Inspection on 24/04/07 for St Philips Close

This inspection was carried out on 24th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Philips Close 31/05/06

St Philips Close 29/11/05

St Philips Close 19/07/05

St Philips Close 01/02/05

St Philips Close 29/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 St Philips Close 3 St Philips Close Middleton Leeds West Yorkshire LS10 3TR Lead Inspector Dawn Navesey Unannounced Inspection 24th April 2007 09:15 St Philips Close DS0000001501.V337537.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 Philips Close DS0000001501.V337537.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 Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Philips Close Address 3 St Philips Close Middleton Leeds West Yorkshire LS10 3TR 0113 2778068 F/P 0113 2778068 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: 3 St Philips Close is a purpose built bungalow located in a residential area of Middleton close to local amenities and public transport routes. There is roadside parking to the front of the home. There are well maintained gardens to the rear of the property that are accessible to service users. The home is registered to provide personal care for four people with learning disabilities. The accommodation includes four single bedrooms, a lounge, combined kitchen and dining room, a communal bathroom and toilet, a domestic style kitchen and separate laundry room. The current scale of charges at the home is £8,730.60 per annum. Additional charges are made for toiletries, magazines, outings, activities and taxis for college. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector between 9-15am and 4-10pm carried out this unannounced inspection. The purpose of this inspection was to make sure the home was providing a good standard of care for the people living there. And to monitor progress on the requirements and recommendations made at the last random inspection on 20 November 2006 and the last key inspection of 31 May 2006. The people who live at the home prefer the term service user; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking with service users and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Before the visit, survey cards were sent out to relatives and visiting professionals to the home. One of these have been returned and this information has also been used in the preparation of this report. A telephone call was also made to a relative. There were no visitors to the home on the day of the visit. Feedback was given to the manager at the end of the visit. Thank you to everyone for the pre-inspection information, returned survey cards and for the hospitality and assistance on the day of the visit. A requirement and recommendations made during this visit can be found at the end of the report. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The assessment process for service users is thorough and detailed and makes sure the home can meet needs well. Care plans and risk assessments have detailed and specific information on care and support needs. The support plans are person centred, again making sure needs can be met. Staff are now accessing an accredited medication training course, which should help them to administer medication better. The home has a new hall carpet. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 7 The home is fully staffed, including an increase in the management team which gives the support staff more supervision and direction. The manager has introduced a system to analyse accidents to look at ways they can be avoided in the future. 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 Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and their carers can be sure that the home will meet their needs following assessment before moving into the home. Also from written and verbal information that is comprehensive and provides enough information for them to decide whether the home will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide are documents that give information on what the home can provide. These have been produced in an easy read format using easy words and pictures. They are kept on display in the entrance hall of the home and each service user or their representative is given their own copy. A relative confirmed they had received a copy. The manager has recently reviewed these documents, making sure there is up to date information available. The CSCI inspection reports are also available in the entrance hall for any visitors to see. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 10 Pre–admission assessment has recently been carried out for a service user who has just moved into the home. This has been done to a very high standard with lots of detailed and individual information. The manager of the home, the operations manager and a senior support worker were all involved in this. The service user and her relatives have been consulted and contributed to the assessment. Care management, speech and language therapist and community nurse assessments have also been obtained. This means that the home can be sure they can meet this person’s needs. The moving process was tailored to meet this person’s needs and the needs of her relatives. Visits and overnight stays were arranged and a moving in date agreed by all concerned. This assessment period also considered the needs of the current service users. The other service users’ needs are also being re-assessed as the organisation has developed some new documentation called Personal Support Plans. This involves the service users and it is clear that their own words are being used to describe their support needs. This is person centred and good practice. Service users have a contract with the organisation that outlines all the terms and conditions. The person who has recently moved into the home has not got a full contract in place yet. The manager said this will be done at the six week placement review meeting when all funding issues will be addressed. Staff from the organisation have made good efforts to explain finance and funding issues to a relative. This had been recorded in the service users’ daily notes. Service users who were able to say, spoke highly of the home and services provided. One said, “It’s very good here.” A relative said, “I couldn’t have chosen anywhere better, the home is lovely.” St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individual needs are met by the implementation of clear and detailed support plans and risk assessments, which have involved service users and relatives. Service users have a say in the day to day running of the home and are encouraged and supported to make choices. EVIDENCE: Some further progress has been made with the standard of service users’ care plans and risk assessments. Those seen, gave clear, detailed instruction on how service users’ needs are met. Much of the information is person centred. It is written in the first person and gives good information on likes and dislikes and preferences with care and support. More information is now included on service users’ leisure and recreational needs. The plans are reviewed regularly and any changes made are well documented. