Inspection on 16/03/07 for Tooting Bec Gardens, 11

This inspection was carried out on 16th March 2007.

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

The inspector found 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

Tooting Bec Gardens, 11 27/01/06

Tooting Bec Gardens, 11 08/08/05

Tooting Bec Gardens, 11 23/02/05

Tooting Bec Gardens, 11 24/09/04

Tooting Bec Gardens, 11 24/03/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Tooting Bec Gardens, 11 Streatham London SW16 1QY Lead Inspector Mary Magee Unannounced Inspection 17 ,19 &22nd March 2007 10:00 th th DS0000022770.V328664.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 DS0000022770.V328664.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. DS0000022770.V328664.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tooting Bec Gardens, 11 Address Streatham London SW16 1QY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8769 1235 0208 769 9160 jacky_warrick01@yahoo.co.uk The Frances Taylor Foundation Mrs Jacqueline Warrick Care Home 8 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places DS0000022770.V328664.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. to include one person over the age of 65 years Date of last inspection 27th January 2006 Brief Description of the Service: 11 Tooting Bec Gardens is one of a number of homes owned and managed by Frances Taylor Foundation a registered charity. It is a large detached house set on a busy route in Streatham. The large garden located at the rear of the property leads into the very pleasant grounds of the residential home/convent next door. The home is fully double glazed to reduce traffic noise. The home is a minutes walk from the large shopping centre of Streatham. It is conveniently situated to bus and rail links to Central London and other suburban shopping centres. It also has a very large park/common within five minutes walk away. The home currently provides residential care for 7 women with learning difficulties. Accommodation provided comprises of single bedrooms for all service users as well as ample communal space. Charges range from £400 to £745 per week. DS0000022770.V328664.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over three visits. The inspector met with the registered manager and four support workers over this period. Individual discussions were held with five service users, the manager and two support staff. The inspector acknowledged an invitation from service users and staff and attended a social gathering which service users, their family and friends attended. During this period two relatives gave their views of the service provided. A selection of records was examined relating to service users and staff. Discussions were also held on day two with a behaviour specialist present from the learning disability team. A tour was conducted of the premises, this included the communal areas and three bedrooms and the garden. What the service does well: What has improved since the last inspection? The home is consistently well presented and continues to retain the high standard with ongoing refurbishment that improves the environment. A number of areas have been redecorated. Consideration has been given to enabling service users make more effective use of the garden by the building of a decking area that is easily accessible for those with poorer mobility. DS0000022770.V328664.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000022770.V328664.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 DS0000022770.V328664.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 5 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a homely and caring environment. Each service user has their individual needs assessed and appropriate plans are in place to address these needs. EVIDENCE: No new service users have been admitted since the last inspection. The home is currently carrying one vacancy. The inspector met five of the service users over the inspection period. They were comfortable with expressing their views on life at the home and feel that the home makes good provision in meeting their needs. As service users’ needs change the home takes this on board and reassessing the environment to make sure that the accommodation is appropriate. For example, following referral a physiotherapist reassessed a service user living upstairs recently as her eyesight deteriorated. The decision taken as a result is that the service user is safe with using the stairs to access her bedroom and could benefit from the exercise. All current service users have lived together for a number of years. Prior to admission they lived together in a large home. The caring and sharing ethos fostered at this small home is enabling service users to become more confident and independent. It has also helped service users become less regimented in their ways and reverse some of the behaviours as a result of experiences from living in a larger setting. The benefits of living in a smaller environment have resulted in service users feeling more valued and in control of decisions that DS0000022770.V328664.R01.S.doc Version 5.2 Page 9 affect the home. Service users have developed good relationships and friendships with each other. Service users know that it is their home for life and feel that it is run in their best interests. Ex-service users come back to visit, this demonstrates the inclusiveness of the environment. The inspector met with two of them when they attended a social event at the home. The Statement of Purpose has been updated recently to reflect the changes in the home and to staffing personnel. Service users have individual copies of contracts of terms and conditions. Service users are referred for and receive the services of other professionals in the community such as dieticians, psychology, and a behaviour specialist. Comments were received from one of these professionals regarding the support given by staff. She finds that staff approach and attitude is good, especially at the management of service users during challenging episodes. service users. Needs assessments are completed for all service users and from these care and support plans are agreed and written. DS0000022770.V328664.