Inspection on 11/06/07 for Stirling Close 8

This inspection was carried out on 11th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stirling Close 8 28/02/06

Stirling Close 8 01/03/05

Stirling Close 8 31/01/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Stirling Close 8 8 Stirling Close Oulton Lowestoft Suffolk NR32 4RA Lead Inspector Jill Clarke Unannounced Inspection 11th June 2007 4:25 Stirling Close 8 DS0000024568.V341632.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 Stirling Close 8 DS0000024568.V341632.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. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stirling Close 8 Address 8 Stirling Close Oulton Lowestoft Suffolk NR32 4RA 01502 587652 F/P 01502 587652 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) Mr Colin Graham Hallam Mr Colin Graham Hallam Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: 8 Stirling Close provides care for three younger adults with a learning disability. Set in a residential area in Oulton, near Lowestoft, the home is within walking distance of the local shops, Public House and Health Centre. Local shops include a Chinese Take-a-away, hairdresser, newsagent and clothing shop. The bus stop at the end of the road has a regular service into Lowestoft, where residents can take advantage of a range of activities. These include swimming pool, cinema, beaches, theatre, restaurants, shops and train station. The layout of the semi-detached two-storey property is of an ordinary, family home. There are no special adaptations, other than handrails in the bathroom. All residents’ bedrooms are single, one with an en-suite bathroom. Sleeping in staff are provided with their own bedroom and en-suite shower room. There is a small-enclosed garden at the rear of the home, and off road parking for visitors at the front of the premises. Fees vary depending on how much the local authority pay to fund a placement. Currently the rates payable to the home from each of the local authorities are as follows: Norfolk County Council - £356.00 per week Suffolk County Council - £341.00 per week Haringey County Council - £323.68 per week Transport costs are 32 pence a mile. Residents pay normal British Telecom rates when they use the telephone, and pay for their own holidays. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, undertaken over 3 ½ hours, planned on an evening that previous inspections had identified the residents did not normally go out on, and after their return from day services. The inspection focused on the core standards relating to Younger Adults. The report has been written using accumulated evidence gathered prior to, and during the inspection. Commission for Social Care Inspection (CSCI) feedback cards were sent to the home prior to the inspection. This gave an opportunity for residents, relatives, visitors and staff, to give feedback on how they thought the service was run. Comments from the completed residents (3), relatives/advocates (3), feedback cards have been included in this report. Time was also spent talking to 2 residents in private, to hear their views on the home, and observing the daily routines. Residents and staff working at the home made the inspector feel welcome, and contributed fully to the inspection process. This included answering any questions, and providing information/documents as required. A tour of the building took in all the communal rooms, 1 bedroom, and sleeping-in room. Records viewed included, care plans, staff recruitment and training records, Service Users Guide, Fire and medication records. Previous visits to the home identified that people living at Stirling close preferred to be known as residents, this report respects their wishes. What the service does well: The home offers a good level of care within a safe, homely environment. All the residents have lived there for some years, and have got to know the staff and owners very well. This and previous visits has always identified a relaxed family atmosphere, with residents interacting well with each other, and the staff. Staff are committed to working in the best interests of the residents, and will advocate strongly on their behalf, to ensure they can access day services of their choice. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home can expect to be fully involved in the pre-admission assessments, and have trial visits, to support them in identifying if the home is right for them. EVIDENCE: There have been no new admissions for over 4 years. During a previous inspection (8/9/05) the manager was asked to describe what action they would take if a vacancy occurred. They said they would notify Social Services to discuss any persons who have been assessed, and waiting for a suitable placement. Social Services would then send a copy of their Social Care Assessment, for the home to look at. The person would then be invited to visit 8 Stirling Close to meet the people who live and work there. This would then be followed (during the next 2 to 6 weeks depending on level of individual needs) a series of visits to the home, building up to overnight stays. During these visits staff would monitor how the prospective resident got on with the other residents, to ensure they were compatible. The resident’s family and friends would also be encouraged to visit and meet staff. At the end of the trial visits, a meeting would be held with the permanent residents living in the home. They would be asked their views, and if they were happy Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 9 for the person to move in. This is especially important, taking into account the shared communal space. A further meeting would be arranged with the prospective resident, staff, family members/advocate, and social worker, to discuss any issues raised during the trial visits. During these visits staff would have started working with the resident to produce their individual ‘residents guide’. The guide, which uses photographs and text, would give information on what day services they would be attending, social activities, as well as information on the home. All new admissions would be subject to a successful 3-month trial period, before making the placement permanent. The judgement and scoring given for standards covering ‘Choice of Home’, has been assessed taking into account that the home will follow these procedures. Residents are given a Social Services contract, which sets out how much the care costs, and what is included in the fees. Each of the current residents has a contract and letter on file, which gives information on fees, terms of residency, and breakdown of costs payable. Residents who are funded by Norfolk and Suffolk Social Care, receive updates on new costs each April, and for those funded outside these areas, following their yearly review. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are fully consulted and supported to make their own decisions, on all aspects of their lives. EVIDENCE: Each resident has their own care plan, which gives staff clear guidance on how they wish to be looked after, including any prompting/reminding required with their personal care. All 3 care plans looked at, showed they had been reviewed, which identified that no changes in their health provision since the last inspection (28/2/06). As all the residents have lived at the home for a few years. Staff have a good insight into their care needs – and the right level of support/prompting to give to ensure that people maintain their independence. One resident gave the inspector their information file (service user guide), and pointed out the photograph of their key-worker held in the file. The file held information (using photographs, drawings and text) on how the resident would be Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 11 consulted through meetings and reviews, the people involved in their care and support network, and how they will be supported to make decisions about their care. Care records also included information on social interest, likes/dislikes, family and medical history. Information was recorded on all visits to health professionals (General Practitioner, Nurses, Opticians, Dentist), the outcome of the visit, and any further action/support to be taken by staff. Risk assessments had been completed, and regularly reviewed, for each of the residents, which was kept in a separate file. The assessments covered activities undertaken inside and outside the home, which included looking at any environmental hazards. Care plans held a missing person’s form (including photograph and any distinguishing marks), and procedures for staff to follow, if this occurred. Staff kept a daily record, for each resident, which was informative and gave a pen picture on how they spent their day, including any medical appointments, and contact with their families. Time spent with 2 of the residents in private showed that they were still “happy” living at the home, and liked the staff. The CSCI comment cards asked residents if they were able to make decisions on what they did each day, 1 resident had answered ‘always’, and the other 2 ‘Usually’. Relatives surveyed, all said they were ‘satisfied with the overall care provided’. This reflected the findings of the homes own Quality assurance survey (see conduct and management of the home section of this report), which all described the care given as ‘excellent’. Support Worker’s job description highlights to staff that they must ‘ensure confidentiality of all matters regarding residents at all times’. Except for the information file held by each of the residents, all other information (care plans, risk assessments, financial records) are kept in a lockable filing cabinet in the staff’s sleeping in room. Stirling Close 8 DS0000024568.V341632.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): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff to choose, and have access to a range of social, leisure, and educational pursuits, based on their individual preferences and interest. EVIDENCE: Minutes of monthly residents meetings, which all residents had attended, showed they were routinely asked if they were happy with the meals, and any additions they would like to see to the menu. They were asked their views on the social activities/outings arranged by the home, and if there was anything else they would they like to have arranged/join in with. Feedback, which is too personalised to put in this report as it would identify who said what, was informative and supported the day-to-day consultation, already being undertaken at the home. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 13 Records looked at, and discussions with residents and staff, showed that staff works supportively, with individual residents to ensure they can spend a meaningful day. Since the last inspection 1 resident had completed a ‘skills for working life – land based pathway’ course with an accredited college. However, since achieving this, due to lack of funding from their placing authority, they have not been able to access another course/work placement. The resident and manager gave feedback on what action they had taken to try obtaining a placement. It was clear from discussions that the manager was advocating strongly on the resident’s behalf, and would take actions further – if needed. In the mean time, the resident said they were happy assisting the manager on different DIY projects, inside and outside the home, which they enjoyed doing. Residents asked (CSCI survey) if they could do what they wanted to, during the day/evenings and at weekends, had all replied ‘yes’ to each of the questions. They gave examples of the activities they undertook, which included going ‘to day services weekdays’, and ‘home with parents most weekends’. One resident listed the things they liked to do in the evening, which included ‘ watch TV, play games, go to a club or even go to the pub’. Another said they went to a ‘youth club two evenings a week’. Information given, reflected conversations with residents during the inspection, and ‘daily report’ write ups, which gave details of outings and social interaction. The routines of the house during this, and previous inspections, have always been found to be relaxed. After having their meal together, residents choose how to spend the rest of the evening, which included watching television, playing computer games, bathing/hair washing. On Tuesday and Thursdays nights, residents said they always attended clubs. A programme was seen for the ‘Thursday club’, which included keep fit, Disco, and a trip to Great Yarmouth for Fish and Chips. The location of the home allows residents to use the local community, which includes a Public House and Chinese take-a-way. The home has their own transport, which also enables greater flexibility in accessing the local area, included the range of amenities that Lowestoft has to offer. Residents were discussing their holiday arrangements for this year, which for 1 resident included a trip to Turkey. Staff keep close contact with residents families, and they encourage and will support residents to bring their friends home. Discussion with the manager identified that so far; residents had not asked to bring back/formed romantic relationships, which could involve a resident wanting someone to stay the night. However, they are aware that situation could arise, and would be supportive, whilst taking into account the welfare of the other residents living at the home. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 14 Residents are encouraged to join in the domestic routines of the house, and normally would help prepare and clear up after meals. However, these normal routines were not fully observed during this inspection, due to the resident’s involvement and interest (rightly) in the inspection process – which directed their attention away from some of the domestic tasks they would help out with. Menus are made up following consultation with the residents, to ensure peoples likes and dislikes have been taken into account. Range of meals residents had eaten, included Chicken & Vegetables, Fish & Chips, Cottage Pie, Pasta Bakes and a roast on Sundays. No concerns have been raised over the meals, which fit in with the residents’ routines and preferences. Stirling Close 8 DS0000024568.V341632.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported with their health and personal care, based on their wishes, and individual needs. EVIDENCE: The member of staff on duty offered residents support with their personal care, as required, in a sensitive, individualised manner. Residents are able to mainly manage their own personal care, with support given with washing and drying hair, if required. This was happening during the inspection. Previous conversations with staff identified that they sometimes need to give a little reminder at times, when a resident has got sidetracked, and forgotten a task. Residents are fully mobile and require no help from staff. Information held in the care plans showed staff supported residents to maintain their physical and mental health. This was undertaken through contact with a range of health professionals (see individual needs and choices section of this report). Time spent with the manager and staff during this, and previous inspections showed that they had very detailed knowledge of resident’s individual Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 16 physical/medical needs, and situations, which could affect their mental health, and what action they would take to support them. Residents prescribed medication is dispensed from a pharmacist, in ‘blister’ packs every 28 days. The pharmacist also supplies Medication Administration Records (MAR) charts for each resident, with pre-printed information giving the name of the medication supplied, dosage, and time to be given. Staff sign or enter a code, to confirm that the medication has been given, or as otherwise indicated by the code letter used. MAR sheets looked at showed that staff had been completing them, and recording the amount of medications received into the home. Staff also had a separate book to record any medications, no longer required, which were returned to the chemist. Currently none of the residents require controlled drugs. If the situation occurred, the manager is aware that they would need to upgrade the current storage facilities. The ‘blister’ packs and MAR sheets are kept in a locked cupboard, with restricted key access. On removing the rack which held the blister packs, it was noticed that a tablet was loose on the shelve – under the rack. Staff felt that the tablet had most likely fallen out of the blister pack after the foil seal - holding it in, had become accidentally damaged. The tablets were ‘as and when required’ medication from February 2007, which the resident was no longer taking. The normal shelf life of tablets supplied in blister packs is 8 weeks. The manager confirmed that they would return the blister packs to the chemist, and if it was required in the future, ask for it to be supplied in it’s original container, not a blister pack, as it would have a longer shelf life. Staff giving out medication during the visit, did this safely, and completed required paperwork. Good practice was seen with a separate list of medication, held for each resident, which gave information on the drug, what its used for, and any known side effects that staff need to be aware of. Stirling Close 8 DS0000024568.V341632.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express any concerns; in the knowledge that staff will listen and have been trained, to ensure that the appropriate action is taken, to safeguard the residents interests. EVIDENCE: The home’s complaint policy is produced in 2 formats, one in normal text, contained with the Statement of Purpose, and the second, which residents keep in their information file, uses symbols and pictures. Residents surveyed, were asked if they knew who to talk to if they were unhappy, had all replied ‘Yes’. Their comments showed that they would either speak to their family or staff (or both). The home has systems in place to record any complaints and what action has been taken. The complaints log showed no complaints had been received. Relatives completing surveys also confirmed that they knew how to make a complaint. Residents felt staff treated them well, and would listen and act on what they said. Staff files showed that they had received ‘safeguarding adults’ training in October 2006. The manager said as there had been problems accessing some of the safeguarding training through Suffolk, they had taken advantage of being so close to the ‘border’, and accessed training in Norfolk. However, they were fully aware of Suffolk’s local protocols for reporting any concerns or allegations of abuse. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean, comfortable, homely, safe environment, which meets their individual needs. EVIDENCE: During previous inspections, the inspector has visited all the bedrooms, which were personalised, and residents confirmed met their needs. Bedrooms reflected the different personalities and interests of the people living there, and were kept in good decorative order. Duirng this inspection, time was spent talking to 1 of the residents in their bedroom. The room was set out how they wanted, and was their ‘own space’ where they could go when they choose to and play their computer games. Communal space consists of a dining room, lounge and kitchen, which lead out into a small-enclosed garden. Areas visited were clean, tidy and odour free. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are cared for by trained approachable staff, who are able to support residents with their individual assessed needs. EVIDENCE: There is 1 member of staff on during the day, when residents are not attending day services. A member of staff sleeping in on-call provides the cover at night. In addition to the care hours, the Registered Manager, and their partner, who is co-owner of their second home in Norfolk, split their time between the 2 homes. Both arrive soon after the start of the inspection, with 1 of the residents who had been out with them for the day. All the relatives completing the survey felt that the home always had sufficient numbers of staff on duty. The home’s own stake holders quality assurance surveys, held comments made on the staff from doctors ‘clients appear well cared for’, Day centres ‘staff have always been very friendly and helpful when dealing with issues over the phone’, and Dentist - staff accompanying residents have ‘appeared friendly and helpful indeed’, that the residents ‘seemed very at ease’. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 20 Since the last inspection 1 member of staff had left, and another recruited. To monitor that the home was following safe recruitment procedures, the new member of staff’s personnel file was looked at. It held a completed application form, and where gaps in their employment history had been identified, staff had clarified the reason why. The file held 2 written references, interview feedback sheet, medical questionnaire, paperwork to validate their identity, and Criminal Bureau Records (CRB) clearance notification. The manager confirmed that until a member of staffs CRB clearance has been received (and deemed acceptable) they are not left to work on their own, instead they will shadow a permanent staff. Discussions with a new member of staff, confirmed that they had worked “2 to 3 weeks shadowing” until their clearance came through. This was seen as positive, and ensured they received a good induction, and were able to get to know the residents. The staff file also held a completed induction training book, and certificates to show that they had attended training sessions which included, the role of a ‘keyworker’ training, ‘Person Centred Approach to planning’ and supporting people with ‘Challenging behaviour’ and ‘medication administration in care homes’. The home employs 4 carers, 3 of whom have obtained their National Vocational Qualification (NVQ) at level 2 or above. Time spent talking with the member of staff without the qualification, showed that they were actively trying to get on to a course, and looked forward to be able to do the training. They were new to care, and were enjoying their role. The staff file looked at, showed that they had received formal 1 to 1 supervision, notes of which had been signed by both parties. The member of staff confirmed that they felt well supported by the owners. This reflected comments in the home’s own quality assurance survey which asked staff how they rated the their supervision and appraisal. Replies fell in the ‘Good’ and ‘Excellent’ category. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is committed to working in the best interests of the people they care for. EVIDENCE: The home is owned and managed by Mr Colin Hallam, who is also Registered Manager and co-owner of a small registered home 15 miles away in Norfolk. Although the manager divides his time between the 2 homes, they are able to provide sufficient managerial cover to both homes. There were no concerns raised during this and previous inspections, from residents, relatives, or staff, over the management of the home. Mr Hallam said that he had completed his Registered Managers Awards (RMA), and was currently concentrating on finishing his NVQ 4 in Care. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 22 The manager is also supported by his wife, who is co-owner of their second home, and works the occasional shift at 8 Stirling Close. Otherwise they both share their time between the 2 homes, and supplement the support given by the carers. Discussions through this, and previous inspections showed that Mr Hallam has a detailed knowledge of the current resident’s physical and emotional care needs. He also works co-operatively with the CSCI, and where any minor shortfalls are identified during the inspection, will take action to address them straight away (see Personal and Healthcare Support section of this report). His enthusiasm and commitment is reflected in the positive atmosphere of the home. Since the last inspection the home has sent out their annual Quality Assurance (QA) questionnaires to relatives, staff and ‘stakeholders’ (people who come in contact with the home, i.e. Doctors, Dentists, and staff from Day Services). 14 surveys were received back, and all gave positive feedback and comments on the service, some of which have been used earlier in this report. Some of the questions on the surveys sent to Stakeholders were not totally relevant, therefore not fully completed. The manager is aware that they need to look at changing some of the questions in their QA surveys, and will be looking to do this in the future. The completed surveys received back between September 2006 and January 2007, have been analysed, but has not been put into a published format. Feedback from residents is undertaken on a day-to-day basis, during reviews, through their key worker, and partaking in the monthly residents meetings. These formats were seen as a positive way of receiving on-going feedback from people using the service, taking into account there are only 3 people living in the home. Since the last inspection a Fire Safety Audit has been undertaken, and a letter from the fire service ‘confirmed that the outcome was considered to be satisfactory’. The home has a fire risk assessment in place, which has been seen by the Fire Safety Officer and deemed satisfactory. Records showed that the fire alarm system was being checked weekly, which coincided with the time of the inspection. Residents on hearing the alarm evacuated the home, which is part of their weekly fire drill. The home has a current liability insurance certificate, and fire equipment had been serviced/checked in February 2007. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 3 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 3 X 3 3 3 X X 3 X Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations Systems should be in place to monitor the shelve life of PRN medications supplied in blister packs, to ensure they do not deteriorate. Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Stirling Close 8 DS0000024568.V341632.R01.S.doc Version 5.2 Page 26 - 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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