Inspection on 20/05/08 for Touchsky

This inspection was carried out on 20th May 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Touchsky 19/04/07

Touchsky 24/10/06

Touchsky 03/05/06

Touchsky 01/09/05

Touchsky 13/04/05

Touchsky 12/08/04

Touchsky 06/04/04

Touchsky 16/03/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Touchsky 240/242 Odessa Road Forest Gate London E7 9DY Lead Inspector Rob Cole Unannounced Inspection 20th May 2008 09:00 Touchsky DS0000007250.V363200.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 Touchsky DS0000007250.V363200.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. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Touchsky Address 240/242 Odessa Road Forest Gate London E7 9DY 020 8534 0035 020 8926 6560 touchsky8@btinternet.com 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) Mrs Florence Ndiedzei Muyambo Mrs Florence Ndiedzei Muyambo Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2007 Brief Description of the Service: Touchsky is a care home registered to provide support and accommodation to six adults with mental health issues. The home is situated in a quiet residential area of Forest Gate in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities, and is in keeping with other homes in the area. The home is privately run. The current range of fees charged by the home is between £425 and £2000 per week. Touchsky DS0000007250.V363200.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 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place on the 20/05/08 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present throughout the course of the inspection. A nurse also visited the home during the course of the inspection, and the inspector held a discussion with them about the care in the home. The inspection also included an examination of records and other documents, along with a tour of the premises. The inspector had the opportunity of observing staff carrying out their duties, including interacting with service users. Prior to the inspection, the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. Surveys were also sent out by the CSCI to both service users and their relatives. All of this was included in the overall inspection process, and has contributed to the judgments made within this report. What the service does well: What has improved since the last inspection? What they could do better: Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 6 There are some areas that must be addressed. In particular, the home must ensure that medications are recorded and administered appropriately, and that pre admission assessments must be carried out on any prospective service users. The home must ensure that service users have access to community based social and leisure activities in line with their assessed needs, and that staff undertake food hygiene training. 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. Touchsky DS0000007250.V363200.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 Touchsky DS0000007250.V363200.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): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors judgement that service users are provided with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the service. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place, and the inspector examined both of these documents. Both documents are written in plain English, and have been subject to review within the past year. The Statement says “Touchsky aims to provide its service users with a secure, relaxed and homely environment in which their care, comfort and well being are of prime importance.” The inspector was pleased to note that since the previous inspection the Statement now contains accurate information about the home and is in line with National Minimum Standards. The Statement includes information on the aims and objectives of the service, the philosophy of care and details of the management and staff team. It also includes information relating to equality and diversity issues, around how the home can meet individual needs, for example around culture and religion. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 9 The Service User Guide is likewise of a satisfactory standard. It includes a summary of the Statement of Purpose and the homes complaints procedure. It also includes a service users charter that sets out eight rights for service users, including the right to dignity, individuality, a high quality of life and the right to take risks. All service users are given their own copy of the Guide. Each service user is provided with a written contract/statement of terms and conditions. The inspector looked at three of these and found them to be satisfactory. They include details of fees payable, along with details of the services and facilities provided. One service user has been admitted to the home since the previous inspection. The Statement of Purpose includes information an the admissions procedure, and states that any prospective service users will be given the opportunity of visiting the home before making a decision as to move in. The inspector spoke with the service user, who was able to confirm that they had indeed had the chance to visit the home. The procedure goes on to say that service users will initially move into the home on a six week trial basis, after which a placement review meeting will be held. The homes manager informed the inspector that they had carried out a pre admission assessment of the service users needs, but that they had subsequently lost the hand written notes from this assessment before they had the chance to write it up, and their was consequently no evidence that this assessment had taken place, or any relevant information provided about the needs of the service users. It is required that pre admission assessments are carried out for all prospective service users before they move into the home. These assessments help determine whether or not the home would be able to meet their needs, and also forms the basis of any care plans to be developed in the event that they do move into the home. Touchsky DS0000007250.V363200.