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for supporting and assisting service users are good with person centred planning operated. The home develops effective risk management procedures. Service users receive the necessary advice and support regarding risk taking as part of leading an independent lifestyle. EVIDENCE: The home has arrangements in place to meet the assessed needs of service users. The arrangements for two service users were examined. Service user profiles are completed for individuals giving a good picture of personalised needs, likes, dislikes, background and histories. Person centred plans have been developed with service users. People using the service take ownership with individuals holding a copy of these plans in their bedrooms. The plans are focused on achievements for service users based on goals and objectives. Service users have allocated key workers that work with them to help them achieve their goals and aspirations. The person centre plans vary in stages of development; one contained much more up to date information and demonstrated the stage of progress. The DS0000022770.V328664.R01.S.doc Version 5.2 Page 11 second plan when examined on day one fell short in some areas. The information was updated by the second day of the inspection and contained all the necessary information. The inspector found that more time is needed for all support staff to become familiar with person centred planning and to use it in the most effective way. A recommendation is made. Daily records are made of service users’ progress, these are held in individual service user’s diaries. The content is good and describes in detail the well being of individuals. Any changes are identified, recorded and transferred to care plans to reflect how support is tailored to meet individuals changing needs. Service users have reviews completed twice a year. One consists of an internal review and the second one is the statutory review completed together with the local authority. The inspector found that there is a need for the home to complete a six monthly review, as the records of statutory reviews are often late in arriving, sometimes they are very brief. A recommendation is made. The home ensures that the necessary and appropriate arrangements are in place to manage and control risks; these are linked to support plans. Plans contain details of the restrictions assessed and where necessary restrictions and actions necessary to safeguard individuals. In addition, individuals are encouraged and supported to take informed risks as part of leading an independent lifestyle. Care plans also include details on managing safely any service user that is prone to episodes of challenging behaviour and how to manage safely other service users at this time. Recently staff took appropriate action to manage safely a situation. The home experienced the challenging needs of one service user becoming more pronounced. A referral was made to behaviour specialist. During the inspection a consultation was taking place with the behaviour specialist. The key worker supplied the specialist with useful information on the behaviour patterns observed and of any triggers that might contribute. According to the behaviour specialist staff were very good at following the recommendations made and take the appropriate steps to manage effectively the risks involved. It was identified that on some occasions the risk management procedures had not been updated to reflect the progress made in areas. A recommendation is made regarding updating risk assessments. Service users are involved in the recruitment process. A number of new staff have begun work at the home in the last twelve months. As part of the selection and appointment process service users met prospective candidates and contributed their views on suitability. DS0000022770.V328664.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support arrangements in place for service users enable them to develop social, practical and independent living skills. Healthy eating is promoted with service user choice fully respected. EVIDENCE: The majority of service users participate in a range of activities outside the home. Some attend college and further education classes. Others enjoy developing cookery skills. Weekly activity plans are in place for all service users. Service uses integrate in the community. The location of the home is good with a shopping area, large park and many leisure facilities available and close at hand. They receive the necessary support to use the facilities. There are sufficient numbers of staff available to support those requiring it to attend and pursue their interests. As service users become older and less interested in participating in external events this is acknowledged. Staff recognise that for a DS0000022770.V328664.R01.S.doc Version 5.2 Page 13 small number their previous experience of living in a larger establishment has resulted in people becoming more institutional. Staff were seen encouraging service users to adapt to a more homely environment. Examples were seen of how this is promoted. Service users that choose to rest for longer periods get up at later times if they are not attending a planned activity, routines are flexible with individuals encouraged to relax in their home and attend services that they choose. Support staff were seen interacting with service users, this was observed to enable individuals to develop confidence and self esteem. Holidays and day trips are planned with service users. They choose the venues and staff make all the necessary arrangements. Two of the service users were delighted to share with the inspector their experiences of the last holiday. The inspector attended a social event taking place over the inspection