Inspection on 23/11/06 for Spring Lake

This inspection was carried out on 23rd November 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spring Lake 20/10/07

Spring Lake 15/02/06

Spring Lake 28/07/05

Spring Lake 17/02/05

Spring Lake 22/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Spring Lake Spring Lake 17 Forty Lane Wembley Park Middlesex HA9 9EU Lead Inspector Judith Brindle Key Unannounced Inspection 23rd November 2006 08:25 Spring Lake DS0000017450.V319468.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 Spring Lake DS0000017450.V319468.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. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Lake Address Spring Lake 17 Forty Lane Wembley Park Middlesex HA9 9EU 020 8908 5233 020 8908 5233 i.jones1@btconnect.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 Ian Jones Perpetua Mary Caesar Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Spring Lake is a registered care home that provides care and support for up to 11 adults who have a learning disability. It was first registered in 1997. The care home is a large detached house located in Wembley Park, and includes two furnished and decorated outbuildings where residents have the opportunity to participate in day care activities. The care home is located close to a variety of amenities, which include local shops, including a large supermarket, banks, a post office, a library, and cafés. Bus and train public transport facilities are accessible within a few minutes walk from the care home. The home has a large enclosed and well maintained garden at the rear of the home. There is parking for several vehicles at the front of the house. All admissions are planned and the home does not accept emergency admissions. The bedrooms are all single occupancy and one with en suite facilities. Up to date information/documentation about the service and the range of fees including additional costs are accessible from the care home to residents and others. Fees in regard to individual residents are recorded in their care plan documentation. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during a day in November 2006. The inspector was pleased to meet all the eight residents during the inspection. The residents have varied communication needs, most of whom communicate with sounds, gestures, and signs. One resident speaks a few words. There were three vacancies at the time of the inspection. The purpose of the inspection was to spend time with the residents, assess 27 National Minimum Standards (Adults), including key National Minimum Standards, and to follow up and assess as to whether requirements and recommendations from the previous inspection had been met. The inspection included a tour of the premises, and inspection of resident’s care plans, staff personnel records, medication storage and administration systems, and inspection of a variety of other records. The inspector also spent a significant part of the inspection talking with staff, and observing interaction between residents and staff. Due to the communication needs of the residents observation was a significant tool in the inspection process. The registered manager was present during most of the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. The inspector thanks residents and staff for their assistance in the inspection process. Requirements from the previous inspection were judged as having been met. What the service does well: The care home has a welcoming atmosphere. Staff have knowledge and understanding of managing and meeting residents varied and often complex needs, including on occasions behaviour that challenges the service. Staff receive varied and appropriate training. Resident’s health needs are well catered for with timely referrals made to appropriate health care professionals. Residents are given the opportunity, with staff support, to access numerous varied preferred activities, which meet their individual needs. The registered manager ensures that there are clear lines of leadership, and is pro active with her staff team in ensuring that a quality service is provided to residents. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Spring Lake DS0000017450.V319468.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 Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where to live. Arrangements are in place to ensure that prospective residents have their needs assessed prior to their admission to the care home, to ensure that the care home is able to meet their needs, preferences and aspirations. EVIDENCE: The registered manager supplied the inspector with an up to date statement of purpose in regard to the care home. Copies of the service user guide documentation were accessible in the resident’s personal files. The service user guide recorded evidence of having been recently reviewed and included pictorial and written format. The care home has an admission procedure. Care plans (including a care plan of a recently admitted resident) inspected, included evidence of comprehensive assessment of residents needs, completed by staff from the care home, and from the relevant purchasing local authority. Records confirmed that an initial assessment of prospective residents is completed by care home management Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 9 staff. Staff reported that this initial assessment was comprehensive, and was particularly important due to the varied and complex needs of the residents that live in the care home. Assessment continues during visits to the care home by prospective residents. Staff informed the inspector that generally prospective residents visit the care home several times prior to their admission. Staff confirmed that family and/or significant others are fully involved in this assessment process. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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. Arrangements are in place to ensure that each resident has an individual plan of care and support, with agreed personal goals. Residents are supported in making choices about their lives, are given opportunities to be as independent as possible. Development in some aspects of recording of purchases could be improved Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: All the residents have an individual plan of care. Three care plans were inspected. These included personal details, a photograph of the resident, information from parents/significant others, finances, family support/contact, personal care and health needs, a behavioural support plan, and recorded staff guidance to meet residents varied and often complex needs. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 11 Individual staff guidance procedures for residents likely to be aggressive or cause harm or self-harm, were documented in resident’s behavioural support plans. Cultural and religious needs a recorded in the care plans inspected. The care plans include an individual 24-hour programme in regard to each resident. These documents include personal care needs and health needs and activities to support and develop skills and independence, and clear staff guidance to meet these assessed needs. Individual resident’s targets, and goals are recorded in this documentation. The care home continues to work hard to develop ways to support and enable the residents with significant communication needs to make decisions and choices. Photograph books are accessible. A staff member reported that these are developed for individual residents, and include photographs of activities, places, food choice and other items, which support staff to gain knowledge and understanding of residents significant and varied communication needs. Staff reported that these tools are particularly useful for staff to assist them in explaining/describing what place they planned to visit, and so enable the resident to gain an understanding of the activity and therefore be enabled to choose as to whether they wished to participate. Staff spoke of ways that they got to understand individual resident’s needs and preferences, and of how they used the photographs to assist in this. Staff demonstrated this during the inspection and were observed to offer residents a number of choices during the inspection. The inspector observed that photographs and pictures were also used to assist staff in supporting residents in meeting their needs, such as personal care needs, and that these photographs were accessible in resident’s rooms. The manager reported that several staff had received Person Centred Planning training. Records confirmed that care plans are regularly reviewed. Care plans developed by the relevant purchasing Local Authority were accessible in care plans inspected. Staff reported that all residents require support with the management of their finances. Several residents have their monies managed by relatives/significant others. The manager is the signature for some building society accounts. Residents’ monies and bank books are kept securely in a safe. Three residents monies were inspected. There was evidence of up to date records being maintained of incoming and outgoing payments. A receipt inspected did not identify the individual items bought. These items were recorded as cosmetics. The registered person needs to ensure that all resident’s items that are bought are clearly individually identified (possibly with an attached petty cash slip). This was discussed with the deputy manager. It is recommended that the systems for archiving receipts be reviewed. There were several hundred receipts (numbered) in the residents’ cash tins. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 12 Systems are in place to enable residents to take assessed risks. Records confirmed that there were individual recorded risk assessments i.e. behaviour risk assessments, and in regard to accessing the community facilities. These risk assessments include goals and targets for individual residents. Health and safety risk assessments are also documented. Spring Lake DS0000017450.V319468.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): Standard 12,13,15, 14, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have the opportunity to access a variety of activities with support from staff, and are supported in maintaining contact with their family/friends. Meals provided are wholesome and varied, and meet the individual needs of residents. EVIDENCE: Records and staff confirmed that the home has continued to develop a programme of varied activities and leisure pursuits that meet individual resident’s needs. The care home has a passenger vehicle and employs a driver. The care home has a Day Services Co-ordinator. He has responsibility for day and community services, and liaises with the National Autistic Society. He has developed a weekly activity programme, which includes ‘travel training’, trips Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 14 into the community, bowling, shopping, going to cafes, aromatherapy sessions, and accessing the library. Local community presence and participation by residents was evident from observation, records, and from talking to staff. The home has a sensory room, which was used by some residents as an activity/relaxation session during the inspection. During the inspection several residents participated in a music session that took place in a venue outside the care home. Residents also participated in a variety