Inspection on 06/11/06 for St Mungos Association

This inspection was carried out on 6th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Mungos Association 21/10/08

St Mungos Association 25/10/05

St Mungos Association 19/07/05

St Mungos Association 19/01/05

St Mungos Association 03/09/04

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 St Mungos Association 53 Chichester Road London NW6 5QW Lead Inspector Julie Schofield Key Unannounced Inspection 6th November and 7th December 2006 09:50 DS0000017439.V317732.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 DS0000017439.V317732.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. DS0000017439.V317732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mungos Association Address 53 Chichester Road London NW6 5QW 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) 020 7624 4453 020 7328 2438 St Mungo Association Mr Michael Dunne Care Home 27 Category(ies) of Past or present alcohol dependence (27) registration, with number of places DS0000017439.V317732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Chichester Road is one of a number of projects run by St Mungos Association. It is a wet home for men and women with alcohol dependency needs and is registered to accommodate 27 service users, many of whom have been rough sleepers. Staff provide encouragement and support, including assistance with personal care and help with managing finances. Staff give information and support in respect of the service users health care needs and advice regarding the importance of eating well is supplemented by the appetising meals offered. There is a life skills worker who organises a programme of activities, both inside and outside the home. There are bedrooms and bathrooms on the ground, first and second floor. There is a lift that links the ground and first floor and there is a TV room (dry room), a games room (wet room) and a dining room on the ground floor. Service users use the garden areas at the front and the back of the building when the weather is fine. Details regarding fees may be obtained from the home, on request. DS0000017439.V317732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 visits to the home. The first visit started at 9.50 am on the 6th November and finished at 1.50 pm. The second visit started at 8.50 am on the 7th December and finished at 11.35 am. The Inspector would like to thank the manager, deputy manager, members of staff and residents who took part in the inspection. During the visits discussions took place with managers, staff and with residents. An examination of records took place. The serving of a meal was observed. A site visit of the premises was conducted and proposals for changes to the physical environment were discussed with the manager and the Life Skills worker. What the service does well: What has improved since the last inspection? New carpet has been laid in the corridors of the 1st and 2nd floors. A statutory requirement was identified during the previous inspection that records of the administration of medication must be up to date and complete. Recommendations were also made regarding the staff that would be most suitable to be involved in the administration of medication. The home reviewed its practices and records inspected during this inspection met the requirement. DS0000017439.V317732.R01.S.doc Version 5.2 Page 6 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. DS0000017439.V317732.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 DS0000017439.V317732.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): 2, 4 Quality in this outcome area is good. A comprehensive assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A trial visit to the home gives the prospective resident an opportunity to sample life in the home and to decide whether the service provided is suitable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four case files relating to residents that had moved into the home during the 12 months prior to this inspection were examined. It was noted that each file contained information provided prior to the admission of the resident. Referral forms were accompanied by information from health care and social care professionals including the GP, the community nurse, the consultant, the OT and the social worker. There were copies of the continuing care assessment tool and the community care assessment summaries on file. There was evidence that residents had been involved in the assessment process although when they were unable or unwilling to give certain information this was noted. DS0000017439.V317732.R01.S.doc Version 5.2 Page 9 Before a resident is admitted to the home the resident visits the home for a 3day trial period. At the end of the trial period the resident may stay if the resident, the home and the funding authority are satisfied that the placement is suitable to meet the needs of the resident. A record is kept of the trial period and a copy of this was present on each of the case files examined. The form consists of recordings on each of the 3 days and includes comments in respect of diet, personal care, finances, interpersonal skills, alcohol use, mental health and medication. On the morning of the second visit a prospective resident and their social worker were making an introductory visit to the home. DS0000017439.V317732.