Inspection on 08/02/07 for Spout House Support Services

This inspection was carried out on 8th February 2007.

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

The inspector 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

Spout House Support Services 09/02/06

Spout House Support Services 20/10/05

Spout House Support Services 14/03/05

Spout House Support Services 08/06/04

Spout House Support Services 09/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Spout House Support Services Spout House Bay Horse Lancaster Lancashire LA2 9DE Lead Inspector Mrs Joy Howson-Booth Unannounced Inspection 8th February 2007 1:00 Spout House Support Services DS0000010040.V323012.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 Spout House Support Services DS0000010040.V323012.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. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spout House Support Services Address Spout House Bay Horse Lancaster Lancashire LA2 9DE 01524 792261 01524 792261 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) Mrs Pamela Joyce Broxup Miss Joanne Helen Swindlehurst Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Spout House is a small care home registered to accommodate up to five people of either sex who have a learning disability and associated needs. The home’s aim is to provide a domestic environment, which consolidates existing skills and abilities and endeavours to develop the lifestyles and potential of each of its service users. The current range of fees are from £510.00 per week to £2414.99 per week. Further details over fees can be obtained from the registered manager of the home. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first site visit and was unannounced so the registered provider, manager, staff and service users were not aware of the visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered manager. Comment cards were made available to service users and GP surgeries. Only one response was received from a GP surgery. The site visit took place over half a day, with an additional short visit taking place, and included taking time to sit and speak with service users, observing staff on duty performing the day-to-day routines, speaking with staff, examining documents held in the home and speaking with the registered manager. The inspector looked around parts of the home, including communal rooms and one service user’s own bedroom. The tour also provided an opportunity to find out about any improvements made and to see if the home was a comfortable, clean and safe for people to live in. Additional information was also supplied from a pre-inspection questionnaire completed by the registered manager. The site visit was positive with everyone welcoming, friendly and co-operative during the visit. Spout House has been assessed as a good home, although a small number of recommendations have been made. What the service does well: Spout House is a small home, which continues to provide the service users with an individual, needs-led service, which respects the skills, abilities and needs of each of the service users accommodated. The five service users have all been at the home for a number of years and continue to have good relationships with each other and with members of staff. It was noted that service users asked staff to assist them in completing comment cards for this inspection, which displays trust and confidence that their comments will be relayed. Comments on the remaining card were discussed with the registered manager who provided further information and clarification over the comments made. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 6 Comment cards were also received from one GP who confirmed that the staff at the home work in partnership and communicate clearly with them and they are satisfied with the overall care provided by the home. Being small, the staff team are supportive and encouraging and there is a real commitment to making sure staff are provided with relevant training to meet the individual needs of each of the service users. Staff spoken with during this site visit again commented on the good team working that they feel helps in the delivery of the care, particularly at times when service users are needing more in-depth support. There have been some changes to the staff team but there remains a core group of experienced carers who know the service users well and can provide a consistent approach and familiarity to the service users. There is equal consideration given to all prospective employees, with both male and female staff being employed at the home. Training and development programmes are offered to all members of staff. The registered manager confirmed that 4 staff are trained to National Vocational Qualifications (NVQ) Level II. This means that service users are cared for by suitably qualified and experienced staff. At the time of the visit the inspector saw friendly and positive exchanges between the staff on duty and the people living at the home, with each resident being treated as an individual and given the time and attention needed. Service users are encouraged to retain their independence with a small number of service users retaining contacts with their local communities. Service users are able to maintain their own lifestyles and daily routines and staff support is provided, when needed. Information supplied by the home confirms that there are a range of policies and procedures which ensure service users are provided with the care they need and respects their rights irrespective of their race, gender, disability, sexuality, age, religion or beliefs. The home is reasonably well maintained and homely with communal rooms being accessible to the service users. The registered manager confirmed that there are plans to upgrade the bathroom facilities in the home and complete the remaining outstanding redecoration and refurbishment work. One service users’ room was seen during this site visit which was well maintained and homely. Service users are also encouraged to bring in treasured personal items to personalise their rooms. During the site visit, a number of service users were seen and spoken with and all appeared to be well cared for and content. One relative was spoken with who confirmed they were very happy with the care provided by the home. A GP comment card confirmed they are satisfied with the level of care provided and included “patients always well looked after and seem contented and happy”. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 7 The registered manager works at the home on a full-time basis which provides a good opportunity to gain feedback from both service users and staff and provide support as needed. Again, the registered manager continues to demonstrate openness and co-operation with the Commission for Social Care Inspection and it is hoped this can continue in the future. 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. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 8 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 Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 9 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): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good arrangements in place to make sure a full assessment would take place so that the needs of the prospective service user can be identified and the home can take an informed judgement as to whether these can be met within this care setting. EVIDENCE: It was confirmed that the arrangements previously assessed remain in place. There is a comprehensive referral and assessment procedure in place which would ensure both the prospective service user and the service can be provided with information prior to any decision being made regarding admission. The assessment procedure involves information being obtained from the funding agency/Social Worker and the opportunity for the prospective service user to have a visit to the home and an overnight stay. Following this a further multi-disciplinary review meeting (involving all parties) would then take place to look at all the information gained. At this meeting the prospective service user’s needs, abilities, specialist input, etc., will be identified and a decision taken as to whether the placement will go ahead, or identify what, if Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 10 any, further actions are needed. Comment cards completed by service users confirmed that the admissions procedure outlined above was followed, with home visits, overnight stays and written information being provided to them. There have been no new admissions to the home since the last inspection. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 11 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): Standards 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. There are clear and very comprehensive care documents in place which mean staff know and understand areas of risk and how to meet service users needs. Service users feel consulted and are able to make decisions about their lifestyles and feel listened to. EVIDENCE: There have been no new admissions since the last inspection. Two care plans were examined and were seen to continue to provide very comprehensive information over the needs of the service users and how these were to be met. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 12 Comment cards received from one GP surgery made positive comments about the service and stated “patients always well looked after and seem contented and happy.”. Where appropriate, there are guidelines in place for support and areas of risk and include daily routines, community activities, etc. Where support may include breakaway or restraint practices there are clear instructions in place provided as a result of specialist input along with training for staff. Staff confirmed that they are not involved in breakaway or restraint unless they have had the appropriate training. Staff spoken with demonstrated a very good understanding of the needs of the service users and also confirmed that care plans and other guidance are reviewed 6 monthly and changed as required. There was evidence on care files that service users continue to be involved in the care planning process and have signed to confirm this. Service users are able to make decisions about their lives but, because of their individual needs, this is often with assistance and guidance of the staff. Each service user has their own key worker who takes a lead role in their care. Discussions with service users all confirmed that they are happy with the care provided. Individual comment cards also completed confirmed a satisfaction with the service provided. Information supplied by the home confirmed that two service users currently receive support from independent advocacy workers. Information provided by the home also confirmed that one service user manages their own benefit book, four service users manage their own service user allowance monies and each service user has their own individual bank account. Support over finances is also provided by the staff at the home Discussions with service users confirmed that they continue to be happy with the staff and with the care provided and feel they are consulted about what goes on in the home. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 13 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): Standards 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. Service users are supported to have a good quality of life which includes experiencing a range of social and leisure and activities which are age appropriate, positive and reflect their preferences and wishes. EVIDENCE: Each service user has their own individual care plan which also sets out their daily routines and activities. At present, service users at this home do not wish to seek paid employment, although one service user spoke about their new voluntary work which is clearly enjoyed and providing a positive experience. This service user now Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 14 does her own washing and, feels in her words that she “has come a long way”. Another service user is support to attend a local Church on a Sunday. Information supplied by the home’s manager confirmed that there are a range of activities provided both inside the home (including pool table, T.V. Garden, BBQs, DVD, etc.) and outside the home (including walks, picnic, sports, swimming, pubs, library and college). Given the location of this home, service users are reliant on staff support to access public transport or for staff to use their own cars. All service users are registered to vote, although some prefer not to do so. Staff are employed to work flexibly with the service users with additional staff being brought on duty for community activities. Comment cards received from service users indicated that generally the home does provide suitable activities, although one service user commented that sometimes it depends on the number of staff on duty. As previous inspection reports note, family and other contacts are welcomed. Two service users continue to visit their relatives in another town and there are good arrangements in place to ensure risks are minimised. Service users spoken with felt they are happy with the activities to date. It was noted that service users enjoyed a holiday this year and one comment card stated “we get to go on holiday once a year. Abroad or in England and it is very exciting.” Service users spoken with continue to feel their rights are respected by staff. It is noted that where there are any restrictions for service users these are decided within a multi-disciplinary setting and clearly recorded on the individual service users file. Service users also confirmed they were happy with the meals provided by the home. Each service user is able to be involved with choosing and preparing a meal throughout the week. A range of choices are available and records kept on individual meals taken. As mentioned earlier, one service user has a specialist diet which the staff at the home have worked hard to ensure that appropriate meals have been provided. Spout House Support Services DS0000010040.V323012.