period. Service users had invited their friends from other homes. Also present were individuals that had lived at the home and that have now moved to supported living. The atmosphere was cordial and service users welcomed all those attending. Service users had also helped decorate the home for the social event and extended the invitation to a large number of family and friends. They joined in the spirit of celebrating the feast day and had engaged artists for entertainment. All five service users present spoke with the inspector and conveyed their feelings about life at the home. They find that the lifestyle they experience matches their expectations. Two family members spoke to the inspector. They are pleased with how service users are supported and find that staff are very good. “We know our relatives are well cared for and very happy living in this environment” were some of the comments received. Service users spoke of how much they enjoy looking after their own bedrooms. They like to take responsibility for cleaning and maintaining bedrooms. Two service users showed the inspector their rooms and showed a keen interest in the décor and furnishings. The home offers service users a healthy diet. Staff have experienced issues with a service in relation to the promotion of healthy eating. Referrals were made to speech and language and to the dietician to seek expert advice in this area. Despite much encouragement the issues remain unresolved with service user’s choice respected. Menus were seen of meals planned and served weekly. Service users take responsibility for buying and choosing food as part of the development of independent living skills. As the inspector visited the home on three occasions for this inspection observations were made that the quality of meals served is good. Service users (five) spoken to find that the food served is excellent and that it is what they like and enjoy. The weights of service users are monitored and recorded. Appropriate action is taken to promptly to respond to any issues associated with weight gain or loss and eating disorders. DS0000022770.V328664.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): 18 19 20 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The key working practices ensure that service users receive personal support from a staff member they knows and feel confident in. Medication procedures are thorough with service users receiving prescribed medication at the times specified and medication reviews conducted regularly. EVIDENCE: Service users are allocated key workers that they help choose and that understand the way in which they like personal support. This according to service users is done in a way that maximises privacy and dignity. Service users choose their own fashionable hairstyles, select and buy clothes that they like to wear and take pride in their appearance. When the inspector attended the social event it was evident that service users enjoyed the opportunity to wear the most attractive clothes for the occasion. The health care needs of service users are monitored consistently. Records with consultants and specialists are maintained in daily diaries held for each service user. Service users are registered with a local GP practice. Support workers assist them to attend surgeries and other appointments with health professionals. Health action plans are in place for all service users, records of appointments and follow-ups are kept recorded in these books. The inspector DS0000022770.V328664.R01.S.doc Version 5.2 Page 15 found that these could be used in a more beneficial way. Currently they do not always link up with person centred plans, the information is held separately on health action plans and is not cross-referenced with support plans. A recommendation is made. A medication profile is also in place for each service user. There was evidence that medication reviews are conducted regularly. Medication procedures were examined. A recent pharmacy inspection was completed. The report made of this demonstrated that procedures are satisfactory and that recommendations are currently being addressed. The inspector viewed the management of medication for two service users. Handwritten medication charts were available. Medication received into the home is checked by staff and acknowledged. Staff record accurately all medication administered. For short term prescribed medication such as antibiotics staff make sure that records clearly record the start and finish dates, they also monitor closely service user’s response to medication and respond if there are any adverse effects. Two support workers undertake all medication administration. Signatures of staff competent in medication administration are held on file. During staff induction training is given in medication administration, staff are also completing distance learning in this area. Support staff respond to service users changing needs, particular attention is given to responding to service users that are approaching old age. Service users choose to remain within the group where they have formed long lasting relationships and to live in a home that they love and feel very much part of. Staff respond to issues such as ageing that some service users are experience. As they prefer a more relaxed lifestyle and take life more slowly this preference is acknowledged. Mobility issues are monitored and staff ensure that if service users find using the stairs difficult they are offered the opportunity to relocate to bedrooms on the ground floor. One vacant bedroom is on the ground floor. A recommendation is made regarding further training staff to deal with ageing and end of life arrangements. DS0000022770.V328664.