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors view that service users have a large degree of control over their daily lives, and that they are involved in the day to day running of the home. EVIDENCE: At the time of inspection the home was in the process of updating it’s care planning system to a more person cantered approach. The inspector examined four of the revamped care plans and found them to be significantly improved since the previous inspection. Although the new plans are not as yet complete, they are very close to completion, and the manager informed the inspector that it was envisaged they would be finished within two months of the date of this inspection. They are at present sufficiently detailed to provide a viable working document, and to provide information on how the home is able to meet the vast majority of service users needs. Plans are clear and Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 11 comprehensive, and include information on mental health, personal care, daily living skills, social and leisure needs and equality and diversity needs such as around religion, culture and sexuality. Plans are drawn up with the involvement of the service user, as evidenced by their signing all elements of the care plan. Their keyworkers and the homes manager are also involved in the care planning process. Care plans are reviewed on a monthly basis. All service users are on the Care Programme Approach, and have a meeting at least annually, which feeds into the care planning process. Minutes of these meetings were seen in the home by the inspector. A new system of risk assessments has also been developed; again the inspector read several of these and found them to be of a good standard. Assessments are generated through any risks that are identified through the care planning process. Along with identifying risks, the assessments also include strategies to manage and reduce those risks. Assessments make it clear that service users are supported to take reasonable risks, for example one service user likes to visit the local shop on their own, which helps to promote their independence and dignity. A risk assessment has been put in place around this, which helps to minimise any potential risk. Assessments cover risks around smoking, diet, accessing the community, and since the previous inspection there are now assessments in place around managing any challenging behaviours that service users present. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. One service user said “I can get up and go to bed when I like.” Service users are able to choose their own clothes to wear, and were seen to eat their meals at different times as they pleased. Some service users are able to access the community without the support of staff, and although they are encouraged to inform staff when they are going out, they are free to come and go as they choose. Other service users need staff support to access the community, on the day of inspection it was seen that one staff wanted to go shopping, while another wanted to go the barbers, and both of these requests were seen to be facilitated by staff in the home. Service users are involved in the day to day running of the home. Their involvement in daily routines is included in care plans, and service users were observed to set the table and do the washing up after lunch. Service users also informed the inspector that they help to keep their bedrooms tidy, and with the gardening. Monthly service user meetings are held, these are minuted. The minutes seen by the inspector indicated that service users are consulted over the running of the home, for example about holiday destinations. The AQAA supplied by the home provided information on some decoration work that has recently been carried out, and indicated that service users were involved in choosing the new décor. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 12 The home has a confidentiality policy in place, this was seen by the inspector, and made clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are generally supported to live valued and fulfilling lives, although the home must ensure that service users have more access to community based social and leisure activities. EVIDENCE: No service users are currently involved in any formal employment or educational opportunities. Service users spoken to informed the inspector that they did not wish to be at this time. Service users have access to the local community, as mentioned, on the day of inspection service users went out to shops and the hairdressers. Service users also have access to banks, post offices, parks and public transport, including buses and trains. All service users are on the electoral register, and the Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 14 manager informed the inspector that they are able to vote in elections if they wish. The home also seeks to meet needs around equalities and diversity issues through the community, for instance one service user has attended a black persons mental health group run by the local authority. It is highlighted in the care plan for one service user that their appearance is very important to them, and records indicated that they routinely visit hairdressers and manicurist, and go out clothes shopping. Service users have access to a variety of social and leisure activities in house, for example music, board games and television. The home also arranges occasional parties to celebrate birthdays. Records are maintained of social and leisure activities based in the community. However, as at the last inspection, these indicated that the home is not fully meeting the needs of service users in this area. For example, the care plan for one service user identifies that they like to go swimming and to the cinema. Indeed, the service user said to the inspector “I would like to go swimming sometimes.” Yet the records indicated that they have not been either swimming or to the cinema for several months. The manager informed the inspector that they were the only member of staff who was able to support service users with swimming, and had found it difficult to make time for this. Another service user commented “I wish we could all go out on an outing.” The manager informed the inspector that now that summer was here, they would be arranging some day trips. It is a repeat requirement that service users have access to community based social and leisure activities, in line with their assessed needs and stated preference. Since the last inspection several service users have been on a holiday to Blackpool. Service users spoken to said they hoped to go on holiday again this year, and the service user meetings evidenced that discussions are taking place around holiday destinations. Visitors are welcome at the home at any reasonable hour, and service users are able to see visitors in private if they so wish. Service users are given their own mail to open. Service users informed the inspector that they are able to maintain contact with family and friends by telephone. Menus are kept, these were checked by the inspector, and indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection a lunch of pork chops, roast potatoes and fresh vegetables was served. The inspector sampled this, and found it to be attractively presented and appetizing. Mealtimes were observed to be relaxed and unhurried. One informed the inspector that “The foods not too bad at all.” The home seeks to meet equalities and diversity needs through the provision of food, and traditional English and Jamaican food are regularly served. Service users were observed to help themselves to drinks and snacks throughout the course of the inspection, and fresh fruit was available in the home. The kitchen was clean and tidy, and food was stored appropriately. Touchsky DS0000007250.V363200.