Care Home: 112 Henderson Road

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What the care home does well While the home is registered to accommodate three people, during 2006 one of the residents was assessed as being able to move on to a more independent lifestyle. This is an example of what the home does well. The focus of the service is to support and encourage people to make the most of their life skills, to be as independent as possible. At the time of producing this report a new service user has been admitted to the home. The social work professional who arranged the placement was impressed with the home`s approach to the preadmission process, which was person centred and thorough. People who live in the home are consulted and involved in its daily running. They retain their own personal plans, which are very `person centred` and play an active part in the monthly reviews of their needs. There is a stable staff team to support them. Observations and discussions during the site visit showed that staff were very positive, and committed to the wellbeing of the residents. The evidence gained during the inspection showed the home is run for the benefit of the people who live there, and continues to promote ordinary life styles for them within their local communities. Comments from the visiting relatives survey under this heading suggested the home provides shelter and emotional support. What has improved since the last inspection? Many of the recent environmental improvements had been completed just before the last inspection in January of this year. Arrangements were in hand to replace floor coverings in identified areas and the dining room was in the process of being redecorated. Staff training is ongoing and scheduled for dates throughout the year. What the care home could do better: The front of the building needs redecorating and stands out in that respect from others in the road. Old and well-worn furniture in one person`s bedroom needs to be renewed. Comments from the visiting relatives survey under this heading suggested the home could provide more communication and better provision for physical support. CARE HOME ADULTS 18-65 112 Henderson Road Southsea Hampshire PO4 9JG Lead Inspector Neil Kingman Unannounced Inspection 3 October 2007 16:30 112 Henderson Road DS0000067309.V347486.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 112 Henderson Road DS0000067309.V347486.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. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 112 Henderson Road Address Southsea Hampshire PO4 9JG 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) 02392 783373 Bayrose Limited Miss Claire Alison Cusack Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users only to be admitted between 25 and 65 years of age Date of last inspection 4 January 2007 Brief Description of the Service: 112 Henderson Road is a residential home providing care, support and accommodation for up to three younger adults with learning disabilities. The home has been in existence for some years but was registered under the Company Bayrose Ltd in March 2006. The home is one of a terrace of ordinary family style houses, situated in a residential area of east Portsmouth. Local shops and other facilities, including the beach and swimming pools are all within easy reach. The home aims to promote the rights of the resident group to lead as independent and ordinary a life style as possible. The three single bedrooms for residents are sited on the first floor. While the home is not centrally heated each room is provided with a stand-alone heater. Windows are double-glazed. Communal areas comprise a lounge, dining room, kitchen, bathroom/toilet and separate toilet with wash hand basin. There is a small garden to the rear of the property to which the residents have access. Parking spaces can usually be found in Henderson Road or other adjoining roads. The manager states that fees are currently £525 per week. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by 112 Henderson Road and brings together accumulated evidence of activity in the home since it was last inspected on 4 January 2007. Part of the process has been to consult with people who use the service and to this end responses to ‘easy read’ surveys were received from both people who live in the home. In addition, we received one response to the visiting relatives survey. Included in the inspection was an unannounced site visit to the home by an inspector on 3 October 2007. During the visit we toured the building, looked at a selection of records, spoke with the manager, staff on duty and both residents. In addition, a telephone discussion was held with a social work professional involved with placement of a new service user at the home. Prior to the site visit the manager sent to the Commission a selection of information about the service including an Annual Quality Assurance Assessment (referred to as the assessment during the report). However, the assessment lacked detail in all areas, especially the key areas of what the service does well and what they could do better. What the service does well: While the home is registered to accommodate three people, during 2006 one of the residents was assessed as being able to move on to a more independent lifestyle. This is an example of what the home does well. The focus of the service is to support and encourage people to make the most of their life skills, to be as independent as possible. At the time of producing this report a new service user has been admitted to the home. The social work professional who arranged the placement was impressed with the home’s approach to the preadmission process, which was person centred and thorough. People who live in the home are consulted and involved in its daily running. They retain their own personal plans, which are very ‘person centred’ and play an active part in the monthly reviews of their needs. There is a stable staff team to support them. Observations and discussions during the site visit showed that staff were very positive, and committed to the wellbeing of the residents. The evidence gained during the inspection showed the home is run for the benefit of the people who live there, and continues to promote ordinary life styles for them within their local communities. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 6 Comments from the visiting relatives survey under this heading suggested the home provides shelter and emotional support. 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. 112 Henderson Road DS0000067309.V347486.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 112 Henderson Road DS0000067309.V347486.