Inspection on 31/10/06 for St Catherines

This inspection was carried out on 31st October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Catherines 15/02/06

St Catherines 19/09/05

St Catherines 17/01/05

St Catherines 23/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 St Catherines Coventry Road Coleshill Birmingham West Midlands B46 3EA Lead Inspector Catherine Mundy Key Unannounced Inspection 31st October 2006 11:00 St Catherines DS0000004299.V315113.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 St Catherines DS0000004299.V315113.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. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherines Address Coventry Road Coleshill Birmingham West Midlands B46 3EA 01675 434050 F/P 01675 434050 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) Father Hudson`s Society Care Home 16 Category(ies) of Learning disability (16), Physical disability (16), registration, with number Sensory impairment (16) of places St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may only provide care for service users who have a learning disability. However, service users may also have a physical &/or sensory disablty 15th February 2006 Date of last inspection Brief Description of the Service: St Catherines is a registered care home for 16 younger adults with learning and physical disabilities. The care home consists of 3 interlinking purpose-built bungalows and the provision of management facilities. The Father Hudson’s Society provides 24 hour care and support for the people living in the home. The home is situated within the Father Hudson’s Society main complex, which is situated in the small town of Coleshill, North Warwickshire and close to all local amenities and services the town, has to offer. Each bungalow has a large open planned lounge and dining/kitchen area, a fully adapted bathroom to meet disability needs and a light sensory room. Service users each have their own bedroom with en-suite facilities. These reflect the service users preference for a shower or bath; adaptations are made where these are needed. There is a well-equipped laundry room and small office in each bungalow. There are separate garden areas for each bungalow, which are well maintained and easily accessible. The current weekly charge ranges from £781 to £1309, with additional charges made for hairdressing, chiropody, toiletries, magazines, aromatherapy, activities and holidays. This information was provided by the home on 22nd September 2006. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It took place on 31st October 2006 between 11am and 6.30 pm. It included a tour of the home and observations of the interactions between staff and service users. Records were also examined and staff and service users were spoken with. The homes manager, area manager and personnel manager also assisted with the inspection. The home completed a Pre-inspection questionnaire and the service users and their relatives completed comment cards. The comments made are included in this report. What the service does well: The home is comfortable, clean and homely and reflects the individual needs and personal preferences of the service users, the atmosphere in the home is welcoming. Observations during the inspection indicated that the service users felt relaxed and comfortable. Comments made by the service users and their relatives in comment cards are complimentary. All of the relatives commented that they are made welcome in the home and that they are satisfied with the care that is provided. Other comments made include “my son is extremely happy” “care given is always above and beyond” “I know I couldn’t find anywhere better than St Catherine’s” “the staff and the care that they give is as always excellent”. All of the documents seen were well ordered, easily accessible and up to date. The service users continue to have a plan of care that meets their changing needs and reflects their personal preferences. These are regularly reviewed and updated. Any risks identified are managed appropriately. The staff have a good understanding of the service users needs, they adapt the levels of support that they provide to reflect the individual service users needs and abilities. The service users continue to be able to participate in a broad range of activities that reflect their personal preferences, promote their independence and that they enjoy. Most of the service users attend a day placement on weekdays; they are able to choose to have a day of if they wish to spend time pursuing other activities. The home has good staffing ratios, with additional staff provided when activities are planned. The staff are experienced and have the knowledge and skills to enable them to meet the service users needs effectively. During the inspection they interacted with the service users in a way that promoted the service users independence, respected their privacy and dignity and enabled the service users to make a valued contribution to the running of the home. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 6 As noted at previous inspections there were high levels of interaction between the staff and service users. The manager and staff were relaxed and respectful when talking to and working with the service users. The bungalows are decorated and furnished to a good standard and reflect the service users personalities, preferences and mobility needs. Specialist equipment is provided and adaptations made where these are needed. Each bungalow has a team of staff; the staff do not go into another bungalow without being invited. Although there have been changes to the management of the home this has not affected the quality of the care that is provided. St Catherine’s continues to be a well-run home. 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. St Catherines DS0000004299.V315113.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 St Catherines DS0000004299.V315113.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): X EVIDENCE: The standards within this section have been met at previous inspections. There have been no changes to the service users residing in the home since that time. These standards were therefore not assessed on this occasion. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff continue to be provided with detailed information and have a sound understanding of how the service users needs are to be met. The service users continue to be provided with opportunities supported by the use of appropriate communication aids, to make decisions about their everyday lives. EVIDENCE: A sample of service users care files were examined. These are well ordered and contain clear and concise information that details the service users needs and how these are met. The care plans are written using language that is easy to understand they are enhanced by the use of ‘Change bank’ pictures. Comment cards completed by the service users relatives confirmed that when the service user is unable to make a decision they are consulted about the care that is provided. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 10 Observations during the inspection confirmed that the care plans are implemented. Discussions with a number of staff confirmed that they have a sound understanding of each individual service users needs and how the service users prefer these to be met. Risk assessments have been completed and strategies in place to reduce the risks identified. Both care plans and risk assessments are reviewed regularly at planned intervals or as the service users needs change. Observations during the inspection, discussions with staff and service users and examination of records confirmed that the service users continue to be enabled to make decisions that affect their every day lives. The staff use a variety of communication techniques to facilitate this. The technique used is thus dependant upon the needs and abilities of the individual service user. The staff demonstrated a sound knowledge of each individual service users preferred method of communication; this is also documented in their care plan. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users continue to have a good quality of life; they are able to participate in a range of valued and fulfilling activities that they enjoy and maintain relationships with family and friends. Their rights and responsibilities are respected and they have a varied diet that reflects their needs and preferences and that they enjoy. EVIDENCE: Discussions with the staff, examination of records and observations during the inspection confirmed that the service users continue to be able to take part in a broad range of valued and fulfilling activities. These include cinema, meals out, walks, theatre, food shopping, household chores and food preparation. On the day of the inspection most of the service users attended their day placement returning home late afternoon. On their return some of the service users were given the opportunity to participate in a variety of activities, two St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 12 service users went for a meal out. Others spent time relaxing or chatting with the staff. One Bungalow had a Halloween Party, which the service users enjoyed. Three service users did not attend a day placement. Activities were provided by the staff for these service users. The staff said that the service users could choose to have a day off from their day placement, where they can choose how they would like to spend their day. Additional staffing is provided to support the activities chosen. A tour of each of the bungalows confirmed that the home provide a broad range of activities to do at home. The service users are able to pursue their hobbies. The service users were seen to move freely around the communal areas of their home and were able to choose when to spend time alone. It was pleasing to note that the service users and staff did not access the other bungalows without being invited. Staff were observed to knock on bedroom doors before entering. The service users can lock their bedroom doors if they wish; they confirmed in their comment cards that they are able to keep their things private. The arrangement for supporting service users to open their mail is recorded in their individual care plans. Discussions with the service users and staff and observations during the inspection confirmed that the service users continue to be supported to maintain relationships with their family and friends. Records examined and discussions with service users and staff confirmed that the service users are supported to receive visitors or to visit their family. The staff confirmed that family and friends are invited to special occasions and parties arranged by the home. Family members commented that they are welcomed in the home and can visit their relative in private if they wish. Some of the service users have a telephone in their bedrooms, and each service user has an email address. The staff said that they support the service users to use the phone and send and receive emails. The staff also confirmed that they support the service users to write to their relatives and to send cards on special occasions. Discussions with the staff and service users and examination of records confirmed that the service users are able to choose the meals that are provided. Each bungalow holds a weekly meeting where the service users are shown pictures of a selection of meals that they can choose from. The staff said that they take into consideration the service users likes and dislikes and special dietary requirements. These are recorded in the service users plans. The menu plans seen confirmed that the service users have a varied diet. A variety of drinks and snacks were available for the service users. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 13 Observation during the inspection confirmed that the service users meals are prepared in a way that enables the service users to maintain independence. Specialist crockery and cutlery is provided. Some service users require staff support to eat and drink; this support was given in a sensitive way that promoted the service users dignity. The level of support required is detailed in the service users plans. The staff confirmed that alternative meals are provided if a service user indicates that they don’t like the meal that is available. Observations during the inspection and discussions with the service users confirmed that the service users like their meals. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users personal and healthcare needs are met in a way that reflects their preferences, promotes their privacy, dignity and independence and is responsive to changes in the service users needs and wishes. EVIDENCE: The service users files examined contained detailed information as to how the service users prefer their personal care needs to be met. Discussions with the staff and observations during the inspection confirmed that they are aware of the service users individual needs and preferences, respecting the service users choices as to how care is delivered. Observations during the inspection confirmed that the service users are supported sensitively in a way that promotes their dignity and well being. The staff demonstrated that they provide care in a flexible way that responds to the service users changing needs and wishes. Throughout the inspection the service users appeared to be relaxed and comfortable. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 15 The service users continue to receive support from a variety of health care professionals and access routine health screening at the local GP surgery, dentist, chiropody and opticians. Appointments are recorded in the service users files with detailed information as to the outcome for the service user. The service users are also able to see an aromatherapist if they wish. Discussions with the staff and examination of the service users files confirmed that they are proactive in addressing the service users changing health needs. Detailed records are maintained to enable the service users GP and other health care professionals to make an accurate assessment of the service users health. Relatives confirmed that they are kept informed about the service users care and in the event that the service user is unable to make an informed decision, they are consulted. Feedback from service users in comment cards indicates that the service users feel that they are well cared for. The service users needs are such that the home retains responsibility for ordering, storage, administration and disposal of the service users medications. Discussions with the staff and information provided in the preinspection questionnaire confirm that all staff complete medications training before they are permitted to administer medication to the service users. Discussions with the staff confirmed that they have a sound understanding of the service users medication needs, the demonstrated knowledge of how and when medications are to be administered and of the need for regular review with the service users GP. Medications are stored securely, and records maintained of medication administration. Records are also maintained of any medications that are returned to the pharmacy for disposal. Examination of the medication records identified that the home did not always accurately record the medications that they have received on behalf of the service users. Since the inspection the manager has provided evidence that this has been addressed. A new procedure for receiving medication is in place. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the home have an acceptable procedure in place to enable service users and their relatives to raise concerns or make complaints, the staff were not sufficiently trained to protect the service users from abuse. EVIDENCE: The home has an acceptable complaints procedure in place. Feedback received from service users and their relatives confirms that they are aware of this procedure. The relatives confirmed that they have not had cause to complain about the service that is provided. The manager confirmed that the home has not received any complaints since the time of the last inspection. The Commission for Social Care Inspection has not received any concerns or complaints about this service. Discussions with the manger and staff confirmed that they are aware of their responsibilities in the event that concerns that are raised or a complaint is made. The service users are given opportunities to raise concerns or make suggestions informally at house meetings. There is evidence that suggestions made are acted upon. The records provided confirmed that the staff have received training in the protection of vulnerable adults. However discussions with the staff and manager during the inspection identified that in the event of an abuse being St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 17 alleged or suspected proper procedures would not be followed. A referral to the adult protection team would not be made. Discussions with the area manager following this inspection confirmed that the organisation has taken steps to address this. Evidence has been provided to confirm that all of the staff will complete training in adult protection in January 2007. The information provided confirms that this training will inform the staff of their responsibilities in the event that abuse is alleged or suspected. The manager confirmed that in the event of a service user showing distress or there is a change in their normal behaviour records relating to health and wellbeing will be examined to establish probable cause. The manager demonstrated in discussion a detailed knowledge of the indicators of abuse. The service users comment cards indicated that the service users feel safe and well cared for. Records relating to the service users finances were examined . These were acceptable. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment is high providing the service users with a safe, clean, comfortable and homely place to live. EVIDENCE: A tour of the three bungalows confirmed that the service users continue to live in a homely, comfortable and safe environment. The home is maintained to a high standard. The manager confirmed that there is a plan in place to redecorate some areas of the home that have been damaged by the service users wheelchairs. This is proactive, as the level of damage that has been caused does not currently detract from the overall appearance of the home. Each of the service users has a large bedroom with an ensuite bathroom. The bedrooms are furnished, decorated and personalised to reflect the individual personalities of the service user to whom they belong. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 19 The bungalows have a large communal space that includes a lounge, dining area and kitchen. The kitchens are fitted with low-level work surfaces for the service users to use. Each bungalow has a sensory room for the service users to use, sensory equipment is also provided in the service users bedrooms. The bungalows have their own gardens these are accessible from the dining area of the homes. Each bungalow has a large shared bathroom, which has a parker bath. In addition the service users each have an ensuite shower room, this is with the exception of one service user who has a parker bath in his ensuite. The aids and adaptations that are required to support the service users with personal care are provided. Each bathroom also has an emergency call button. The staff were wearing the receivers for these during the inspection. The staff also said that one service user who is deaf has an adaptation that he wears to alert him should the fire alarm sound. During the inspection it was noted that the homes were clean and tidy. Each bungalow has a domestic person who is responsible for the cleaning on weekdays. The care staff complete these tasks when the domestic person is on leave and at the weekends. Records are maintained of the cleaning tasks performed by the care staff in the communication book. One service user said that he cleans his own bedroom. This is with staff support. Records of this are maintained in the service users file. Discussions with the staff and observations during the inspection confirmed that the home has appropriate procedures in place to reduce the risk of cross infection. Hand washing facilities are available in the kitchen and laundry and appropriate cleaning materials and equipment were available. Each bungalow has a laundry room. The laundry facilities are appropriate for the needs of the home. They consist of a washing machine, which has a facility to wash items at high temperatures if required and a tumble dryer. Cleaning materials were stored securely. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users benefit from receiving support from an experienced staff team, who have the knowledge and skill to enable them to meet their needs effectively, they are protected by the organisations recruitment procedures. EVIDENCE: On the day of the inspection there were sufficient staff on duty to meet the service users needs and to facilitate activities. Four staff members were on duty in each bungalow. The manager was also available, she is supernumerary to the staffing rota. The staff and manager confirmed that these staffing ratios are the norm for the home and that staffing ratios are increased to enable planned activities to take place. Each bungalow has an assistant manager. The assistant managers have one day per week allocated to administrative duties. Feedback from relatives confirms that they also feel that there are sufficient staff on duty to meet the service users needs. This is with the exception of one relative who expressed concerns relating to the completion of domestic duties St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 21 when the domestic staff are away from the home. It is noted in the environment section of this report that in these circumstances domestic tasks are undertaken by the care staff. The staff confirmed that they are able to maintain the cleanliness of the home and complete caring duties. They and the service users confirmed that the service users assist with this. The staff and manager demonstrated throughout this inspection that they have a clear understanding of their roles and responsibilities, and have the necessary skills and ability to perform their roles effectively. It is clear that positive relationships have been formed between the service users and staff. Examination of records relating to the service users needs and to staff training and discussions with staff confirm that the staff have received training that is appropriate to their role. This includes training relating to epilepsy, diabetes, makaton, and healthy eating. This is in addition to mandatory training in medication administration, food hygiene, manual handling, fire safety and first aid. There is evidence that this training is reviewed at regular intervals. It is noted earlier in this report that although the staff have received training relating to adult protection, this requires review and update. Following this inspection the area manager has provided evidence to confirm that a suitable training package has been developed and will be implemented in January 2007. The staff were able to demonstrate in discussions how their practice had changed following the training they had received. Information provided in the pre-inspection questionnaire confirms that 56 of the staff team have a qualification that is equivalent to NVQ level II. The manager confirmed that 7 staff members are to enrol on this course in the near future. The home has a minibus. Staff are required to complete a minibus test before they are able to drive the bus. This test is retaken at regular intervals. A sample of staff files were examined, and discussions with the personnel manager took place. This confirmed that the organisation continues to follow acceptable procedures when recruiting new staff members. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for service users consultation are good with evidence that the service users views are sought and acted upon. The home takes appropriate action to promote and maintain the health and safety of the service users and staff. EVIDENCE: Since the time of the last inspection there has been a change to the management arrangements of the home. The deputy manager is now ‘acting’ manager. Discussions with the manager and staff, feedback from relatives and service users, examination of records relating to the service users and the management of the home and observations throughout this inspection confirm that despite this change the quality of the service provided in the home has St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 23 been maintained. The manager has demonstrated her ability to fulfil her role effectively. She is supported by a competent team of staff who are aware of their own roles and responsibilities within the home. The organisation has provided evidence to confirm that there is a plan in place to recruit a permanent manager for the home. The organisation has produced a 5-year development plan for the home. This was not examined on this occasion. The manager seeks the views of the service users, their relatives/representatives, visitors and professionals involved in the service users care annually. The feedback received is incorporated into the development plan. In addition to this each bungalow holds a weekly meeting with the service users to discuss issues that are important to them. Records relating to this were examined. These confirmed that the service users have the opportunity to contribute to the running of the home, choose meals and activities and identify health and safety issues. There is evidence that the suggestions made by the service users are acted upon. The manager monitors that the staff are fulfilling their roles during staff supervision and appraisal meetings. A sample of records relating to the health and safety of the home were examined. This along with information provided in the pre-inspection questionnaire and observations during the inspection confirm that the home takes appropriate action to maintain the health and safety of the service users and staff. St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 2 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 4 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 2 X 3 X X 3 X St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13(6) Requirement The provider must continue with the plan in place to provide all staff with Adult protection training. Timescale for action 31/01/07 2. YA37 8 This requirement also relates to standard 35. The provider must continue with 31/01/07 the plan in place to recruit a permanent manager for the home and make an application to register this person with the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 St Catherines DS0000004299.V315113.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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