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): Standards 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. There are good systems in place which ensure service users are provided with good personal and healthcare support. EVIDENCE: Care files examined evidenced that service users continue to access a range of healthcare professionals, as needed. Information supplied by the home stated that these include : GP, District Nurse, Pharmaceutical service, CPN, Dietician, Dentist, Optician, etc., with other healthcare professionals being accessed via a GP referral as needed. Service users spoken with confirmed that they feel their healthcare needs are met. A specialist dietary programme for one service user is ongoing but has incurred some setbacks outside the control of the home. However, the staff at the home continue to act as a strong advocate for the service user concerned. It was felt that some benefits had been seen and as this is an ongoing Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 16 programme it continues to be monitored by the service user’s consultant and GP. Discussions with staff also confirmed that they escort the service users to visit healthcare professionals, with support and guidance as needed and following set protocols, particularly for one service user. Comment cards received from service users and discussions with staff confirmed that service users are able to follow their own daily routines, although guidance is given as outlined in their individual care plans. It is noted that one service user uses pictures to assist with her anxiety and this enables her to see things she needs rather than verbally asking. Service users have access to all female staff for personal care and each has their own key worker. Comment cards received from service users included the following comments : “I plan what I am going to do, e.g. go to Garstang, out for coffee.” Medication records were examined and found to be accurately maintained. The stocks were held in a clean and secure cupboard. Information provided by the home confirmed that only staff who have undertaken the safe handling of medication training give out medications to the service users. Spout House Support Services DS0000010040.V323012.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): Standards 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 arrangements for dealing with complaints are good. speak up and feel that they are listened to. Service users can Service users are safeguarded by trained staff who are supervised by a competent manager EVIDENCE: Confirmation was given that the home’s complaints procedure remains the same. Comment cards received from service users and through discussion confirmed that all know who to go to if they are not happy or are concerned about any aspect of their care. Observations during this inspection noted that service users are treated sensitively and listened to when exhibiting anxiety or needing information or reassurance. Discussions with staff also confirmed that there is a good understanding of what to do should an incident of abuse be suspected. It has been confirmed that staff have raised concerns with the registered manager who took the appropriate steps to address the issues. Staff also confirmed that they have received training in safeguarding adults and restraint and confirmed that they are not allowed to become involved in restraint until they have been appropriately trained. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 18 Records of incidents and restraint were seen to be kept and confirmation was given by the registered manager that any incident is recorded and notified to the service users named social worker. Spout House Support Services DS0000010040.V323012.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): Standard 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Spout House is generally a safe place for people to live in although some improvements are still required. EVIDENCE: Repairs to the roof of the home have now been completed. There is a planned programme to finish off the outstanding decorating work and also plans to upgrade the bathroom facility, with new bathroom suite and shower to be installed. The registered manager noted that there are difficulties in getting trades people in to do work but is hoping that the planned work will be completed by the end of the summer. Not all areas of the home were seen, specifically individual service users’ rooms but those seen were clean and tidy and providing a good standard of Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 20 accommodation. Rooms have been personalised by the service users and are used freely by them. Comment cards received from service users all confirmed that they feel the home is kept clean and tidy. One comment included “my room is a bit untidy and Pam helps me tidy it.” Areas of the home seen were found to be clean and tidy with no offensive odours. The provision of a separate smoking area for service users to use has greatly enhanced the home. A new cooker has been ordered for the kitchen. Outside the home there is a derelict building which is currently partly cordoned off. The registered manager was advised to undertake a risk assessment so that service users who use the garden area are kept safe until a decision is taken over this building. Spout House Support Services DS0000010040.V323012.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): Standards 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are cared for by a professional, supportive, trained and committed team of staff. The homes recruitment procedures are thorough and ensure the vulnerable service users are protected from abuse. Staff are well supported by the management team. EVIDENCE: The staffing ratio was confirmed with at least 3-4 staff on during the day at differing times and sometimes 5 staff, dependent on service users’ individual activities. One resident currently has 2-1 funding. Service users spoken with said that they were happy with the care provided by the staff. Observations of service user and staff interactions were positive and sensitive and demonstrated a good understanding of the individual needs and support required. The staff clearly work as a close knit team, each with their own roles and responsibilities and receiving guidance and direction from the Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 22 registered manager as needed. Overall there continues to be a good atmosphere in the home. There have been some staff changes over recent months, but generally the home has a core group of experienced staff who have worked at the home for a number