Inspection on 19/08/08 for Stephendale Road, 78-80

This inspection was carried out on 19th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stephendale Road, 78-80 17/06/09

Stephendale Road, 78-80 09/07/07

Stephendale Road, 78-80 10/06/06

Stephendale Road, 78-80 06/09/05

Stephendale Road, 78-80 18/01/05

Stephendale Road, 78-80 27/09/04

Stephendale Road, 78-80 09/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOME ADULTS 18-65 Stephendale Road, 78-80 Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 19th August 2008 10:00 Stephendale Road, 78-80 DS0000019144.V367945.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 Stephendale Road, 78-80 DS0000019144.V367945.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. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stephendale Road, 78-80 Address Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ 020 7371 8908 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) rob.walker@yarrowhousing.org.uk Yarrow Housing Robert George Walker Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 9th July 2007 Date of last inspection Brief Description of the Service: Stephendale Road is the home for six people with a learning disability. The care is provided by Yarrow Housing Limited, which is a voluntary organisation. Notting Hill Housing Trust owns the property. The home is located in a quiet residential street in Fulham and is close to transport links and local amenities. There are 4 people living at Stephendale Road presently, each person has a single bedroom. There are two bedrooms on the ground floor, two bedrooms on the first floor and another two bedrooms on another level up three steps. Washbasins are in each bedroom. There are WC, bathrooms and shower rooms situated close to bedrooms and communal areas. There is a passenger lift to the first floor. There is a garden to the rear of the home and a lounge and kitchen/dinning area. The weekly charge for Stephendale Road is £ 1,503.22. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Tuesday 19th August 2008; we spent 4.30 hours visiting the home. The Inspector spent time talking to the registered manager, deputy manager three people living at Stephendale Road and a member of staff. We checked the care records of two of the residents; all medication records were looked at and were well recorded. The finance records of two residents were looked at and there were entries of presents being purchased for another resident’s birthday, this procedure was discussed with the registered manager. All of the bedrooms were looked at and all communal parts of the home. The home is in need of a cyclical programme for the redecoration of the whole house internally including the bathrooms and toilets. The home was seen to be clean and tidy on the day of this inspection. We received four residents’ surveys, five staff surveys and one professional survey; comments from the surveys will be included throughout this report. Six requirements that were set 09/07/07 have been met; six new requirements have been made from this visit. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. What the service does well: We looked at the personal and healthcare care records of two residents, there were up to date Person Centred Plans (PCP) in both files. The PCP records were very good including drawings, photographs and information pertaining to the aims and aspirations of the residents. Both of the files looked at were in order up to date and relevant. We discussed the care provided to the residents in great depth with the registered manager and deputy manager both were very knowledgeable about the care needs of the four people living at Stephendale Road. Two of the residents told us that staff provides a good service and they are happy living at Stephendale Road. We looked at the risk assessments for two residents that were reviewed 08/08/08, all of the risk assessments did work in conjunction with the care plans showing staff what actions to take to minimise any risks identified. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 6 We looked at the medication records and storage of medication; the records were countersigned by two staff at all times that is good practice. All (MAR) Medication Administration Records were well recorded with no anomalies; all PRN medication was recorded appropriately. The medication storage cupboard is in the kitchen/dinning area that is locked at all times. What has improved since the last inspection? What they could do better: We looked at the financial transaction records for two residents; there were entries for staff purchasing a birthday present for another resident. One of the residents is able to make the decision to purchase a birthday present however one resident that has dementia could not have made the decision. We requested that the registered manager notify the relevant local authority and discussed the organisations policy and procedure in financial transactions and acting on behalf of a resident. We also saw entries made for residents purchasing furniture for their bedrooms, in discussion with the registered manager this was agreed for one of the residents that wanted a lot of more elaborate furniture that when looked at was very fancy. One resident had an entry for new knobs for their dressing table, this was discussed and we requested that the registered manager liaise with the organisation, as furniture should not be paid for by residents unless a specific agreement has been made with the resident and the placing local authority. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 7 We had a full tour of Stephendale Road including all communal areas and bedrooms. The home is in need of a cyclical programme for the redecoration of the whole house internally as the home is now looking unkempt. We looked at resident’s bedrooms one female resident has a blue bedroom that was a colour chosen by a male resident and was not redecorated when she moved in. All of the other bedrooms require the walls painting in the colours chosen by residents also all wood work needs painting. The bathrooms and toilets in the home also need to be included in the cyclical programme. The flooring in Stephendale Road is lino that is extremely marked and old, the organisation must look at replacing the flooring that is in all communal areas. 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. Stephendale Road, 78-80 DS0000019144.V367945.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 Stephendale Road, 78-80 DS0000019144.V367945.