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 12 Any risks identified for service users are properly assessed and an action plan put in place to manage the risk. These are also evaluated and reviewed regularly to meet service users’ changing needs. The person who has recently moved in does not have all their care plans and risk assessments in place yet. Staff said that they are using the detailed assessment information to deliver the care and support for this person as they get to know her needs better. The manager said that full care plans and risk assessments will be fully developed as soon as possible. This will make sure that all care and support needs are fully met. It is clear that a good response was made when this person’s relative highlighted a risk issue and staff drew up a management plan for it. As mentioned in the Choice of Home section, the organisation is currently introducing new care planning documentation called Personal Support Plans. This is a type of person centred planning and is made up from a variety of styles such as essential lifestyle planning, goal planning and circles of support. The manager has been trained in its use and is a person centred planning facilitator. She is currently training all staff to use the support plans with service users and their families. Staff spoke highly of the training they have received and said they felt the whole team was working together to develop these plans and look forward to the involvement of relatives. Staff have a good knowledge of service users’ needs. They were able to accurately describe the care they give and talk about the detail of how service users like to be supported in their daily routines. They showed a good awareness of the support plans and risk assessments. Key workers carry out a monthly review of support plans with service users. Notes are kept of these meetings. Service users were offered choices throughout the day, for example, what to do, where to go, what to eat, whether to have the radio or the television on, whether to spend time in the lounge or in their own room. Staff respected service users’ choices and responded well to their requests. Due to the complex needs of the service users it is difficult to hold formal meetings with them. However, the manager said that at the evening meal, time is spent asking service users if they are happy with things such as food and activities. The service users who can verbally communicate then have anything they are happy or not happy with noted down in their daily notes and looked into. Service users who do not use verbal communication are observed for their body language and facial expressions in response to questions. The manager has also asked a local advocacy service to provide advocacy for service users. There is however, a big waiting list for this service. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their lifestyle and supported to develop their life skills. Appropriate activities are arranged and a good, healthy and varied diet is offered. EVIDENCE: Service users are involved in various activities each week. This includes, college courses in art and gardening, day centres, Gateway clubs, a music therapist who visits the home, shopping, trips out to the pub and for meals, walks to local parks and visiting friends and family. The new deputy home manager has developed a programme of art and crafts activities for service users and staff to do in the home. This has been well organised and makes sure that each service users response to the activity is documented to see if they enjoy it and want to carry on. It seems that service users are developing St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 14 hobbies such as gardening and painting through this. One service user had made the hanging baskets for the garden. Others had made some very attractive art work that has been tastefully displayed in the home. One service user said he had enjoyed the baking and cooking sessions and was very proud of what he had made so far. Staff said they felt there is always enough staff on duty to make sure of a good level of activity. The manager is creative with the staffing rota to make the best use of staff time. One service user said they always had something to do but would like to go to the pub more. On the day of the visit one service user was out all day at a day centre and another went out shopping. Service users are encouraged to meet up with old friends and to keep in contact with their families. A thank you card had been received in the home from a service user’s family, thanking them for a recent party and being made to feel so welcome. Staff support service users with their diverse needs. A male volunteer is about to start work at the home as a “buddy” to a male service user who likes some male company and chat. A male member of staff is key worker to this person too. A service user who likes to express her femininity is supported with this. She likes to wear perfume and jewellery so staff make sure this happens. Another service user likes to have fresh flowers in the home at all times. She shops locally to buy the flowers and is supported to arrange them. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure service users are as independent as possible for their dignity and self esteem. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. Menus appear to be well balanced and nutritious. The manager and deputy manager are currently looking to introduce a new healthy eating plan that should meet the needs of all service users. They are in the process of consulting with service users’ GP’s and a community dietician about this. Service users are involved in doing the weekly shop and this is based on their likes and dislikes, which means there is always something available that service users like. However, if a service user wants something different to what is on the menu, this can be done. A good variety of food is available and staff make sure there is a good selection of fresh produce available. The main meal of the day is eaten at teatime. Staff make sure there are a variety of lunches on offer. Service users can help themselves to snacks and drinks throughout the day. One service user said, “They’re all good cooks here, especially the porridge” another service user nodded and smiled when asked if she enjoyed the food. St Philips Close DS0000001501.V337537.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 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal and health care support is provided in a way that meets service users needs. There are, in the main, good systems in place for safe management of medication. EVIDENCE: Staff support service users with their personal care needs in private and with dignity. The level of detail in support plans on how personal care and health related tasks are to be carried out makes sure that service users’ needs are fully met. Staff have good knowledge of their likes, dislikes and preferences. The support plans also have details of any health professionals that service users see. These include, GP, speech and language therapist, dentist, specialist nurse, and optician. Records are kept of any health appointments and their outcome. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 16 Some service users have specialist health needs such as epilepsy. Most staff have received training in epilepsy. The manager said that any specialist training needs that arise will be addressed through local training providers or the organisation’s training department. A recent example of this has been a particular syndrome that a service user is diagnosed with. Another example has been training in dementia and the needs of elderly people. The manager has also made contact with the RNIB (Royal National Institute for the Blind) to see if they can access any of their training courses on visual impairment. She is also looking at any services the RNIB have which may be of use to a service user who is blind. Service users’ emotional well being is seen as important. Bereavement counselling has been arranged for a service user in the past and they are supported by staff with on-going work from this. The home uses a monitored dosage pre-packed system for medicines. All senior staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration records (MAR) were checked and showed no errors in administration. The home also uses homely remedies and has obtained permission from each service users’ GP to administer them when needed. The manager must put some written guidelines in place to show how this system is managed as the present system could lead to errors in administration. St Philips Close DS0000001501.V337537.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 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect service users from abuse. EVIDENCE: The home has a complaints procedure displayed in the entrance hall of the home. This is also in the Statement of Purpose and Service User Guide. It is an easy read complaints procedure, making it more accessible. The home has not received any complaints since the last inspection. A service user said they would complain to staff if they had any complaints. It would be good practice to put the complaints procedure on tape for a service user who is blind. Staff have received training on safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. They knew where the policy on adult protection was kept and could refer to it. Service users are protected by the use of body maps to document any bruises, scratches or marks they may have and are not able to say how they happened. This is good practice to monitor for any signs of possible abuse. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 18 Good records are kept of service users’ finances and their monies are kept safe. Proper handovers of the monies takes place at each shift change and the manager regularly checks the finance records and receipts. St Philips Close DS0000001501.V337537.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, 29 and 30 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers an attractive, homely, clean and safe environment for service users and provides appropriate specialist equipment. EVIDENCE: The environment of the home continues to get better and better. The home is tastefully and attractively decorated and furnished throughout. The use of soft furnishings, ornaments and pictures gives the home a very homely feel. It is warm, very clean, fresh smelling, light and airy with a good layout. Service users’ bedrooms are well maintained and show their individual interests and personality. A service user who has recently moved in has had a new carpet fitted to suit their needs and choice. The relatives of this person St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 20 are involved in getting new things and bringing things in from home to enable the person to settle in more easily. There is a choice of a bath or shower for service users. Tracking hoist has been fitted for service users who need it. The bathroom and shower room are attractively decorated and made interesting by the use of pictures and other decorations. It has been identified that a service user needs some specialist seating and an occupational therapist assessment is being arranged for this. The hallway has a new carpet. This was fitted as previously it was a laminate floor and staff were aware that the sound of their footsteps on this flooring could wake service users up at night or disturb those who enjoy a lie in. The home has an attractive enclosed garden. This is shared with the home next door. Some service users are interested in gardening and have been supported by staff to do this. Clinical waste is properly managed and staff wear protective clothing when attending to service users’ personal care needs. Staff have received training in infection control and were able to say what infection control measures are in place. St Philips Close DS0000001501.V337537.