with them well. The manager said they have good links with GP surgeries and other health and social care professionals. This included support teams who offer people support and guidance to manage their behaviour and emotions, and specialist nurses and social workers for people with learning disabilities. Visiting professionals supported this and said they had good working relationships. One professional said the manager was prompt at producing reports for clinicians and this helped individuals with their treatment. One professional said they were satisfied that the home provided good care and support; but felt that the home could improve communications with visiting professionals to make sure that information about peoples appointments and treatment times were clear. The home had good procedures in place to support people who have disruptive behaviours. This included training and an approach that provided safe interaction with people. The manager was qualified to train staff and he said the training focussed on de-escalating (calming down) situations before they become a crisis. People who needed support had care plans that reflected this. The manager said because the home followed consistent and safe approaches this had reduced the number of behaviour incidents for some people and improved their quality of life. The homes medication systems were in good order. The storage was clean and uncluttered, records were clear and up-to-date and the administration followed safe procedures. Staff shared information with individuals (who wanted to know) about their medication, this helped them to understand what and why they take the medication. This was good practice and promotes people’s dignity, rights and respect. DS0000056401.V337757.R01.S.doc Version 5.2 Page 18 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. People can express their views and the managers and staff listen and take action. People are protected from harm and abuse because the home follows good safeguarding policies and procedures. EVIDENCE: People at the home, and relatives, said they knew how to complain if they needed to. Relatives said they knew the managers and staff would take action if they were concerned about anything. The home had the complaints procedure on display for people to see and kept a record of what action they take to address people’s concerns. The deputy manager had nominated all staff to receive up-date training on adult protection this year. She said this would make sure they had the right knowledge and skills to identify and deal with situations. The homes and the local authorities procedures were available for staff to refer to. And staff received information and guidance about what is bad practice and what to do about it during their induction. DS0000056401.V337757.R01.S.doc Version 5.2 Page 19 The inspector checked a sample of finance records. These were clear and easy to follow. The records contained signatures and receipts to support people’s withdrawals. The manager reported that he had received no complaints or dealt with any adult protection issues since the last inspection. And the Commission for Social Care Inspection had not received any complaints or information relating to adult protection. DS0000056401.V337757.R01.S.doc Version 5.2 Page 20 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, 26 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, clean and homely environment. EVIDENCE: People said they were satisfied with the homes environment. In particular people said they were pleased with their own rooms. They were able to personalise these to their own tastes and staff respected people’s own rooms as their personal and private space. The homes décor was clean and bright and people at the home, and staff, had added personal touches, this made the building homely and welcoming. Staff had supported some people to follow their hobby, such as gardening, and they had made good provision in the homes garden for this. They maintained the garden well with flowers, cut lawns and outdoor seating areas. DS0000056401.V337757.R01.S.doc Version 5.2 Page 21 The responsible individual said the organisation was renewing and refurbishing areas of the home. This included new furniture; the manager was looking at new quality lounge chairs and included people to make choices for the home. The home had a good cleaning system, which involved all staff making sure the home was clean and tidy. Staff understood what duties they were responsible for and signed to say they had completed the task. For example cleaning fridges and kitchen areas. The deputy manager audited this to make sure staff cleaned the home to a good standard. In addition to this the home employed a cleaner who also carried out specific tasks. As a result people lived in a clean, organised but relaxed environment. The home also had a maintenance person who carried out the homes decorating and maintenance. Both staff said they had sufficient time and budgets to keep the home clean and well maintained. The deputy manager said the home had a recent environmental health inspection and had good feedback with only one requirement asking them to renew the chopping boards. These were on order. The home had bought a new washer and dryer, this was semi industrial and better designed to meet the laundry demands at the home. The home also had a domestic washer and dryer available so that people who wished to do their own washing could do so. DS0000056401.V337757.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People had good support from an effective staff team. This was because the staff have good training and the home follows good recruitment procedures. EVIDENCE: Relatives said about the staff team, “The staff are great” “We have always found management and staff helpful and pleasant” “Staff are always very pleasant” “Staff are always pleasant and know the needs of each individual” “I have no doubt, the staff have the right skills and experience to look after people properly” The deputy manager organised staff training. This included access to National Vocational Qualification in care, which over 50 of care staff had achieved. This met with national guidelines. Over and above this the home offered staff DS0000056401.V337757.R01.S.doc Version 5.2 Page 23 access to level 3 NVQ in care. This showed the home invests in its staff team well. The outcome of staff having National Vocational Qualifications is that they can demonstrate good knowledge and skills in caring and supporting people. People therefore receive up-to-date, safe and consistent support. This is reflected in the outcomes found throughout this report, and because people and their relatives have expressed satisfaction with the homes care and support. The home followed good recruitment procedures. They carried out staff checks, which included references, the criminal record bureau checks, employment histories and interviews before offering them employment. New staff completed an induction and the deputy manager monitored their progress. The home expected each staff member to complete LDAF training (learning Disability Award Framework) this gave staff specialist skills and knowledge in supporting people with learning disabilities and associated needs (such as communication and promoting independence). Staff had good access to training and guidance that related to peoples specific needs. For example recent training included conditions such as Aspergers syndrome, autism and fragile x syndrome. This helped staff have a good understanding about people’s specific or complex needs. The manager said staff have a mixture of internal and external training. This is good practice because it encourages staff to network and have a wider understanding about care issues. All staff receive training about how to deal with people’s behaviours. This involves using skills to avoid potential violent or aggressive situations from escalating. The manager delivers the training and assesses people’s competence. The British Institute of Learning Disabilities have accredited the non-violentphysical-intervention training; it is recognised as a suitable and safe approach to use. DS0000056401.V337757.R01.S.doc Version 5.2 Page 24 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive good quality care from a well-run home. EVIDENCE: The manager has over two years experience in a management position and is working towards the registered Managers Award. This will give the manager the recommended qualifications for the role. The manager has managed the home well. The homes development and improvement over the past two years reflects this. DS0000056401.V337757.R01.S.doc Version 5.2 Page 25 The manager, deputy manager and staff team have worked hard towards improving the service for people and meeting National Minimum Standard requirements. The home has good quality assurance checks. The homes Annual Quality Assurance Assessment (AQAA) reflect this, and the manager has identified good working practice and areas for improvement. The responsible individual visited the home regularly. The responsible individuals reports show that during these visits the responsible individual consults with people, relatives, staff and the managers. He also checks the building and samples of the homes records. This is good practice because it keeps the quality of people’s care and accommodation under constant review. The manager and deputy manager carried out regular audits. These included staff monitoring, hygiene, maintenance, health and safety and care plans and finance records. The maintenance person confirmed he was responsible for carrying out most of the health and safety checks. This included water temperature checks and fire safety checks. The inspector checked a sample of records including fire safety checks and these were up-to-date. Staff had training in safe working practices. This included fire safety, food hygiene, moving and handling and health and safety). Staff said they have training often and the training is relevant for them to carry out their jobs and help keep people safe. The deputy manager had audited staff safe working practice training. Where staff were due for up-date training the deputy manager had identified this and nominated people for planned training this year. DS0000056401.V337757.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X 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 X 26 4 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X DS0000056401.V337757.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 Refer to Standard YA19 Good Practice Recommendations The manager should contact visiting professionals to ask their opinion about the homes communication and consider ways to improve this. 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