of activities with care staff and the Day Services Co-ordinator in two well equipped day resource buildings located on the premises of the care home. One resident attends another day centre three days of the week. Records confirmed that there is a significant emphasis in ensuring that residents have a full activity/leisure programme, which meets their preferences and needs. The day services file was inspected. This recorded lots of clear staff guidance for supporting residents to meet their individual social and activity needs, in regard to developing independent living skills of residents. There was also evidence of regular review of each resident’s progress in his or her activity programme. These reviews were very comprehensive, positive, and are linked with assessment of the resident’s coordination, concentration, colour identification, self awareness, and self image. It was evident that each resident has an individual activity programme to meet their needs, develop skills and meet assessed aims and objectives. Staff and records confirmed that residents had had the opportunity to go on holiday this year. During the inspection the inspector observed that there was generally 1-1 staff/resident support. Records and staff confirmed that residents had significant and regular contact with relatives, significant others and advocates. This contact includes visits to the care home and visits to relatives/significant others homes, by residents. Family/friends/advocates attend care plan review meetings, and there was evidence that the care home staff ensure that they are kept informed of the resident’s progress. The home has a visitor’s room. The care home has a missing persons procedure. There was evidence that the care home encourages and promotes resident’s independence according to their individual assessed needs. Residents were observed to be supported by staff in regard to carrying everyday living skills including household tasks. Staff were observed to respect resident’s privacy, and were seen to interact with residents in a positive and respectful manner. Residents were observed to freely access communal areas of the care home. Records confirmed that residents ‘bedtimes’ were flexible, i.e. it was recorded in a care plan that a resident’s bedtime could vary from 20.00hrs to 02.00am. The home employs a cook. The menu was available for inspection and included varied and wholesome meals. Residents were observed to be Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 15 supported by a staff member on a one to one basis in preparing their own breakfast. This is positive. A staff member spoke of how resident’s skills had developed since commencing this activity. The residents appeared to enjoy preparing their own breakfast with staff support. A staff member informed the inspector that a resident regularly participates in the preparation of her own lunch, and often invites family members to join her for a meal, which she has assisted in preparing. Records confirmed that resident’s dietary needs and preferences including cultural dietary needs are assessed and documented. Residents were offered food choices, and the breakfast and lunch meals that took place during the inspection were unhurried. Residents were observed to be given assistance with their meal if they so required. Meals provided during the inspection were judged to be wholesome. Drinks were offered regularly to residents during the inspection. Spring Lake DS0000017450.V319468.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): Standard 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. Arrangements are in place to ensure that residents personal care and their health needs are met. Systems are in place to ensure that medication is administered safely to residents. Some development in areas of medication administration and training could be in place. EVIDENCE: Records, and staff informed the inspector that resident’s personal care and healthcare needs are met by the care home. Clear staff guidance is recorded in residents care plans in regard to supporting and meeting resident’s personal care needs. It was evident that staff have knowledge and understanding of residents cultural needs. A resident had her hair plaited by a staff member during the inspection. Resident’s healthcare is monitored. Residents receive care and treatment from healthcare professionals, which include chiropodist, dentist, optician and Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 17 psychiatrist, and community nurse. All residents are registered with a GP. Records confirmed that residents have access to specialist healthcare professionals, which include speech and language therapists and dieticians, psychologists, and attend hospital appointments as and when needed. The medication storage and administration systems were inspected. Medication is stored securely. It is recommended that a resident’s stock of diazepam tablets be reduced to 2-3 tablets. Medication administration staff guidance is displayed in the home. Records confirmed that residents have a medication assessment and individual medication profiles are recorded. Records informed the inspector that some residents were receiving ‘homely’ remedies. There needs to be recorded evidence that a GP is aware of this and agrees with the administration of all homely remedies. Two staff administer and witness medication administration. A sample of medication administration records was inspected. Theses were up to date and fully recorded. Records confirmed that staff receive general medication training. There needs to be recorded evidence that staff are trained to administer a medication (suppositories) by a particular route. The deputy manager was inducting a staff member in medication administration during the inspection. The care home should develop a record of this ‘in house’ medication training; to ensure that there is a clear record of the medication administration procedures staff have been trained in. Refresher ‘in house’ medication training for all staff should also take place regularly and be recorded. Spring Lake DS0000017450.V319468.