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): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager completes a needs assessment on all individuals that move into the home. The needs assessment is directly linked into the local authority referral showing how the home can meet the needs of the individual. EVIDENCE: We looked at the Statement of Purpose and the Service User Guide both documents are very condensed with adequate information about Stephendale Road. We discussed the documents that had been up dated and suggested the organisation make sure all documents are standardised with other Yarrow homes. We looked at the assessment records of two resident’s the information in place was very informative and directly linked into the local authority referral. The care plans and risk assessment records were informative showing the residents social and healthcare needs, looking at their aims and aspirations and showing how the staff at Stephendale Road was going to support the residents. Stephendale Road, 78-80 DS0000019144.V367945.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): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care which affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. EVIDENCE: Comments made by people who use the service and their relatives. ‘Staff are very helpful to me and always offer their advice’. ‘Staff are quite caring and friendly’. ‘The staff treat me very well, I like the staff’. ‘My relative is very well cared for at Stephendale Road’. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 11 We looked at two residents files that had a comprehensive care plan that was fully completed had a lot of information linking into the daily routine of the individual. There was also twenty-four hour support plans with up to date relevant information showing what care needs each resident has throughout a twenty-four hour period. Reviews were looked at in each residents file showing that the residents care needs are closely monitored and care plans are up dated to reflect any change. There was a Person Centred Plan (PCP) in both of the residents files that was very informative showing the individuals likes, dislikes their family and what activities they enjoyed doing. The Person Centred Planning (PCP) is in pictorial formats and is used as an ongoing record. In discussion with two residents we were told they liked the home and the staff were really nice. One resident who is being supported to be more independent attended to their own personal care liaised with the staff on duty discussing their plans for that day. We spent time with two residents that told us they are happy with the support given to them by staff and that they like living at Stephendale Road. We looked at the risk assessment records for the two residents; all risk assessment records had been reviewed on 8th August 2008. The risk assessments linked into the care plans for any risk areas with action plans in place to show how the staff were eliminating or minimising the risk. The registered manager has recently updated the fire evacuation risk assessments of all four residents that were looked at; all had the relevant information for the safe evacuation of each resident. Stephendale Road, 78-80 DS0000019144.V367945.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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been involved in the planning of their lifestyle and quality of life. EVIDENCE: All of the residents have an activity plan that was written in their files and also on the notice board in the office and the kitchen/dinning room. The residents all attend different venue’s in the local community where they participate in activities. One of the residents attends Options daily, the resident told the Inspector that she enjoyed going out and was able to travel most of the way on her own and that she would call the home on her mobile to inform them she had arrived. We were also told about her membership in a gym that she attended three times a week. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 13 Two of the residents had been taken out on the day of the Inspection, one for a walk the other resident was going to a day centre. The file contained a lot of information regarding information about the resident’s likes, dislikes, hobbies and leisure interests. We looked at daily records for the people staying at the home and there was information written daily about what activities an individual had done including shopping, eating out, and going for walks and attending any community centres. Information including photographs was seen in the two residents files showing their holidays. One resident discussed their holiday arrangements; we were told that she was going to Cornwall with her boyfriend in a few days time and that she was really looking forward to it. We looked at the care records of two residents, included was information about attending relationship classes with Hammersmith and Fulham local authority. The groups meet on a regular basis to discuss their personal relationships and are given the support to spend time with the people who are important to them. Two residents told us about visiting their partners that live in other Yarrow homes; we were also told that their partners visit Stephendale Road for meals on a regular basis. We looked at photographs of the resident’s partners visiting the home and enjoying outings together. We were told that the home does a big weekly shopping for food but shop regularly for the food requested by the residents as they have different dietary needs, one of the residents also requires a special soft diet. In discussion with two residents we were told that they liked the food provided and always had a choice of what they wanted to eat. Records of what residents had eaten were looked at and discussed with the staff. The Annual Quality Assurance Assessment (AQQA) form completed does go into detail about the different diverse cultural differences of the staff group and how residents are offered at times meals from the different cultures. Birthday parties are held for all residents at Stephendale Road photographs were looked at showing birthday celebrations that were attended by family, friends and residents partners. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and healthcare support using person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan. EVIDENCE: We looked at two of the residents files that had information in place including Twenty- four hour care plans showing what the residents health and social care needs were on a daily basis. (PCP) Person Centred Plans also go into detail about what assistance the residents require in attending to their personal care. We spent time with two residents that told us they always choose what clothes they are going to wear, records also show when the residents have their hair done at a local hairdressers. We saw records from and reports from social workers, psychologists, occupational therapists and speech and language therapists. The reports each contained useful information and guidance for staff. In discussion with the staff on duty at this site visit it was clear that different levels of support are required from monitoring to assistance of care support. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 15 All of the people living at Stephendale Road are registered with their own GP. We saw records in the two residents files that show visits to the GP for different health checks. We looked at the medication records kept at the home that were well recorded and accurate, there are always two staff that check the medication when it is administered and sign the record kept in the medication file. There are residents that have PRN medication this was recorded appropriately, the information regarding all medication was written in the care plans looked at. The two files also contained Health Action Plans that had all information regarding health checks including optical, podiatry, dental and other regular health checks. The records show that the residents have had regular check ups when required. We looked at the staff training records that show all staff have had medication training and are fully aware of the medication policy and procedure. The home has recently had a great loss of one of the residents. The registered manager and team respected the resident’s wishes and cared for her at the home with the assistance of healthcare staff until she died. The other residents living at the home have had support in dealing with their grief and loss. The registered manager told us that it was a very difficult time for staff and residents however the wish of the resident was carried out. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff has had training around safeguarding adults however some of the staff understanding is limited. This leads to inconsistent practice within the service. EVIDENCE: We looked at the complaints file that had no complaints recorded in the last 12 months. We were told by the staff on duty that they have attended complaints training as part of the organisation induction. The registered manager must make sure that the complaints procedure is placed on the notice board for residents and visitors to make a complaint or make a suggestion. The complaints procedure is available in different formats including pictorial. There have been two safeguarding incidents at the home in the last 12 months. Records looked at show that the safeguarding procedures were followed linking into the Hammersmith and Fulham social services safeguarding procedures. Records show that one incident has been closed however the other is still being investigated. The Inspector looked at the finances of the two people living at the home, the records were correct with receipts in place for any financial transactions made with the resident or on their behalf. There was however financial transactions showing that residents had purchased a birthday present for another resident, one resident can make the decision to buy a present, the other resident is diagnosed as having dementia and could not have agreed to the decision to spend their money on a birthday present. In discussion with the registered manager we required that the local authority be informed and the registered manager would have to take guidance from them in an investigation to staff purchasing presents on behalf of residents. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 17 There was also a record of a cake being purchased for a birthday party that the registered manger will have to get information about and notify the local authority. The AQQA and training records show that all staff has attended POVA training. In discussion with the registered manager we discussed all staff revisiting the policy and procedure of the organisation in staff representing residents and making decisions about their financial transactions and what they purchase on their behalf. We looked at Person In Control (PIC) records that show visits are now taking place on a monthly basis with recommendations recorded for the registered manager or the organisation to meet. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27, 28 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment does not reflect the standard that is written in the statement of purpose. EVIDENCE: We had a full tour of the home and all areas were seen. There is a need for Stephendale Road to have a full cyclical programme in place as all areas are in great need of redecoration. The communal areas and resident’s bedrooms look unkempt, walls are badly stained in some areas and the woodwork needs to be painted. The bathrooms and toilets that are communal areas and are used by all residents also need to be included in the programme. The lino flooring that is throughout the home needs to be replaced, as it is extremely old and marked in places. The organisation must provide a homely environment for residents to live in as written in the Statement of Purpose. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 19 We went into all four residents bedrooms three of the bedrooms are adequately furnished, one of the female residents bedrooms was painted blue that was a colour chosen by another resident and the bedroom had not been painted for the resident when she was moved into it. One of the residents has purchased a large bed and very elaborate bedroom furniture. In discussion with the registered manager we were told that the resident choose to have the furniture and spend her own money. We requested that the registered manager liaise with the organisation into providing some of the funding, as the furniture was very expensive. One of the resident’s financial transaction records did show that they had paid for new knobs for their dressing table to be replaced, we received a mail from the registered manager the following day to state that the resident had been reimbursed the money. We looked at the garden that is at the back of the home; the garden was looking a lot better and an enjoyable place for residents to sit. The home was clean and tidy on the day of this inspection. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough qualified, competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas take into account the needs and routines of the people using the service. EVIDENCE: On the day of the Inspection there were four staff on duty including the deputy manager and registered manager. We looked at rotas and sufficient staff was scheduled to be on duty on all shifts. There are nine full time staff including the managers, there are no vacancies in the home. One of the staff surveys stated that the registered manager was at times rostered to be on duty and work as a residential carer, however at times because of management obligations he would spend time in the office, that made the shift busier for the staff than usual. In discussion with the registered manager we were told that at times this may occur and that he would look into making sure that the staff are assisted to minimise the workload on the shift. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 21 We were given a copy of information showing that all staff including agency staff has a full Criminal Records Bureau (CRB) Disclosure. We looked at the training programme that all staff has completed. The registered manager told us that all staff are up to date in mandatory training and have all completed first aid training. We looked at the training records of two staff that show they are up to date with training. We met with a residential carer who had recently been employed at Stephendale Road, we were told that the individual had attended a full induction training programme and was nominated to attend a lot of other relevant training. The member of staff told us that they enjoyed working at the home and were happy with the teamwork and had a good working relationship with all staff at the home. One survey suggested that they had not attended training; we requested the registered manager audit all staff training records to make sure that the training is being provided to all staff. All recruitment is completed by the Human Resources team at Yarrow head office. There is an induction/information pack in place for any bank staff that was very informative. The registered manager and deputy manager are at present registered to complete an NVQ level 4, the manager keeps a training and development schedule for himself and the Annual Quality Assurance Assessment (AQQA) states that the manager undertakes regular training courses to update his knowledge. There is a currently two staff member who has an NVQ with two working towards a level 2 or 3. We were told that the three remaining staff would be registered to start an NVQ this year. We discussed the supervision of all staff with the registered manager and deputy manger that told us that they are up to date in supervising staff. The frequency of supervision is provided six weekly to two monthly. We were shown supervision records that show staff are receiving regular supervision. In discussion with a residential carer we were told that they had recently attended a supervision meeting and that any issues they raise are dealt with appropriately. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the home. They are aware of and work to the basic processes set out in the NMS. EVIDENCE: In discussion with the registered manger we was told that he is registered to complete an NVQ level 4 in Management. The registered manager has worked in social care for many years and has lots of experience. We looked at two residents files and each had quality assurance questionnaires in place. The residents had both been assisted by other people to complete the questionnaires, one of the residents was assisted by a member of their family and another resident was assisted by a support worker at Options day centre. The residents had no issues and stated they were happy living at Stephendale Road. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 23 Yarrow collates all of their quality assurance information and produces a document annually to show outcomes of their audits. We looked at residents files and included was a summary of the Quality Assessment for the organisation from 2007, that showed how the organisation was working at improving their service provision where there are issues and also lots of positive information from residents living in Yarrow homes. We spent time talking to two residents living at Stephendale Road that were able to express their feelings about the staff and the home, and stated they were happy. Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 2 26 2 27 2 28 1 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 2 X 2 X Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. YA23 YA7 Standard Regulation 13 Requirement The registered manager must audit residents finances on a regular basis to make sure that any financial transactions made are appropriate, to protect the residents money. The organisation must replace lino flooring that is in all communal areas so that the environment is homely and comfortable for the people living there. The organisation must action a cyclical programme for the redecoration of all residents’ bedrooms so that the environment is homely and comfortable for the people living there. The organisation must make sure that residents are not paying for there own furniture or to finance the replacement of broken furniture fixtures. The organisation must action a cyclical programme for the redecoration of all communal areas so that the environment is homely and comfortable for the people living there. DS0000019144.V367945.R01.S.doc Timescale for action 19/09/08 2 YA24 23 19/11/08 3 YA25 23 19/11/08 4 YA26 23 19/09/08 5 YA28 23 19/11/08 Stephendale Road, 78-80 Version 5.2 Page 26 6 YA40 13 The manager and all staff must revisit the financial transaction policy and procedure for the organisation to make sure that all staff is following the correct procedure and all residents finances are safeguarded. 19/09/08 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 YA42 Good Practice Recommendations The registered manager to make sure that the hot water temperatures are also taken from all residents bedroom sinks to make sure the they are set at a safe temperature. The manager to put a copy of the organisations complaint procedure on the notice board in the dining room for a resident or any visitors to make a complaint or make a suggestion. 2 YA22 Stephendale Road, 78-80 DS0000019144.V367945.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Stephendale Road, 78-80 DS0000019144.V367945.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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