Inspection on 22/06/06 for St Bridget`s Home

This inspection was carried out on 22nd June 2006.

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

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

Other inspections for this house

St Bridget`s Home 22/11/05

St Bridget`s Home 25/07/05

St Bridget`s Home 29/11/04

St Bridget`s Home 10/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 St Bridget`s Home Ilex Close Rustington Littlehampton West Sussex BN16 2RX Lead Inspector Mrs J Aston Unannounced Inspection 22nd June 2006 09:00 St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Bridget`s Home Address Ilex Close Rustington Littlehampton West Sussex BN16 2RX 01903 783988 01903 859235 sara.willis@ic-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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 Sara Margaret Willis Care Home 38 Category(ies) of Physical disability (38), Physical disability over registration, with number 65 years of age (38) of places St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only persons in the category PD (18-65) to be admitted to the home Date of last inspection 22nd November 2005 Brief Description of the Service: St Bridgets is a private residential care home registered to accommodate thirty-eight people with a physical disability. The premises are purpose built, set in their own grounds in a residential area between Rustington Village and the sea front. Residents accommodation is provided on the ground floor of the main building and in three separate bungalows. The proprietors are The Leonard Cheshire Foundation. The Responsible Individual for the organisation is Mr Peter Bray and the Registered Manager is Ms Sara Willis. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is the first inspection in 2006-2007. It is called a key inspection and will determine the frequency of inspections hereafter. Planning for this inspection took place prior to the site visit. Surveys were sent to each service user and comment cards sent to relatives and Professionals who know the service. Twenty-five surveys were received from service users, eighteen from relatives and eight from Professionals and one from a GP. A visit to the home took place on the 22nd June 2006 and was an announced visit. Both inspections in the year 2005-2006 were unannounced. Seven and a half hours were spent in the home. A tour of the premises was undertaken, four members of staff were interviewed and a sample of records was examined. Most service users had indicated on their survey that they did not wish to speak with an Inspector however three service users were spoken with during the visit. Relatives who were visiting a service user were also spoken with. A visit was made to the home on the 3rd July 2006 to provide feedback about the inspection to the Service Manager. What the service does well: St Bridget’s continues to provide a busy and stimulating environment with well organised activities that provide opportunities for learning, personal development and pleasure. Services within St Bridget’s include support from an Occupational Therapist, Physio therapist, I.T, co-ordinator and from a substantial number of volunteers. The Registered Manager ensures that the organisations recruitment procedures are followed that protects service users and ensures that the right people are employed. A wide range of training is made available for members of staff ranging from the mandatory Health & Safety training to National Vocational Qualifications topics relevant to the conditions of the service users accommodated. The home is kept safe by regular safety checks being undertaken on all areas of the home and equipment. Relatives provided some very positive feedbackabout the service: Our family are generally very happy with the care at St Bridgets. I have always found it easy to get problems sorted out and have great respect for the staff. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 6 My daughter has been very contented and happy at St Bridgets. It is a very caring home, well run and happy. Feedback from Social Workers and Care Managers was good: It is always a pleasure to visit St Bridgets. The staff are friendly and welcoming and seem to know their clients very well. They are always willing to take on board any suggestions or alterations to the care plan if needed. The service users seem happy and have very busy lives if that is their wish. What has improved since the last inspection? What they could do better: Through undertaking this inspection feedback has been received from service users, relatives and members of staff about inadequate staffing levels. From further investigation it appears that there is a certain time of day when staffing levels are low but service users require substantial assistance that means staff are hurried and stressed and service users may receive a poor service. This has been discussed with the Care Supervisor and Service Manager. The Inspector is aware that the Management of the home are currently reviewing staffing levels and have consulted members of staff individually. A requirement has not been made at this inspection as action is being taken to address this matter and the home need time to work to the new rota. This will be montiored at future inspections. Three recommendations have been made in this report in respect of: Locking bedroom doors when service users are out of the home for the day. Members of staff should ensure that storage of equipment in bathrooms and toilets is kept to a minimum. The Registered Manager should ensure that all relatives are aware of the complaints procedure. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 7 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. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The organisations admission policy and procedures are followed by the home to ensure that service users have sufficient and appropriate information to make a decsion about moving into the home. EVIDENCE: The organisation has a comprehensive assessment and admission policy and procedure for Registered Managers to follow to ensure each admission is undertaken in a planned way. There was evidence to demonstrate that the procedure is being followed. The records relating to a new service user admitted to the home were examined. This demonstrated that a Social Worker and the Manager of the home had undertaken an assessment of the service user’s needs prior to the inspection. A medical assessment had also been obtained. A further assessment was undertaken once the service user had been admitted to the home. The service user was spoken with during the visit to the home and confirmed that he had visited the home before admission and had received good information about the home. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 10 A service user who had been admitted to the home at the beginning of the week was also spoken with during the inspection. He and his relatives who were visiting at the time confirmed that written information about the home had been received and he had visited the home before moving in. A trial period has been arranged. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Service users needs and wishes are recorded appropriately. Service users receive support and assistance from members of staff to make choices and decisions in their lives. Service users are supported to take appropriate risks in their lives with risks minimised as far as possible. EVIDENCE: Four service user plans were examined during the visit to the home and some were selected randomly. Service user plans provide information about the needs of each service user and how they wish to be assisted. A pen picture is included in the plan that provides some information about the service users life history. There was evidence that service user plans had been reviewed. The service user surveys received prior to the inspection indicate that nineteen out of twenty five people said that staff listen to them and act on what they say. At the last inspection it was identified that there are a number of ways in which residents can have their say about any aspect of the home. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 12 There is a residents committee that holds regular monthly meetings, a residents meeting with the management of the home every two months and an open meeting for anyone to attend six times a year. Residents also have regular individual review meetings. Information held about each resident is stored appropriately and securely. St Bridget’s have policies and procedures in place in respect of data protection and confidentiality of information. Members of staff have to sign a policy in respect of the handling of information stored on computers. The manager confirmed that guidance on confidentiality of information is given during the induction training for new members of staff and further discussed at staff meetings. At this inspection, from the sample of service user plans examined, it was noted that the service user plan also contains assessments on potential risks for each individual ranging from falling out of bed, moving and handling, making tea, using an oven. There was evidence that risk assessments had been reviewed. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Service users are supported to live in an environment that meets their needs and provides them with a range of opportunities for self development. Service users are supported to maintain contact with family and are provided with a varied menu that includes healthy eating. EVIDENCE: It was evidenced at the last inspection that St Bridget’s provides every opportunity for a resident to further develop their education or independence. Service users are supported to access local facilities and participate in the local community. In discussion with members of staff at this inspection and from evidence from service user plans it was demonstrated that where able service users have been supported to take up work opportunities in paid or voluntary work. One service user is working at a local supermarket and another undertaking voluntary work. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 14 There are a substantial number of volunteers who provide individual support to service users, with transport and escorting out to local shops and other activities. Service user plans indicate where service users would benefit from support from a volunteer. The Volunteer co-ordinator has a substantial amount of involvement with volunteers supporting and organising fundraising events and activities within the home. The Inspector was informed that they had just had a Leonard Cheshire week that took an international theme and provided residents with different menus and tastes from around the world. It was noted at this inspection that a lounge had been decorated for the World Cup Football and a large television screen had been set up in the activity room. This was also being used for anyone who wished to watch Wimbledon. Fifteen out of the twenty five service users who responded to the inspection through surveys indicated that there are always or usually activities arranged by the home that they can take part in. There was evidence that staff at St Bridgets support service users to keep in touch with family and friends. From the information provided by relatives through comment cards fifteen out of the seventeen who responded said that they were made welcome into the home, sixteen out of seventeen said they could visit their relative in private, fourteen out of seventeen said that they were kept informed about the care of their relative, and eleven out of seventeen were consulted about the care of their relatives. All Social Workers/Care Manager who responded to the inspection through comment cards indicated that they could speak with service users in private. The Inspector was informed that after consultation with service users the morning routine has recently changed. This is to ensure that all residents have been assisted to get up by 9am. Staffing arrangements have been reorganised to ensure that this can happen. Members of staff spoken with confirmed that residents had been consulted and that individual choice is still adhered to. It was noted in the service user plans that residents have indicated the time they wish to be assisted to get up. Daily routines are dictated by activities that services users are involved in for example going to college, and joining the activities within the home and meal times. As found at the last inspection the provision of meals at St Bridgets is still under the responsibility of Caterlink. Menus are on individual tables daily. Residents have opportunities on a daily basis to choose between the daily menus or an alternative and this applies to breakfast, the main meal of the day and supper. A vegetarian meal is always provided. A resident’s choice is cooked every week. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 15 Hot and cold drinks are available from the dining room at any time. There are fresh fruit juice, milk and water dispensers for self-service and a hot water boiler on at all times for hot drinks. At this inspection service users indicated through surveys that fifteen service users said they always or usually like the food, eight said they sometimes like the meals. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Service users personal care and health needs are met appropriately. The service operates effective and safe procedures in the administration of medication. EVIDENCE: Four service user plans were examined during the visit to the home. It was noted that medical advice and information had been obtained as part of the pre-admission assessment for a new service user. All health matters had been assessed at the time of admission and monitored as necessary. The service user plans records appropriate daily monitoring as required e.g. bowels, weight, diabetes etc. An Occupational Therapist and Physiotherapist assessment had been undertaken. A tour of the premises demonstrated that service users have the technical aids and equipment they need for moving and transferring and maintaining independence. It was evidenced from training records that members of staff receive Moving and Handling training as part of their induction training and updated as necessary to ensure they know how to assist service users safely. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 17 On looking at each service user plan for the last optician, dentist and chiropody check ups these forms had not been completed for some time. There was other evidence that these checks are being undertaken but the forms are not being used. This was raised with the Service Manager who will ensure this is improved. Service users were asked through surveys: Do you receive the medical support you need? Thirteen out of twenty-five said yes, eight said usually and two said sometimes. At the last inspection it was identified that residents are generally registered at the same Doctors surgery but a number of Doctors are available at the practice so residents can have a choice about whom they see. A nominated Doctor holds a surgery at the home on a weekly basis and residents are free to consult the Doctor confidentially. There was evidence from service user plans that advice is sought from Health Professionals on a regular basis and recorded appropriately. From observations made at the time of the visit to the home it was evident that members of staff strive strongly to obtain the necessary medical support for service users. A comment card received from a regular GP indicated that the practice have not received any complaints about the home, the home communicates clearly with them, there is always a senior member of staff to confer with, that staff demonstrate a clear understanding of the needs of service users and overall was satisfied with the care provided. The storage of medication was examined at the site visit. The medication was appropriately stored and secure. Storage and medication records looked to be in good order. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Complaints are dealt with appropriately. The service has ensured as far as possible that service users are protected from abuse. EVIDENCE: There had been no complaints made to the Commission for Social Care Inspection prior to this inspection. The complaints record within the home recorded that no complaints had been received since the last inspection. From this inspection a concern had been raised through comment cards, this has been discussed with the person who raised the concern and has been passed onto the Service Manager to address. From the service user surveys that were received prior to the inspection twenty-service users out of twenty-five said they know who to speak to if they were not happy and nineteen out of twenty five said they knew how to make a complaint. From comment cards received from relatives it was indicated that eleven out of the seventeen relatives who responded were not aware of the homes complaints procedure. It is recommended that the Registered Manager ensure that all relatives are aware of the complaints procedure. From training records examined it was evidenced that all staff had received training in the protection of adults. Members of staff spoken with confirmed they had received the training. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 19 The pre-inspection material indicated that the Policy and Procedures in respect of adult protection procedures had been reviewed in December 2005. All service users have their own bank account and receive advice and support about welfare benefits and financial matters from the Residents Personal Assistant. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. The standard of accommodation provided for service users is good and provides a safe environment. EVIDENCE: A tour of the premises was undertaken. The home looked generally clean throughout. Service user rooms looked individually decorated and furnished and suitable for the needs of the service users. One bedroom was being decorated at the time of the visit and another that had been identified as needing redecoration by the Inspector is next in line to be redecorated. Although service users have signed to say they do not wish to have a key to their room, it is recommended that where service users are out of the home for the day that there rooms are kept locked. Storage of equipment still a problem in the home with so many items of individual equipment. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 21 This is not easily solved but it is recommended that members of staff ensure that storage of equipment in bathrooms and toilets is kept to a minimum. The garden was accessible to service users and was well kept. The kitchen wall in the Cheshire Cottage requires painting. The Service Manager confirmed that this will be addressed. Records examined demonstrated that safety checks on the property and utilities are regularly undertaken and comply with safety legislation. The Fire log book was examined and was in good order. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is adequate. These judgements have been made from evidence gathered both during and before the visit to this service. Staffing levels could be improved in some areas. This is being addressed currently. There are good recruitment procedures and individual supervision of staff is regularly undertaken. There is a wide range of training available for staff. EVIDENCE: A Care Manager said, I have always found the staff very helpful, open, communicative and caring. Another said, Staff are always available to respond to queries. All service users report they are happy with the care provided. Staffing levels during the visit to the home appeared appropriate for the morning shift with thirteen members of staff on duty. However the staffing level for the shift from 1.15 - 6pm seemed inadequate with four members of staff. Members of staff spoken with all identified that it was at this time that it was most stressful due to service users requiring assistance immediately after lunch and due to service users returning from college. This was said to be no different at weekends. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 23 Relatives said: “Staffing is always a problem otherwise the home is excellent. We often feel that staff are overworked, harrassed, seeming hurried staff are not easy to communicate worries to. I do think the home needs more staff, as they used to have more help with the residents personal things, this seems to be the major complaint I hear from my relative. There always seems to be a shortage of staff when I visit at the weekends. Sometimes it is very difficult to find a member of staff when one is wanted. If I do see a member of staff they appear to by trying to cope under very stressed circumstances. Often agency staff are employed at weekends which disrupts continuity. A Social Worker said,there is only one issue -staff shortages, the home needs to try to get a bank of reliable staff/suitable agency staff.” Staffing levels were discussed with the Care Supervisor and members of staff during the visit to the home and the Service Manager after the inspection. The Inspector was informed that from concerns raised by members of staff about staffing levels and shift pattern a review has been underway. There was evidence that all staff have been consulted individually about changes to the rota. A new rota has now been developed which has yet to be worked that will provide more staff around after lunch and will stop the long shifts which staff were unhappy about. The Service Manager plans to employ two other permanent members of staff and feels that this combined with the change in rota will reduce greatly the use of agency workers. A requirement has not been made at this inspection as action is being taken to address this matter and the home need time to work to the new rota. However this section has been recorded as adequate. This will be montiored at future inspections. The records relating to members of staff were in good order. There was evidence that the organisations recruitment process is being followed. New members of staff spoken with confirmed that they were not allowed to work in the home until CRB disclosures had come through. Training available to members of staff is good. There was evidence that all mandatory training has been kept up to date and refresher courses supplied. Training in topics relevant to the service users disability has been undertaken. Fire training had been updated in December 2005 and regular sessions are provided. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 24 National Vocational Qualification training is supported. Pre-inspection material states that seventeen members of staff have achieved an NVQ level 2 or above that is equivalent to 38 . The Registered Manager must ensure that progress in meeting 50 of the staff team trained to NVQ level 2 is made. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. The home is well run, well maintained and safe for service users. The safety of service users and members of staff is considered and risks minimised as far as possible. EVIDENCE: Comment cards received from Social Workers/Care Managers prior to the inspection all indicated that the home works in partnership with them and communicates clearly, there is always a Senior member of staff on duty to confer with, staff demonstrate a clear understanding of the care needs of service users, specialist advice is incorporated into the service user plan, the medication is appropriately managed and they have not received any complaints about the home. All said they were satisfied with the overall care provided. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 26 A Care Manager said, I have found the Manager very approachable and professional, all the staff are open to ideas and keen to improve and develop. Another said, It is always a pleasure to visit St Bridgets. The staff are friendly and welcoming and seem to know their clients very well. They are always willing to take on board any suggestions or alterations to the care plan if needed. The service users seem happy and have very busy lives if that is their wish. Records demonstrated and members of staff spoken with confirmed that training in the Health & Safety topics: Moving & Handling, First Aid, Food Hygiene, Fire and Health & safety is undertaken as part of their induction programme and then updated as required. A Quality assurance self-assessment report had been undertaken on the 1st March 2006. A copy of this has been provided to the Commission. Records seen during the visit to the home and as part of the pre-inspection material demonstrated that annual safety inspections are undertaken on equipment and utility supplies and maintenance systems are in place to ensure the safety of service users and staff. St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 27 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 4 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 3 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 St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 28 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 YA26 Good Practice Recommendations It is recommended that where service users are out of the home for the day there rooms are kept locked. it is recommended that members of staff ensure that storage of equipment in bathrooms and toilets is kept to a minium. It is recommended that the Registered Manager ensure that all relatives are aware of the complaints procedure. 2. YA29 3. YA22 St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Bridget`s Home DS0000014729.V290631.R01.S.doc Version 5.1 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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