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): 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. Arrangements are in place to ensure that there are systems in place that enable residents and others to communicate ‘concerns’ or complaints, which will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The care home has a complaints procedure. Records confirmed that complaints are responded to appropriately, and indicate that people have knowledge and understanding of how to communicate a concern and /or complaint. Staff who spoke with the inspector were aware of the reporting and recording procedure to follow if they are informed of a complaint by a visitor, resident, and/or significant other. The home has a protection of vulnerable adults procedure, and an up to date reporting of significant events policy. Staff had recorded that they had read the ‘abuse policy’. Staff who spoke with the inspector confirmed that they had received abuse awareness training, and they were knowledgeable of reporting procedures in response to an allegation of or suspicion of abuse. Information about abuse reporting and recording procedures was displayed. Spring Lake DS0000017450.V319468.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): Standards 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. Resident’s live in a homely, clean and safe environment. Bedrooms are individually personalised. EVIDENCE: The care home is a large detached house, with an enclosed garden. It is located within a few minutes walk from a variety of local amenities and public transport facilities. The unannounced inspection included a tour of the premises. The home is clean, homely and well maintained. It was evident that there had been significant redecoration of the communal areas and bedrooms contributing to a bright and attractive interior. Pictures and plants are displayed throughout the care home, and furniture and furnishings are of quality. The deputy manager informed the inspector that work was planned to commence on the exterior of the building. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 20 There are handrails throughout the care home. The registered manager spoke of plans to erect handrails from the main house to the activity buildings, to assist in meeting residents mobility needs. This is recommended. Resident’s bedrooms are personalised and include furnishings and fittings, which meet individual resident’s needs. There was evidence of that resident’s bedrooms reflected their particular lifestyle, and that these are well lit and warm. The home employs domestic staff. The care home was clean and free from offensive odours at the time of the inspection. The laundry facilities are located away from food storage and food preparation areas, and hand washing facilities are sited throughout the premises. Disposable gloves and other protective clothing are accessible to staff. Spring Lake DS0000017450.V319468.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): Standard 32,33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent, supervised, staff, and are protected by the home’s recruitment policy and practices. Further development in some aspects of staff training could be further developed and improved. EVIDENCE: Staff who spoke to the inspector were judged to have good understanding of the varied needs of the residents. The inspector observed staff managing sensitively residents varied and complex needs. Staff spoke of how they gradually developed with staff team support; an understanding of residents varied need including communication needs, and so could support residents to make choices and to indicate their wishes. Staff who spoke with the inspector were judged to be very motivated, interested and committed in regard to their roles and responsibilities. All the residents have a key worker. There is a staff shift planner in which the staff on duty, their duties for the shift, and a staff handover record sheet is documented. The inspector was present during a staff ‘handover’ session. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 22 Photographs of staff on duty, and photographs of the residents were displayed on a board in the communal area of the home. There were seven care staff, cook, domestic staff member, driver and activity coordinator, and the deputy manager and manager on duty during the morning of the inspection. There was evidence of 1-1 staff support for residents. The staff rota was available for inspection. This indicated that a staff member had worked four significantly long days including four ‘sleeping in duties from the 18th to 21st November. This number of hours worked together is judged to be excessive and could lead to significant tiredness and so effect the care of the residents. This was discussed with the registered manager who reported that she would investigate this and ensure that this situation would not happen in future. The care home has a recruitment and selection procedure. Three staff files were inspected and included required information and documentation. A staff training and development plan was available for inspection. The training and development plan for staff included report writing, computer skills, understanding policies and procedures, person centred planning and observation skills. A staff member spoke of the specific