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): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel confident in giving their views knowing that they are listened to carefully. Service users and relatives are confident knowing that policies and procedures are in place that safeguard service users from neglect. EVIDENCE: The inspection included examination of the complaints procedure and complaints records. The complaints recorded related to issues raised by two service users in regard to the conduct of a fellow service user. It involved episodes of challenging behaviour and has been dealt with appropriately. Service users said that they feel comfortable with raising issues that concern them with staff and know that staff will respond accordingly. A copy of the complaints procedure is displayed on the notice board in easy read format. The home fosters an environment that welcomes service user views. Regular meetings are held for people to express their views and to shape services for the home. Staff are vigilant in safeguarding service users from abuse or neglect. The staff team have received training on safeguarding vulnerable adults. From speaking to two support workers it was evident that they know the correct procedures to adopt. Records are maintained of any incident or accident no matter how trivial, any noticeable changes in conditions are followed up and responded to appropriately. An example was seen recently when staff observed the changes in a service user’s behaviour and made referrals to behaviour specialist. The risk assessment was also updated to reflect how the situation could safely be managed and prevent distress and injury to other service users. The specialist DS0000022770.V328664.R01.S.doc Version 5.2 Page 17 spoke to the inspector about how well the staff had responded and managed the difficult situation. She also highlighted how positive the response was as staff had the right characteristics and skills to manage effectively the situation. Two relatives spoke of their confidence in the service, “ we feel that the home is a safe place for vulnerable adults to live, staff are very good and know how to appropriately support people with learning difficulties”. The home has robust procedures in place to assist service users manage their finances. Service users have individual bank accounts. Service users are supported where necessary to attend banks to withdraw cash. The home also retains small amounts of cash for service users to use for day-to-day expenses. The process involves daily checks of the cash held at the home by two members of staff. A clear audit trail is held with receipts for all transactions. DS0000022770.V328664.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 25 28 29 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a safe comfortable home that is homely and well maintained. It is well located and convenient to public transport, services and amenities EVIDENCE: Service users enjoy living in a homely and comfortable environment where the service is user focused. It is bright, cheerful and is retained to a high standard. A number of improvements have been made since the last inspection. The lounge and dining room have been recently decorated. A new carpet has been fitted on the hallways and stairs, the colour chosen by service users. The home has an ongoing refurbishment programme that ensures this high standard of presentation is retained. An area of the garden has had decking installed which enhances the area and enables easier access for service users to enjoy the garden. DS0000022770.V328664.R01.S.doc Version 5.2 Page 19 Service users benefit from the additional communal space of the conservatory. It was observed that the step to the conservatory could pose difficulties for those with mobility issues. The registered manager said that this had been identified in the risk assessment completed for the premises. A recommendation is made regarding the provision of a ramp to this area. The home is not fully wheelchair accessible, except for the ground floor. Consideration should be given to how the home plans to make provision for disability access in the future. A service user when showing the inspector her bedroom said that her bedroom had the colour scheme that she choose. It was also the layout that she likes. It looked very attractive, bright and well ventilated. The three bedrooms viewed are spacious, attractively presented, and enable service users to display and store personal possessions. Sufficient numbers of bathrooms and toilets are available and conveniently located for service users. The inspector also viewed the vacant bedroom on the ground floor; it was used as an office in the past. It was completely refurbished and finished to a high standard. DS0000022770.V328664.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): 32 33 34 35 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from an effective key working system that allows them to build and develop good relationships with staff. Staff are skilled, dedicated and committed to the role. Ongoing training and development plans are in place to ensure that staff continue to develop all the necessary knowledge and skills required. EVIDENCE: The home has experienced change in staffing personnel in the past two years. However, according to three service users the changes have been positive. They find the enthusiasm and attitude of the staff to be very good. They find the key working system to be effective and that it has enabled them to develop effective relationships with staff. Two support workers when spoken to demonstrate the fulfilment they too receive from working with service users. “ I get great satisfaction as a reward from my role,” was the comment of one member of staff. The team is small with four permanent support workers plus the manager. Three regular bank support workers are employed to cover the additional hours needed. One support worker has numerous years experience in the learning disability services. Another support worker has acquired NVQ level 2. DS0000022770.V328664.R01.S.doc Version 5.2 Page 21 The inspector found that management are vigilant in ensuring that the right calibre of staff are employed. Working practices are observed and monitored to ensure that