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 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are competent and well supervised to meet the needs of service users. Service users are protected by the home’s recruitment procedures. EVIDENCE: There are staff on duty throughout the day and night. There are usually two staff on the morning shift and two staff on the afternoon shift. At night there is one member of staff on duty. The manager has two shifts per week where she is supernumerary and can attend to her management role in this home and the home next door. At other times she works alongside staff demonstrating good practice. Staff said they felt there is enough staff and they never feel rushed. A relative said they find there is enough staff on duty when they visit. They also said, “ Staff are brilliant, great, they are trying their very best to get to know …….. needs”. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 22 Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. References are verified through telephone calls to the people providing them. This is good practice. Staff’s training is mostly up to date. Records are kept of staff’s training and when their updates are due. The manager assesses this every month to make sure training doesn’t get missed. Staff spoke highly of their training and the support they get from the manager. Some staff have not completed some essential training such as food hygiene even though they have been working at the home for some time. There is an annual training plan provided by the organisation. It seems that availability of training can be a problem in that more courses are needed than is available. The home manager has tried to address this problem by asking the organisation to deliver training in the home in order to get more staff on the courses. She also said that the organisation is currently looking into internet courses that staff could undertake in the home. Well over half of the staff team have achieved an NVQ (National Vocational Qualification) in care at level 2 or above. Most of the rest of staff team are also currently working on their NVQ. One staff member has been recognised with an award from the college that runs the NVQ programme for her outstanding contribution to the NVQ care award. All staff said they felt they had a good team and the manager was very supportive. The home is fully staffed, including all the management team of manager, deputy and senior support workers. Staff said they felt communication and teamwork within the home were great. The staff rotas showed that no agency staff have been used at the home since October 2006. The home has its own relief staff and permanent staff are willing to work additional hours. There were some gaps in the regularity of supervision staff have received. The manager was aware of this and had plans in place to make sure staff receive regular supervision. She has also now started staff appraisals. St Philips Close DS0000001501.V337537.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, 38, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and has a competent management team. This means that the interests of the service users are seen as important to the manager and staff and are safeguarded at all times EVIDENCE: The home has an experienced manager who has almost completed her NVQ level 4 in care and the Registered Managers Award. Her target completion date is June 2007. She also has another management qualification in managing social care. She offers good leadership to the staff and has good systems in place to make sure service users are supported and cared for St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 24 properly. She is currently waiting for a date for an interview with the CSCI to become the registered manager. The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to service users and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation carries out an annual service review, as part of its quality assurance programme. This also includes service users, relatives and staff. The manager said that quite often relatives can’t make the service review meetings. It is recommended that the organisation considers the use of questionnaires to gain the views of relatives or other professionals. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Maintenance records are well kept. Environmental risk assessments are completed and reviewed. Health and safety training is well maintained. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. The manager now has a system in place where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. The home has a comprehensive range of policies and procedures in place to ensure health and safety. The manager makes sure staff are familiar with these and asks them to sign them when read. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 3 3 4 X 5 3 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 4 25 X 26 X 27 X 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 X St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13.2 Requirement The manager must make sure there are written guidelines in place for the use of homely remedies. This will reduce the risk of any errors being made when they are administered. Timescale for action 30/06/07 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 YA35 YA39 Good Practice Recommendations The organisation should consider extending their annual training plan to take into account the numbers of staff who require mandatory training such as food hygiene. The organisation should consider the use of questionnaires to gain the views on the service of relatives and visiting professionals to the home. St Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Philips Close DS0000001501.V337537.R01.S.doc Version 5.2 Page 28 - 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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