training that they had received to enable them to support and meet the particular behavioural needs of a resident. Records confirmed that some staff had received communication training, managing aggression training, sexuality training, ‘break away’ training, and loss and bereavement training. Staff and records informed the inspector that the National Autistic Society assessed the training that was provided to staff. Staff spoke of having received autism awareness training. A training needs assessment that was supplied to the inspector indicated that several staff including ‘bank staff’ need to have evidence of appropriate training including ‘refresher’ training particularly in regard to statutory training such as moving and handling training, and health and safety training. There was evidence from records and staff that confirmed that staff had completed NVQ level 2 and/or level 3 in care. One staff member spoke of being in the process of completing a NVQ level 3 care course. It was recorded in the training and development plan that an aim was that all staff achieve a NVQ level 2 qualification. A completed staff induction record was available for inspection. Records and staff confirmed that staff received regular staff supervision. A staff member spoke of this as being a useful and supportive 1:1 meeting. Spring Lake DS0000017450.V319468.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): Standard 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. Arrangements are in place to ensure that residents benefit from a well run home. The quality of the service is monitored and systems are in place to develop and to continue to improve the service. The health and safety and welfare of residents are promoted and protected. EVIDENCE: The registered manager has managed the care home for several years. She is experienced with working with adults with a learning disability in a residential setting. She has completed an NVQ level 4 in management and is in the process of completing NVQ level 4 in care. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 24 The care home has systems in place to ensure that the service provided by the care home is monitored i.e. care plans are regularly reviewed. A copy of a comprehensive business/ annual development plan for April 2006 to March 2007 was supplied to the inspector. This includes aims and objectives in regard to the service. The deputy manager reported that the care home has recently received a review of its service completed by the National Autistic Society. Some policies (that have not been recently reviewed) should record evidence that they have been regularly reviewed. Up to date certificates of worthiness in regard to the service checks of systems in the care home were available for inspection. These included gas safety and electrical checks. The manager reported that recently a new boiler had been installed in the care home. Radiators are covered. Records confirmed that the home has an up to date Control of Substances Hazardous to Health (COSHH) assessment. Fridge/freezer temperatures are monitored. Accidents are recorded in the daily records/care plans, but not always recorded in the specific accident documentation. The registered person should show evidence that accidents are regularly reviewed and that action is taken to minimise the risk of these re occurring. Records confirmed that required fire safety checks including fire drills are carried out. An up to date employer’s liability insurance certificate was displayed. Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7 Regulation 17 Requirement Timescale for action 01/04/07 2 YA20 3 YA33 4 YA35 5 YA42 The registered person needs to ensure that all resident’s items bought are clearly individually identified. 13(2)(4) • There needs to be recorded evidence that a GP is aware of this and agrees with the administration of all homely remedies. • There needs to be recorded evidence that staff are trained to administer a medication (suppositories) by a particular route. 12,13,18,19 The registered person needs to ensure that she monitors the number of hours that staff work, and that staff do not work an excessive number of hours before a day off. 18 Several staff including ‘bank staff’ need to have evidence of appropriate training including ‘refresher’ training particularly in regard to statutory training. 17 All accidents need to be recorded in the appropriate accident recording DS0000017450.V319468.R01.S.doc 01/03/07 01/03/07 01/05/07 01/03/07 Spring Lake Version 5.2 Page 27 documentation. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA7 YA20 Good Practice Recommendations It is recommended that the systems for archiving receipts be reviewed. • It is recommended that a resident’s stock of diazepam tablets be reduced to 2-3 tablets. • The registered person should develop a record of staff ‘in house’ medication training; to ensure that there is a clear record of what new staff have been trained in, in the care home. • Refresher recorded ‘in house’ medication training for all staff should also take place regularly. Some policies should record evidence that they have been regularly reviewed. The registered person should ensure that the plans to erect handrails from the main house to the activity buildings, to assist in meeting resident’s mobility needs, are actioned. The registered person should show evidence that accidents are regularly reviewed and that action is taken to minimise the risk of these re occurring. 3 4 YA39 YA24 5 YA42 Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Spring Lake DS0000017450.V319468.R01.S.doc Version 5.2 Page 29 - 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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