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): 18,19,20 and 21. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is generally meeting the health and personal care needs of service users. Service users largely manage their own personal care, and have access to health care professionals as appropriate. However, the home must ensure that medications are recorded and administered appropriately at all times. EVIDENCE: Care plans make clear that service users are encouraged to manage their own personal care as much as possible. On the day of inspection staff were observed to encourage service users to take a bath in a sensitive manner. Service users informed the inspector that they are able to choose their own clothes, both to buy and wear. There was evidence to suggest that the home seeks to respect the privacy of service users, for example one service users informed the inspector that staff “Always knock before coming into my room.” Service users are offered keys to their bedroom, subject to the completion of a satisfactory risk assessment. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 16 All service users are registered with a GP, dentist and optician. Records are maintained of medical appointments, and these indicated that service users have access to health care professionals as appropriate, including CPN’s, psychiatrists and dentists. Records include details of any follow up action that is necessary. The home carries out various related health checks, including routinely checking service users weight. On the day of inspection one service user was visited by a nurse from the Home Treatment Team. The inspector spoke with this nurse, who said that they always found the staff to be knowledgeable about the service user, and that relevant records were always kept up to date. The home has a comprehensive medication policy in place. All staff undertake training before they are able to administer medications, and medications are stored in a locked cabinet. No service users currently self medicate, and none are on any controlled medication. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. However, there were some instances of poor practice with regard to the administration and recording of medication. A staff member was observed to put the medication for one service user into a dispensing pot, and then to sign the Medication Administration Record (MAR) chart to say that this medication had been taken, before it was actually given to the service user. Another service user has been prescribed LORAZEPAM tablets and CHLORPROMAZINE tablets on a PRN basis. The MAR charts said that these were to be taken in conjunction with each other, but on one occasion on the 14/5/08 the MAR charts indicated that only the LORAZEPAM was given. In order to help promote the health and safety of service users, it is required that medications are administered and recorded appropriately. Since the previous inspection the home has sought the views of service users on their wishes for arrangements to be made in the event of their death. This has helped to meet needs around equality and diversity issues, for instance one service user has said that they want a Jewish funeral, and this is now clearly recorded on their care plan. The homes manager informed the inspector that service users could remain in the home with a terminal illness, so long as the home could meet their medical needs. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home has appropriate systems in place to help ensure that service users are safeguarded from the risk of abuse. EVIDENCE: The home has a complaints procedure, which includes timescales for responding to any complaints received, along with contact details of the CSCI. A copy of the procedure was on display within the home, and all service users have their own copy within the Service User Guide. The home also maintains a complaints log, and the inspector was pleased to note that since the previous inspection this now clearly records details of any complaints received, including details of any investigations into the complaint and of any outcomes. The home has a copy of the Local Authorities adult protection procedure, and also its own adult protection procedure. The inspector examined this, and found it to be in line with current legislation. All but the most recent members to join the staff team have undertaken adult protection training, and the manager informed the inspector that it was planned that these staff would undertake this training within two months of the inspection date. Staff spoken to during the course of the inspection demonstrated a good understanding of their roles and responsibilities with regard to adult protection. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 18 All service users have their own bank accounts. The home holds money on behalf of service users. Records and receipts are maintained for financial transactions involving service users monies, those checked by the inspector appeared to be satisfactory. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, both internally and externally, and service users are provided with adequate communal and private space. EVIDENCE: The home is situated in the Forest Gate area of the London Borough of Waltham Forest. It is in a quiet residential street, close to shops, transport networks and other local amenities. The home is in keeping with other homes in the area. The communal areas consist of a kitchen, dining area, sitting room, laundry room, designated smoking room and a garden. Service users were observed to move freely around communal areas. The garden presents as an attractive Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 20 space which service users can access, with appropriate garden furniture and a water feature. Since the previous inspection the sitting room and the dining room have been decorated, and the sitting room has a new sofa and chairs. Service users spoken to informed the inspector that they had been involved in choosing the new décor. The home has two bathroom/toilets and two toilets on their own. Bathrooms were clean, tidy and free from offensive odour. All bathrooms had working locks fitted, which included an emergency override device. All service users have their own bedrooms, these have been decorated to their personal taste, for example with televisions and family photographs. One bedroom has been decorated since the previous inspection. All bedrooms had hand basins fitted. Bedrooms had adequate natural light and ventilation. Bedding, carpets and curtains were domestic in character. Bedrooms had furniture in line with NMS, including tables, chairs, wardrobes and chest of draws. The home has taken steps to help reduce the risk of infection spreading. Protective clothing such as aprons and gloves are available to staff, and hand washing facilities were situated throughout the home. COSHH products were stored securely. Laundry facilities are suitable in scale for the home. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34 and 35. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, and this accurately reflected the staffing situation on the day of inspection, and made clear who was in charge of the home at any given time. Staffing levels were adequate to meet the needs of the five service users, during the course of the inspection there were three care staff plus the manager working in the home. Through observation and discussion there was evidence that staff have built up good relations with service users, and that they have a good understanding of the collective and individual needs of service users. Staff were seen to interact with service users in a friendly and respectful manner. Positive examples of staff interaction with service users were observed, for instance chatting in the Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 22 garden over a cup of tea, and gentle encouragement to service users to take a bath. The home holds regular staff meetings, and staff informed the inspector that all staff are able to contribute agenda items to these meetings. The AQAA provided by the home indicates that the home has appropriate employment related policies in place, including on equal opportunities and recruitment and selection. The inspector checked staff employment files, these were found to contain appropriate documentation, including references, proof of ID and CRB checks. The AQAA indicates that over 50 of care staff working in the home have successfully achieved an NVQ Level 2 in Care or equivalent qualification, and that other staff are currently working towards such a qualification. Staff files contained certificates to verify they have attended various training courses in recent months, including on medication, first aid, diabetes, fire training and around equality and diversity issues through values and individuality training. However, several staff have not undertaken training in food hygiene, even though these staff are expected to be involved in food preparation. Indeed, the staff member who made lunch on the day of inspection informed the inspector that they have not undertaken food hygiene training. To help promote the health and wellbeing of service users, it is required that all staff who are involved with food preparation within the home, undertake appropriate food hygiene training. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the homes manager is suitably qualified and experienced to carry out their duties, and that appropriate health and safety and quality assurance systems are in place. EVIDENCE: The homes manager is a Registered Mental Health Nurse with over eleven years experience of managing a care home. They have successfully completed the Registered Managers Award. Staff and service users informed the inspector that they found the manager to be approachable and accessible. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 24 Record keeping in the home was generally of a good standard. Confidential records are stored securely, and the manager informed the inspector that staff and service users could access their own records as appropriate. The AQAA indicates that the home has all necessary policies in place in line with National Minimum Standards (NMS). Those checked by the inspector, including adult protection and medication were found to be satisfactory. Care plan reviews, service user meetings and staff meetings all contribute to the quality assurance process within the home. The homes manager carries out a quality assurance process, which is based upon the NMS. An outside agency also periodically carries out quality assurance checks, which includes talking to service users Fire extinguishers were situated around the home, these were serviced in May 2008. Fire exits were free from obstruction and clearly signed. The home tests its fire alarms weekly, and they were last serviced by an engineer on the 13/5/08. The home checks fridge/freezer and hot water temperatures. The home had in date safety certificates for gas safety, PAT testing and electrical installation. COSHH products within the home were stored securely, and the home has in date employer’s liability insurance cover in place. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 X 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 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 3 3 3 3 Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 26 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 YA14 Regulation 16 Requirement Timescale for action 31/07/08 2. YA2 14 3. YA20 13 4. YA35 13 and 18 The registered person must ensure that service users have access to appropriate community based social and leisure activities in line with their assessed needs and stated preferences. (Timescale 31/07/07 not met) 30/06/08 The registered person must ensure that comprehensive pre admission assessments are carried out on service users prior to them moving into the home. This enables the home to determine if it will be able to meet the service users needs, and forms the basis for any subsequent care plan should they move into the home. The registered person must 31/05/08 ensure that all medications in the home are administered and recorded appropriately. The registered person must 31/08/08 ensure that all staff involved in food preparation in the home undertake appropriate food hygiene training. Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Touchsky DS0000007250.V363200.R01.S.doc Version 5.2 Page 28 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. 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