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): 6, 7, 9 Overall quality in this outcome area is good. Residents’ needs are identified in care plans and are subject to review and the regularity of review meetings needs to be maintained. The minutes of review meetings need to be kept on the case files so that staff are aware of any changes to the care plan that have been agreed. The resident’s right to make decisions about their life in the home is respected. Staff support residents to take responsible risks so that residents can enjoy an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each file examined contained an up to date care plan. Where possible they were signed by the resident. Goals were identified for both resident and member of staff. There was an action plan for the resident and the members of staff and an evaluation of the progress made by both parties. Care plans DS0000017439.V317732.R01.S.doc Version 5.2 Page 11 identified the individual needs of the resident. Files contained monthly outcome reports but there were gaps in the regularity of these, for some residents. Although there was a record in the diary and in a planner that some review meetings had taken place, the minutes of the meetings were not on file. These meetings had taken place in the summer. On one file an internal review meeting was over due as the key worker had left the home. Residents are encouraged to make decisions in respect of their day to day living and examples of this were observed during the inspection. Most residents are assisted with the management of their finances and this is one of agreements made, prior to the resident’s admission to the home. Although an agreed daily budget ensures that there is some money each day for the resident it is not necessarily a popular rule. However one of the residents explained why receiving all of the money for a week in one payment was not in the best interests of the resident. Each case file contained a risk assessment, as part of the admission process. This considered the resident’s physical health, ability to climb stairs, medication, diet, continence, toileting, dressing, bathing, epilepsy, hearing, sight, diabetes, breathing, medical conditions, mental health issues (e.g. self harm), substance use and behaviour. Each file also contained a recent comprehensive risk management form. The form had a record of a number of areas where risks could be identified e.g. diet, financial exploitation. The likelihood of risk was assessed as low, medium or high. Details of the nature of the risk and risk management strategies were recorded. Risk assessments were tailored to meet the individual needs of the resident. DS0000017439.V317732.R01.S.doc Version 5.2 Page 12 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, 14, 15, 16, 17 Quality in this outcome area is good. Providing activities for residents, both inside and outside the home, offers residents an opportunity to develop their social and communication skills and to enjoy an interesting and stimulating lifestyle. The support of staff enables residents to maintain family contact. Respect for the resident’s right of choice was demonstrated in the way in which residents lived their lives, as they wished. A varied and balanced menu is available in the home and staff encourage residents to purchase meals in the home in order to improve the general health of residents. This judgement has been made using available evidence including a visit to this service. DS0000017439.V317732.R01.S.doc Version 5.2 Page 13 EVIDENCE: A member of staff said that encouraging residents to talk and to listen to what they had to say was an important part of building a relationship based on trust. They said that one resident had told the member of staff that they felt a sense of relief after talking about their emotional problems. The Life Skills worker spoke of residents taking part in activities and “confronting emotions at their own pace”. Staff will assist a resident if the resident has any problems with their benefits. Residents are encouraged to use facilities in the community and outings have been arranged to museums, parks and to St Albans. As part of the Black History Month some residents went to the unveiling of a plaque commemorating Bob Marley. Residents are able to access local transport facilities or the home is able to provide transport, if necessary. The Life Skills worker was on duty during the inspection. Activities take place in the games room and in the dining room. A weekly programme of activities was on display, including pictures and illustrations, and activities included a reminiscence quiz, a health group, massage and relaxation, bingo, a film night and games. Recently a group of musicians visited the home and played live music, involving residents. On the second visit to the home 3 of the residents went out for a dog walking session with the Life Skills worker. Some activities help to build a community spirit while others are done on a 1 to 1 basis with residents who are not “team players”. Thought has been given to the activities offered and some activities are especially suitable for residents with dementia or have an impaired memory. Special days in the home recognise seasonal events e.g. Halloween or the different cultural backgrounds of residents e.g. a St Lucia day or a Jamaica day. Residents said that they were able to join in activities as they wished and one resident said that he enjoyed playing darts. A member of staff said that the home goes a long way to make sure that where possible, contact between residents and their families is achieved and maintained. This has included supporting residents in making contact with their family and encouraging visits. Due to the vulnerability of residents staff on duty have to be careful in respect of “visitors” who are unknown to the home. The admission process includes acceptance of the house rules. Although this is a “wet” establishment i.e. alcohol may be consumed on the premises, there are parts of the home where alcohol consumption is not allowed and residents must abide by this. A copy of the house rules, signed by the resident and dated, was present on