of years. A small number of agency staff has been used but the registered manager has used only one agency to ensure consistency and support and induction training has been provided to agency staff. Three staff files were examined and found to be very well organised and containing all the required information. There is a formal recruitment procedure in place, which includes obtaining all the required checks and staff having a formal interview. The registered manager was advised to put a copy of the POVA first confirmation email on personnel files. The home continues to demonstrate that the right person is more important than filling the vacancy and the recruitment procedure reflects this. Previous inspection report noted that the registered manager has also put in place a “return to work” interview, which is held on return to work, dependent on the length of time off, pattern of sickness or nature of the incapacity. There is a formal induction programme in place, which involves new staff completing a comprehensive book covering a range of areas. Staff training continues to be proactively managed for staff. Staff on duty confirmed that a range of training has been provided. Staff file also contain copies of certificates for training completed. Information provided by the home indicates that training already provided included – Learning Tool training; Counselling skills for working with people with hurt and anger; Counselling Level 2; PKU training (specialist diet); National Vocational Qualification (NVQ) training; NVQ assessor training update and positive behavioural support training. Future training planned includes – First Aid; Health and Safety; Fire, Infection control; physical intervention/breakaway; moving and handling; safe handling of medication; food hygiene and the ongoing NVQ training programme for staff. Supervision records were examined. As well as this, the member of staff spoken with confirmed that regular formal supervision is held on a regular basis. The member of staff spoken with also confirmed that they feel well supported by the management team and their colleagues and additional support and guidance is always on hand from a senior member of staff, if needed Spout House Support Services DS0000010040.V323012.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): Standards 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. An experienced, qualified and competent manager runs the home which results in the service users living in a safe and well managed environment. EVIDENCE: As recorded in previous inspection reports, the registered manager has achieved a range of qualifications, including Registered Managers Award (NVQ Level IV, and the NVQ in Care Level IV. Other training has included Recruitment and Selection; Health and Safety in the Workplace; Time Management; and Conducting an Appraisal course. Training continues to be accessed, as needed, by the registered manager. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 24 Under the management of the registered manager, the home continues to provide a well run and professional service, with support being provided to both service users and staff. The main office in the home has benefited from the office systems put in place and paperwork is kept accessible but secure. The application to register Spout House as an organisation/limited company is currently being processed. The registered manager is aware of the need to have the change of registration completed as soon as possible to ensure the service is correctly registered with the commission. Individual comment in comment cards were discussed with the registered manager who gave assurance that individual rights and preferences were respected but the home has a duty of care towards the service users in the home and, given their needs, acts in their bests interests. The quality assurance systems currently in place have not changed. As mentioned in previously reports, a formal external quality assurance system may something that would not be used in such a small home. However, feedback is obtained directly from service users. Staff meetings, house meetings and key worker feedback is also provided. External feedback is sought from from other professionals, visitors, relatives, at the annual review for individual service users. Discussions with service users confirmed that they remain involved in house meetings and their opinions and feedback are sought by the registered manager and staff at the home. From observations and from talking with staff, it is clear that the staff are very much included and involved in the work of the home and feedback from them is actively sought, both on a day to day basis and at formal staff/house meetings, handovers and supervision. Information supplied by the home indicates that the home has the required maintenance and associated records in place. In addition, this information also confirms that requirements made by both the fire officer and environmental health officer were addressed. The registered manager confirmed that all the requirements were addressed promptly at the time. A selection of maintenance certificates were examined – the hard wiring electrical certificate, portable electrical appliance testing certificate and the gas appliance certificate. Confirmation was given that the last fire drill took place in November 2006 and records of staff training in the fire procedure were seen. The home’s accident book conforms to the Data Protection Act and the registered manager confirmed she monitors this on a regular basis to ensure there are no patterns or further training needs identified. A selection of accident records were examined and found to be appropriately kept. Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 25 Policies and procedures are in place and the registered manager confirmed they are reviewed either as legislation changes or to reflect current good practice changes. Spout House Support Services DS0000010040.V323012.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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 x Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA24 Good Practice Recommendations The redecoration and refurbishment programme for the home should continue - confirmation of this should be sent to the Commission once the work has been completed. A risk assessment should be carried out on the outside building and appropriate action taken to ensure service users at not at risk when using the garden area. As recommended in the previous inspection report, a business plan for the home to be developed to identify areas for development in the future. A copy of the email confirming satisfactory POVA first check should be recorded on staff files 2. 3. 4. YA42 YA39 YA34 Spout House Support Services DS0000010040.V323012.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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. 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