Inspection on 24/05/05 for Stairways

This inspection was carried out on 24th May 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stairways 20/07/07

Stairways 19/07/06

Stairways 08/11/05

Stairways 23/11/04

Stairways 21/07/04

Stairways 12/12/03

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Stairways 19 Douglas Road Harpenden Hertfordshire AL5 2EN Lead Inspector Neil Fernando Unannounced 24 May 2005 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 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 Stationary 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. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stairways Address 19 Douglas Road, Harpenden, Hertfordshire AL5 2EN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 460055 Harpenden Mencap Society Darren Lelliott CRH PC 17 Category(ies) of LD - Learning Disability - 17 places registration, with number PD - Physical Disability - 17 places of places Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: This home may accommodate children and adults with learning disability or physical disability (when associated with learning disability). Date of last inspection 23 November 2004 Brief Description of the Service: Stairways offers care to seventeen people with a learning disability, who may also have an associated physical disability. Included in this total is the provision of respite care to four children. It is housed in a large Edwardian property in Harpenden, divided into four self-contained flats each with kitchen, lounge, toilet, bathroom and bedrooms. Flat 1 accommodates up to 5 service users with a learning disability;Flat 2 accommodates up to 4 service users with severe learning disability who occasionally display behavioural difficulties and Flat 4 accommodates up to 4 service users with moderate to severe learning disability. The short-term care unit accommodates up to 4 children plus day care for 1 child. This unit comprises of a kitchen/dining room, bathroom/toilet, utility room, bathroom, toilet lounge, playroom and four single bedrooms. There are spacious grounds surrounding the house and car parking for several vehicles at the front. The house is near Harpenden shops and other community amenities and public transport routes to St Albans and Luton are accessible. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Younger Adults and the Care Homes Regulations 2001. The last inspection was carried out on 23rd and 26th November 2004. Considering that this home also operates a separate respite unit for children between 5 and 19 years of age, consistent with the previous inspection reports it is the view of the Commission that the Children’s Homes Regulations 2001 and the National Minimum Standards for Children’s Homes are also applicable to this aspect of the service provision. This is therefore reflected in the text of the report, where appropriate. Stairways is a service managed by Harpenden Mencap Society – a charitable organisation. It is registered to accommodate a maximum of 17 adults including up to 4 children for respite care, of both genders, plus day care for 1 child. Service users and children have learning disabilities and may have an associated physical disability. The home operates as 4 separate Flats located in the same grounds. At the time of the visit there were 13 adults and 4 children including 2 for day care in residence. The inspection took place over one afternoon/evening in the latter part of May 2005. 7 residents including 3 children and 7 staff members including the Manager were spoken to, in order to seek their views regarding the quality of service offered at this home. In the main, evidence available suggests that the care for service users has been maintained to a good standard. What the service does well: The organisation including the staff team continues to embrace and deliver on the National Minimum Standards for both Young Adults and Children’s Home. The inspection main finding is that a significant number of the National Minimum Standards assessed have been achieved. Information gathered from service users, children, staff members, records and observation made of care practice confirm the core values of both adult and children’s services as well understood, in terms of compassion, respect, trust and fairness. Service users and children spoken to expressed a good deal of satisfaction regarding the quality of care they receive. The complaint procedures are well publicised and service users/children should be able to make a complaint if they are dissatisfied with any aspect of their care. The protection systems including staff recruitment are adequately robust to ensure the safety of service users. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 6 The building and all areas viewed were found to be fresh and clean. The accommodation for the adults is homely, comfortable and furnished to a high standard. Health and safety matters are being attended to. The home has very experienced and sound management team under the leadership of the Registered Manager and Director of services. 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. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 4. The staff team including the Manager understand and appreciate the need to support the service user, the child and their family to make an informed choice as far as possible. The offer of a lengthy “settling in” period wherever necessary, is indicative that identifying needs and individual aspirations during the initial stage are central to a successful placement. EVIDENCE: Records show that all of the current service users were accommodated a significant number of years ago, prior to the National Minimum Standards becoming operational. In spite of this the Manager is clear that any prospective service User and their family will be fully supported by the care staff team, in order to enable them decide if the home is suitable to meet their needs. A service user’s guide for the adult provision and a satisfactory children’s guide for the children’s respite unit are also available. Evidence is available to indicate that a copy of the guides is made available to every service user, child, their representative and professionals, as appropriate. Information available indicates that service users and children admitted to the home are under a Care Management arrangement and have had a full assessment of needs by their respective Social Worker, prior to admission to the home. Other people involved in the assessment process includes a member of staff, the resident/ child, parents/relatives and significant others. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 9 Staff members including the Manager reported that any prospective service user, their relatives/friends are always encouraged to visit and an overnight stay for the prospective resident will be facilitated, as appropriate. The opportunity to meet with residents and staff members, have a meal, overnight stay and seek clarification, appear to be a routine part of the admission process. A minimum 3 months ‘settling in’ trial period of residence would then be offered, followed by a placement review with the service user, Social Worker, their relative and other professionals if required. Three staff members including a senior based in the respite unit stated that the prospective child is invited for several daytime visits and an overnight stay, prior to the first period of respite care. The home can admit a child in an emergency but for a maximum of 28 days only. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 10. This home is a very good example where service users are being appropriately supported to achieve a high degree of independence. It is however essential that a formal system be instituted, so that each child has a placement plan review, in order to ensure that their identified needs are being addressed and unmet needs, monitored. The Commission however acknowledges that the primary responsibility for undertaking any formal/statutory review rests with the placing authority and not with the Registered provider. EVIDENCE: Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 11 Care plans for both the service user and the child are detailed and comprehensive, and include their identified needs and requirements and goals. The key worker completes a monthly report reflecting relevant changes. Each service user has an annual “Whole Life” review. Case files examined indicate that reviews of placement plans for children are being carried out by placing authorities with the exception of those children placed by Hertfordshire County Council. The Manager however, has made contact with the Hertfordshire County Council requesting that a formal system be introduced, in order to ensure that each child has a placement plan review, involving the child, parents and professionals as appropriate. Service users spoken with expressed a high level of satisfaction regarding the assistance they receive. It was not possible to gain any accurate view of the children on the subject of care planning, given their level of learning disabilities. However, the children appeared to be very aware of who their key worker is and generally what is happening in their lives. One of the stated principles underpinning this organisation is that service users would be given the opportunity to make choices about their lifestyles and to be treated as individuals. Some of the service users are independent and they receive minimal assistance from staff. This is a good example where service users continue to enjoy excellent opportunities to develop their own interests and make choices about their day-to-day lives. The staff team are to be commended for their hard work and achievement in this area. Observation of staff’s practice in the more dependent flats demonstrates that residents’ rights to decision-making are also being proactively encouraged and upheld, as appropriate. Evidence gathered suggests that staff respect information given by service users in confidence. Records regarding the resident or the child is compiled and stored in accordance with the home’s written procedures and the Data Protection Act 1998, and in their best interests. A system should however be instituted, in order to demonstrate that the service user/child is being informed that any information about them will be dealt with appropriately and their confidence, respected. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 16. The residents appeared to be well supported to enjoy a full and meaningful life alongside other members of the local community. Service users are clearly benefiting from their placements and assistance they receive. Social and recreational activities for service users and children are adequate and appropriate for their general welfare and development. Equally, the educational arrangements for each child receiving a service at this home appear to be well supported. EVIDENCE: Progress records demonstrate that the service user/the child have good access to the local community resources. Information available also suggests that the staff team and residents have worked very hard at building positive relationships with neighbours. Care plans provide details of the social and recreational activities enjoyed by each individual child. Staff duty rotas are organised in such a manner, in order to ensure that staff are available in sufficient numbers to facilitate planned activities for children. Leisure interests clearly take into account religious and Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 13 cultural needs as well as individual preferences and the pattern followed in the child’s own home. Considering that only respite care is offered to the children’s group, the responsibility for the children’s education remains appropriately with their parents or guardians. The Inspector therefore focused his assessment on whether the staff team support the existing arrangements for the children’s education. The children’s service has an education policy and staff members spoken to are familiar with each child’s educational history. Children continue to attend their own school whilst being accommodated at Staiways. Placement plans viewed for six children clearly reflect their educational needs. There is evidence of good communication between the schools, the home staff team and parents. Overall, staff members appeared to pro-actively support the educational arrangements for each child receiving a service at this home. There continues to be a good range of social and recreational activities in place, based on the identified needs and abilities of the individual service user. Details of social history, previous interest and hobbies are clearly reflected in each person’s care plan. Those who are able are actively encouraged to continue with any activity or hobby they were involved in, prior to their admission to the home. Service users were seen coming and going from and to various activities on the day of the inspection. Some service users are in paid and voluntary work and others attend colleges, day centres and clubs. The home has several vehicles available for transporting service users on trips – “an excellent resource” for accessing a higher level and variety of outdoor activities reported service users and staff members. Information gained indicates that promoting the rights of the service user/child is central to the philosophy of this establishment. Residents’ rights are upheld through policies and procedures and on going staff training and supervision. Risk assessment for each resident is regularly updated, in order to minimise any potential hazard. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19. Service users and children are receiving appropriate assistance from the staff team. The registered person ensures that the physical and health care needs of service users and children are assessed and recognised, and procedures and effective management support enable staff members to address them. Close monitoring from the staff team means that any potential difficulty and complication is identified and dealt with at an early stage, including prompt referral to an appropriate professional. EVIDENCE: There are a variety of dependency levels of service users; some live quite independently with staff assistance available as required; others need ‘one to one’ attention to achieve daily living tasks or to monitor their challenging behaviour; the needs of the wheelchair bound service users are also well addressed. Staff members are aware that any restriction must first be discussed with the resident, their Care Manager/Social Worker, family and other professionals, in order to seek their approval prior to enforcing any restriction. Any restriction imposed is also reflected in the resident’s care plan. Technical aids and equipment needed to maximise the independence of service users are available as required. Documentary evidence is available to indicate that service users are registered with a General Practitioner. Service users are able to see their doctor at their surgery but the doctor may visit a resident at the home in an emergency. The Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 15 children retain their own GP, as they are accommodated only for a short period for respite facilities. Other professionals, residents have access to include Dentist, Physiotherapist, Occupational Therapist, Podiatrist, Community Nurses and other specialist professionals. Some of these professionals also contribute to service users’ care plans and attend their reviews. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The complaint procedures are well-publicised and service users, children and significant others should be adequately empowered to make a complaint. Systems in place should offer adequate protection to service users and children from harm. Providing essential training on the Protection of Vulnerable Adults and Child protection for all staff members as appropriate is indicative of the organisation’s commitment to improve the knowledge and skills of staff to enable them to better protect and promote the welfare of service users and children. EVIDENCE: Information regarding how to make a complaint is included in the service user’s guide, children’s guide and the home’s statement of purpose for both the adults and children’s services. Staff members interviewed including the Registered Manager reported that the procedures on complaints are available and accessible to all staff members, relatives and professionals as appropriate. Members of staff demonstrated a good understanding of the need to investigate and record all complaints, including remedial action taken, if any. Information gathered suggests that staff routinely inform residents/children about the complaint procedures. A separate complaints record is maintained for adult and children services. The Manager confirmed that there has been no complaint or concern received by the home since the last inspection on 23rd and 26th November 2004. The Manager was aware that all complaints, no matter how minor, should be investigated and recorded, including any remedial action taken. The home uses the Hertfordshire procedures on child and adult protection. Comments received from the Local Area Child Protection Committee have been included in the home child protection procedures. All staff members Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 17 interviewed confirmed that the procedures on adult and child protection are available, as appropriate. All care staff members working with adults have received training on the Protection of Vulnerable Adults. Basic grade staff members working with children have received Child Protection Level 1 training and members of the management team have received Child Protection Level 2 in January 2005, facilitated by the NSPCC. There have been no adult or child protection cases since the last inspection in November 2004. Staff members are conversant with the procedures on how to respond appropriately to acceptable and unacceptable behaviour. Given the behavioural and emotional difficulties of many of the children accommodated, physical restraints are used occasionally. A separate dedicated record book is maintained to record any physical restraint applied to any child. A similar and separate record of any sanction applied is also kept. Records examined and information gathered from staff and children suggest that the measures of control being used, including physical restraints are fair, age appropriate and the ones deemed to be most effective with respect to each particular child. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. The accommodation for the adults is suitable for their needs. The central issue is that the physical design and layout of the building are not suitable for the purpose of effectively achieving the aims and objectives of the children’s unit. The proposal to completely refurbish the accommodation for both adults and children will clearly improve the physical environment and no doubt, their quality of life. EVIDENCE: The Inspector did a tour of unit 1 and 4 (adults services) and the children’s respite unit. The physical environment in the adult units has been maintained to a high standard. The adults’ flats are very homely, comfortable and furnished in domestic style. Bedrooms are well personalised reflecting the hobbies and taste in music and pictures of the occupant. The physical design and layout of the building accommodating children are not suitable for the purpose of effectively achieving its aims and objectives. Whilst great effort has been made to improve the standard of decoration, there are clear limitations as to any adaptation work that could be carried out, with a view to improve and promote a more child orientated physical environment. It is however commendable that the staff team continue to manage very well Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 19 within the limited space, keeping the risks to a minimum and reducing the impact of the inconveniences on the children using the service. Evidence shows that the organisation has proactively explored various options and has kept the Commission informed of relevant development. The Director of services has confirmed in a letter to the Commission in April 2005, of the organisation’s intention to undertake major refurbishment work as soon as this is possible. The exact nature of this significant development is yet to be decided by the organisation. However, the Commission hopes to move this matter forward once architectural plans have been received for consideration. It is also positive to note that extensive consultation with relative, carers and professionals has already been initiated with some success. With this in mind, the Commission is of the view that it would be fair and appropriate to view the shortfalls arising in terms of the fitness of the building of the children’s unit in the context of the above welcoming proposal. A high standard of cleanliness was evident throughout those areas viewed in unit 1, 4 and the children’s home. There were no mal-odours present. The laundry facilities are suitable and adequate for the service users and children accommodated. There are infection control policies and procedures in place. The arrangements for the storage and collection of domestic and clinical waste appeared to be satisfactory. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 and 36. The day and night staffing arrangements are deemed to be satisfactory. The needs of the current service users are being well met. Staff recruitment process is robust, which means that residents are in safe hands. Staff members receive training to enable them to deliver a good quality service to residents. NVQ assessment for care staff working with children should be given a higher profile. EVIDENCE: Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 21 The organisation provides discrete and separate staff teams for the adult service users and the children’s respite unit. Staffing levels are deemed to be adequate to meet the needs of residents. Information gathered indicates that staff members in both services have adequate experience and skills to enable them deliver a good quality service and care to service users and children, respectively. In terms of NVQ assessment for those staff members working with adults, 24.9 has achieved an NVQ Level 2 or equivalent, 3 members are currently working towards it and another 3 people are scheduled to start the same course in September 2005. With respect to staff members working in the children’s unit, only 1 member has achieved NVQ Level 3 assessment (14.2 ), 1 person is working towards it and a further 3 members are due to start in September 2005. The Manager is aware that 50 of care staff working with young adults should achieve NVQ level 2 in Care or equivalent by 2005. The minimum ratio of 80 of all care staff members working on the children’s unit to complete their NVQ 3 in the Caring for Children and Young People has not been achieved by January 2005, as stated in standard 29.5 of the National Minimum Standards (Children’s Homes). The Manager understands that this is an area that should be given a higher profile. The home follows the organisation’s procedures for the recruitment and selection of staff members. The Manager reported that the requirements of the Care Homes Regulations and Children’s Homes Regulations are being fully implemented. The recruitment files for 7 new staff members were scrutinised and these were found to be in order, except for a current photograph not being available in a few cases. The Manager has reassured the Inspector that this would be addressed forthwith. Agency staff members used have similar rigorous checks, prior to them starting work at this home. It is evident from recruitment files examined and staff members interviewed, including the Registered Manager that the recruitment process for staff is robust. Staff spoken to in both adults and Children’s units confirmed that they are well supported and receive formal supervision. However, the frequency of supervision needs improving in some cases for staff members working in the children’s unit. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 42. The overall management of this home remains satisfactory. The health, safety and welfare of service users, and staff are being safeguarded. Staiways is a safe home for residents to live in – a view shared by staff members, service users and children spoken to. Records are maintained as required. EVIDENCE: Staff members spoken to stated that they are very happy working at Stairways under the leadership of the Registered Manager and Director of services. The manager discussed the ethos of the home and the team’s efforts to ensure the home’s ethos benefits service users and children. Progress records and observation of staff interaction with the young adults and children clearly demonstrate that the homes ethos is put into practice. Action plans are drawn up for any shortcoming. Staff members receive ongoing training that ensures safe working practice. Disinfectant and cleaning materials are stored in locked cupboards and care is taken by staff members to ensure that residents are not exposed to any hazard. Mandatory training has been facilitated and risk assessments for each Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 23 service user/child are in place. Fire equipment and the fire alarm system including smoke detectors and emergency lighting are serviced within the required frequency. Hot water temperature is tested regularly. Records however indicate that hot water temperature has been up to 49 degrees centigrade in some hand-wash basin. The Manager is aware of this issue and has agreed to take remedial action. Fire drills are carried out once every 3 months at minimum. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 4 x x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 2 x Standard No 31 32 33 34 35 36 Score x 2 x 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stairways Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 2 x I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 25 YES 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 CH12 Regulation 3 Requirement Timescale for action 30.09.05 2. CH 23 31 3. YA42 13 (4) A formal system should be introduced, in order to ensure that each child has a placement plan review, involving the child, parents and professionals as appropriate. (Previous requirement). The physical design and layout of 31.08.05 the building are not suitable for the purpose of effectively achieving the aims and objectives of the children’s respite unit. (This would be addressed in the Organisation’s proposal to completely upgrade the accommodation for the adults and children’s services. The Director of Services to submit plans to the Commission for consideration. Hot water temperature 25.06.05 accessible to residents must not exceed 43 degrees centigrade at the point of outlet. Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard CH10 Good Practice Recommendations A system should be instituted, in order to demonstrate that the service user/child is being informed that any information about them will be dealt with appropriately and their confidence, respected. The NVQ 3 assessment in the Caring for Children and Young People should be given a higher profile, in order to meet the minimum ratio of 80 as stated in standard 29.5 of the National Minimum Standards (Children’s Homes). Improve the frequency of supervision for staff members working in the childrens unit. 2. CH29 3. CH28 Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stairways I52-I02 S19550 Stairways v227861 240505 Stage 4.doc Version 1.30 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. 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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