each of the files examined. A copy is also provided in the information file that is placed in each of the bedrooms. Residents said that the rules are discussed with them before they sign the form. Although rules are in place freedoms are still promoted and these included residents having a DS0000017439.V317732.R01.S.doc Version 5.2 Page 14 key to their room and being able to choose whether they wish to socialise or to take part in activities. They are able to maintain their chosen lifestyle. In 2005 the home piloted a new system in relation to meals available in the home and this has now been adopted. The main meal of the day is served midday instead of in the evening and as a result of this, and with the encouragement of staff, more of the residents are purchasing a meal in the home. The home continues to promote the residents’ awareness of good nutrition and of the importance of making choices within their lifestyle to achieve this. The menu was on display and it was noted that alternatives were offered to the 2 main dishes of the day. Main dishes included those, which met the cultural needs of residents e.g. African Caribbean dishes or Spanish dishes. The evening meal consisted of a choice of hot snacks, soup, sandwiches, fresh fruit etc. As residents left the dining room they said that they had enjoyed the meal. On the first visit to the home steak or a Spanish dish was the main meal of the day. Contract caterers prepare and serve the cooked breakfast and the midday meal and prepare the evening meal for staff in the home to complete and serve. Residents said that the food was good and that the current chef is good. They agreed that second helpings were there if requested, that the cost of meals was very reasonable and one resident said that since coming out of hospital he was building up his appetite again. DS0000017439.V317732.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. Residents receive assistance with or prompting with personal care in a manner, which respects their privacy and dignity. Residents’ health care needs are identified and staff support residents, where necessary, to access health care services in the community. Residents’ general health and well being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the home there are project workers and care assistants as some residents need assistance with personal care tasks or require prompting if they are to maintain satisfactory personal hygiene standards. A resident confirmed that he received assistance with showering. A care assistant said that particular care was needed with residents who had problems with continence DS0000017439.V317732.R01.S.doc Version 5.2 Page 16 and that this would be a priority. The home has a system of key working and meetings take place between the resident and their key worker. There was evidence on case files, and in the daily diary, that residents were escorted to outpatient or clinic appointments, when required and residents confirmed this. One resident with poor mobility said that they were pleased to have someone with them when they went to the hospital. Due to their personal histories residents often suffer with poor health and each case file examined noted access to a range of health care services within the community. There were appointments at the chest, radiology, neurology, dressings, endocrinology, gastroenterology, cardiology and oral maxillo-facial surgery clinics. Appointment cards were present for podiatry services. There were prescriptions for optical services. There was a record of dental appointments. Residents also had blood tests, x-rays, flu jabs and ultrasound imaging. Referrals had been made to the continence adviser, the dietician and the physiotherapist. Recording of this was methodical and up to date, which is essential given the complexity of health care needs of the residents. A book was available for inspection, with records filed according to the number of the room occupied by the resident. Each recording noted the date, the reason for the appointment, the practitioner visited, where the appointment had taken place, the member of staff attending and the outcome of the appointment. Since the last inspection the home has engaged the services of a new pharmacist. The storage of medication was inspected and was safe and satisfactory. The home uses the system of a weekly blister pack for the administration of medication to residents. These were inspected and the blisters that had been “popped” were appropriate for the day and time of the inspection. A statutory requirement was identified during the previous inspection that records of the administration of medication must be up to date and complete. Records were inspected and there was compliance. Liquid medication, creams and inhalers were inspected and it was noted that the date that tubes of creams had been started was not recorded on the tube or the box. DS0000017439.V317732.