staff demonstrate that they have the right approach and characteristics. Supervision is regular and consistent with records held. The induction programme provided for all new staff focuses on charisma and attitude as well as including LDAF training. Ongoing training is provided both by the organisation and through external training. The records of training delivered to two support workers were examined. A comprehensive training was provided according to records. One of the support workers confirmed that she had been well equipped for the role. Training received by staff included, key working, medication, risk management, active support to people with epilepsy, infection control. All the team have received training in health and safety. A number of service users have also participated in this programme. Plans of future training provided evidence of the emphasis on developing the staff team to meet the needs of service users. A specialist from the learning disability team said that she found the staff to have a good approach and to be knowledgeable especially on the management of service users with challenging needs. Two relatives spoken to have confidence in the staff at the home and feel that service users are in safe hands. The recruitment procedures were examined for three support workers. Records seen include completed application forms, interview assessments and two references. There was also confirmation that CRB enhanced disclosures with POVA checks are in place. The inspector found a shortfall in the procedures for one support worker, employment had begun before a POVA check had been received by the home. There appears to be a misunderstanding regarding POVA checks and disclosures. No employment must commence until full and satisfactory information is sought first including CRB and POVA check. A requirement is restated regarding this. DS0000022770.V328664.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): 37 39 40 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that has good management. The environment is well maintained and to a standard that promotes and safeguards service users and staff. EVIDENCE: This home is well run and in the best interests of service users. The manager is qualified and experienced. She undertakes periodic training to keep up to date with knowledge and skills, she ensures that staff team are developed and receive the necessary training. All the necessary notifications are made in good time. Appropriate referrals take place when the expertise of other professionals is required. She relates well to service users and staff, they find her approachable and a good listener. An inclusive and homely environment is promoted by her management style. DS0000022770.V328664.R01.S.doc Version 5.2 Page 23 The organisation has a quality assurance system in place to monitor how effective the home is in achieving its aims and objectives. Year on development plans are in place for service users that links into reviews and support plans. According to records seen polices and procedures are in place that reflect current legislation and that safeguard service users and staff. The policy team within the organisation reviews policies for the whole organisation. Service users are involved in reviewing the policies and procedures within the home via “residents meetings”. The home is maintained to a safe standard. An environmental risk assessment was completed some months prior to the inspection. A recent fire risk assessment was also completed. An emergency plan had been developed to respond to any crisis or emergency at the home to ensure that service users are safe at all times. Records provided evidence that all the essential equipment is serviced and maintained. Records are held of regular testing of fire fighting equipment, also records of periodic fire drills. The induction training includes health and safety training. Both staff and service users have participated in health and safety training. Records are held of any accidents and incidents that occur. Staff are careful to record accurately these no matter how minor they are. DS0000022770.V328664.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 X 2 4 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 X 3 X DS0000022770.V328664.R01.S.doc Version 5.2 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 YA34 Regulation 19 (1) b Requirement The registered person must ensure that full and satisfactory information is available for all newly recruited staff before they commence work. (This to include POVA check and Enhanced Disclosures from CRB for all new staff . (Not met in previous timescale of 1/04/06) Timescale for action 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA6 YA6 YA19 Good Practice Recommendations The registered person should ensure that person centred plans are developed to reflect individuals’ support needs. The registered person should ensure that the care plan is reviewed at the request of the service users, or at least every six months. The registered person should ensure that for service users benefit the health action record is linked up and included in person centred plans to enable a complete picture of all the support needed. DS0000022770.V328664.R01.S.doc Version 5.2 Page 26 4 5 YA9 YA29 6 YA21 The registered person should ensure that risk assessments for service users are continually updated to reflect changes in risk management. The registered person should ensure that consideration is given to the trip hazard posed by the entrance to the conservatory, also to future plans for consideration of disability access to the premises. The registered person should ensure that issues relating to ageing and end of life arrangements are included in future training. DS0000022770.V328664.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000022770.V328664.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. 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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