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. Residents are aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The number of recorded incidents reflects the lifestyles of residents. The deputy manager has developed guidelines for staff on duty, in the form of a chart, in the event of a resident sustaining an injury, being hospitalised, being assaulted, being abused, going missing etc. The guidelines include a list of people who need to be notified, including the Commission for Social Care Inspection. The home has a complaints policy, which includes timescales for each stage of the process and which gives information regarding other agencies, including the CSCI, which the complainant may wish to contact. The complaints records were inspected. Records include the investigation undertaken and subsequent actions. Complainants are notified of the outcome of their complaint. Dates are attached to each stage of the process. The residents’ handbook, a copy of which is given to each resident on their admission to the home, includes details of the complaints procedure. Residents said that if they had a complaint they DS0000017439.V317732.R01.S.doc Version 5.2 Page 18 would speak to some one in the office. If this did not resolve matters they would speak to the deputy manager or the manager. The home has a policy for the protection of vulnerable adults. Residents confirmed that they were confident to speak to some one in the home if there was something that they were unhappy about. The manager said that no allegations or incidents of abuse have been recorded since the last announced inspection. A member of staff on duty confirmed that they had received protection of vulnerable adults training and that this was undertaken on an annual basis. They spoke clearly about what their response would be in the event of a disclosure being made and were aware of the role of the manager and the limits surrounding confidentiality. They were familiar with the whistle blowing procedure and the need to protect the residents. DS0000017439.V317732.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): 24, 28, 30 Overall quality in this outcome area is good. Residents live in a home, which is comfortably furnished and well maintained, although some minor replacement of furniture and a review of storage facilities in the home is needed. They are satisfied with the accommodation and facilities in the home and pleased with its convenient location. Residents enjoy comfortable communal areas in which they can relax, socialise or take part in activities. Residents live in a home where standards of cleanliness are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial site visit took place. It was noted that the combined vanity unit and fitted wardrobe in some of the bedrooms was in need of replacement. Where wardrobe doors had been broken a curtain had replaced them. The “veneer” of surfaces was lifting in places. Residents said that the bedrooms were good DS0000017439.V317732.R01.S.doc Version 5.2 Page 20 and one resident said that due to his decreasing mobility he had moved to a room on the ground floor and described this as “the biggest room in the house”. There is a lack of storage space in the home and it was noted that a box of incontinence pads, a piece of carpet and chair were being stored in a stair well close to a door marked “exit”. Residents said that good security systems in the home protected them. Communal facilities in the home consist of a television room (a “dry room”) and an activities room (a “wet room”), which contains a pool table. Communal rooms are decorated and furnished in a homely manner. During the summer it has been noted during inspections that residents enjoy sitting outside the house, particularly on benches at the front of the building. A discussion took place with the manager and deputy manager regarding the garden area. The home is now in the middle of a “no drinking zone” and so residents can no longer consume alcohol in the local park and there is a need for a quiet and secure place to enjoy the fresh air and to have a drink, if residents wish. With some modifications to the garden at the side of the house, the home could provide this. Plans have been prepared and include the building of a conservatory, which would increase the communal space available to residents. The home has just secured funding for the scheme. It was noted during the inspection that the serving of the main meal in the middle of the day and the provision of activities in the home has resulted in more residents using the home (and communal areas) during the day than in previous years. During both visits to the home, including a tour of the premises, it was noted that all areas seen were clean and tidy and free from offensive odours. Residents commented that the home “was spotless” and that the bedclothes are changed on a regular basis and that the clothes were washed. Laundry facilities are situated on the ground floor, away from the kitchen or dining room. The washing machine has a sluicing cycle. There is an infection control policy in place and staff receive infection control training. DS0000017439.V317732.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): 32, 33, 34, 35 Overall quality in this outcome area is good. The home continues to support staff undertaking NVQ training, although it has not met the target of 50 of staff achieving an NVQ qualification. Although the rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs the staff team lacked on site administrative support. Recruitment practices safeguard the welfare of residents. The training and development plan ensures that training provided enables staff to meet the objectives contained in the Statement of Purpose and to meet the individual and changing needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion took place in respect of the progress being made by the staff team in meeting the target of 50 of staff (project workers and care assistants) achieving an NVQ level 2 or 3 qualification. Of the eleven members of staff whose names were on the rota, 4 members of staff have completed their training, 1 member of staff has almost completed the modules and 3 DS0000017439.V317732.R01.S.doc Version 5.2 Page 22 members of staff are in the process of studying for their qualification. A member of staff confirmed that they had almost finished their NVQ level 2 training. Residents said that the staff working in the home were good and that the night staff were “very nice”. Staff that took part in discussion with the Inspector demonstrated and interest in and commitment to the work that they were undertaking. The staffing rota consisted of both project workers and care assistants, in addition to the manager and deputy manager. Staffing levels were sufficient to meet the needs of the residents and to provide escorts for residents going to health care appointments. A Life Skills worker organises and arranges the activities programme. The home employs janitors that undertake the cleaning of the home. Catering services are provided on a contract basis. Despite the size of the home and the complex needs of the residents the home does not have any administrative support staff. Since the last inspection one new member of staff has started to work in the home. The staff file was available for inspection. There was evidence of 2 satisfactory references, proof of identity and an enhanced CRB disclosure being obtained prior to the member of staff taking up their post. Staff appointed are subject to a probationary period. Staff who took part in the inspection said that the company offered good training opportunities and one member of staff said, “Training gives you confidence”. Staff received training in safe working practices e.g. first aid, health and safety, food hygiene and manual handling. They also receive training in respect of meeting the needs of resident’s e.g. managing aggression, care planning and key working and boundaries and good practice. A training and development plan is in place. DS0000017439.V317732.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): 37, 39, 42 Quality in this outcome area is good. A competent and knowledgeable manager is able to direct the quality of service received by residents. Quality assurance systems identify satisfaction with current services and changes in the needs and expectations of residents. This information shapes the development of the service as it is incorporated into business planning. The health and safety of residents is promoted through staff awareness and training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000017439.V317732.R01.S.doc Version 5.2 Page 24 The registered manager has a Diploma in Social Work and has also achieved an NVQ level 4 in Management. A copy of the Client Satisfaction Survey results for 2005 was on the board in the meeting room/visitors room on the first floor. The manager said that the 2006 survey results were expected soon. The survey includes comments on food, safety and comfort, staff competence, access to health care facilities and access to the complaints procedure. This information is used to develop a clients needs survey for individual establishments within the company and benefits from comparisons with previous years. Residents confirmed that they attended the weekly residents’ meetings although said that one or two residents always had a lot to say. A member of staff on duty said that the staff team was taking part in an “away day” tomorrow and that there was a system of quarterly questionnaires for staff and for residents to give feedback on the quality of the service provided. The manager said that the number of accidents occurring in the home had decreased following the introduction of the main meal in the home being served at midday rather than in the evening. This was due to a decrease in alcohol consumption on the part of some of the residents. There was a COSHH file with an assessment dated 8/06. The file contained the manufacturer’s data information sheets for each product used in the home. There were also recent, recorded risk assessments for food handling, night working, infection control and fire. Weekly fire alarm tests and fire drills records were up to date. There was a valid Landlord’s Gas Safety Record and record of the testing of the portable electrical appliances. Staff confirmed training in safe working practice topics. DS0000017439.V317732.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 X 2 3 3 X 4 3 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 2 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 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 4 3 X 3 X 3 X X 3 X DS0000017439.V317732.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15.2 Requirement That a copy of the minutes of review meetings are kept on the resident’s case file. If these are not received by the home, within 4 weeks of the meeting taking place, the home must contact the placing authority, in writing, and make a request. That the care plan and placement is reviewed at least on a 6 monthly basis. While the placing authority convenes at least 1 review meeting a year the home must convene a meeting, if necessary, to maintain the continuity. That a programme of refurbishment is drawn up for bedrooms where combined vanity units and built in wardrobes need replacing. That the programme of refurbishment is carried out. That storage facilities are reviewed and items are removed from areas where they may create a hazard. That 50 of staff supporting residents achieve an NVQ level 2 qualification. DS0000017439.V317732.R01.S.doc Timescale for action 01/02/07 2 YA6 15.2 01/03/07 3 YA24 16.2 01/06/07 4 YA24 13.4 01/02/07 5 YA32 18.1 31/12/07 Version 5.2 Page 27 6 YA33 18.1 That administrative support is provided on site. 01/04/07 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 YA6 YA20 Good Practice Recommendations That monthly outcome reports are completed on a regular basis for each resident. That the date of first using a tube of cream is recorded on the tube or the box in which it is being stored. DS0000017439.V317732.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 DS0000017439.V317732.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. 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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