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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that the care support needs of the people who use the service will be met by undertaking a proper assessment prior to them moving into the home. EVIDENCE: Pre-admission assessment 112 Henderson Road provides long-term care and support for up to three younger adults with learning disabilities. One of the aims of the home is to support and encourage residents to be as independent as possible, with a view to them being able to move eventually to a more independent living scheme. At the time of the inspection the home was accommodating only two residents, the third having moved on to independent living during 2006. It has been five years since a new resident moved in. However, the manager confirmed that a new service user was due to join the home later in October 2007. In discussions it was clear that a lengthy assessment process had been ongoing and this person had paid several visits, including two overnight stays to establish compatibility with existing residents. The pre-admission assessment tool was in the process of being completed and staff had received additional training to meet the specific needs of the individual concerned. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 9 At the time of producing this report we have had an opportunity to speak with the social work professional who arranged this particular placement with the home. It was confirmed in discussions that the pre-admission assessment tool used by the home was person centred and very thorough. The assessment went very well, there was confidence that the home would meet this person’s needs and staff showed a willingness to support the new resident and help them settle into the home. 112 Henderson Road DS0000067309.V347486.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 and 9 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs and goals are met. Decisions about their lives are determined by assessment and recorded in individual personal plans, which they have been involved in making. EVIDENCE: Personal plans – Each person who uses the service has a personal plan, which reflects their individual needs, aspirations and goals. They look after their own plans and retain them in their rooms. At the site visit both residents showed us their plans and were happy to talk about them. It was clear from discussions that they were very much involved in the development of their plans and contributed to the monthly reviews that take place. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 11 We noted the plans were very person centred, covering all aspects of their daily lives, including guidelines for staff around routines. The manager explained that there is a form of key-worker system in the home but with only two residents it is not so important, as the process of meeting residents’ needs is shared by all staff. Decision making Speaking to the residents and observing their interactions with the staff showed that they know how to express their opinions and make choices in their lives. They are independent in many respects, from choosing their own clothes, fashions and lifestyles to going out alone, and in one case finding and keeping a job. During the site visit one person returned from a local day service and made ready to go out to an evening employment. It was clear from discussions with this person that they very much decided on what they wanted to do, and the home provided all the support they required. A stable staff group has many years experience of working with these residents; they know what they want and provide them with the information and support they need to make decisions. The manager was very clear about the benefits of accessing the advocacy service in appropriate circumstances. One resident can call upon family for independent support if needed, and the other has the cognitive ability to make their own decisions about advocacy. Both residents have the ability to manage their own finances with minimum support. The home provides lockable facilities for them and arrangements for their own banking. All support in this respect is documented and kept under review. We had an opportunity to speak with both residents in the presence of staff, and in the privacy of their rooms. They stated they were happy with the level of independence they are given and the support provided by staff. The response to the visiting relatives survey indicated the home usually meets the needs of their relative but they were never kept up to date with important issues. This was taken up with the home. However, the response indicated the home always gives support to their relative. Risk taking – We noted clear and specific risk assessments on residents’ personal plans. They are encouraged and supported to take responsible risks which enhance their enjoyment of life, e.g., going out to the shops, to a social club and to have personal relationships. Provider’s Annual Quality Assurance Assessment - 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 12 The assessment identified what the service does well in this area: • Detailed individual care plans • Clients moving forward and becoming more independent. Individual plans for each client have been updated and clients have been involved. 112 Henderson Road DS0000067309.V347486.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): 12, 13, 15, 16 and 17 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Education and occupation Both residents attend the local day centre to which they make their own way. At the day centre they are involved in a range of activities, mainly craft based that help with their independent life skills. At the last inspection it was noted that one person had secured, mainly therapeutic employment, helping out at a nearby pub. This employment is still ongoing and the resident confirmed that they continued to enjoy the job and looked forward to going when they finished at the day centre. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 14 Community links, social inclusion and relationshipsIt was clear from our observations and from information in personal plans that residents enjoy going out from the home. A weekly programme of activities ensures their lives are varied and interesting. Staff treat residents as individuals and support them variously to visit local pubs, restaurants, shops and a social club. One resident has regular weekly contact with family and has had a personal relationship with a person of choice. The other has less contact with family but has developed long term friendships with people via local church activities. The home makes visitors welcome and residents are able to receive visitors in the communal areas, or the privacy of their rooms. It is understood from previous inspections that both residents take the opportunity to vote at elections. Daily routines Bedrooms were seen to be well personalised and reflected residents’ different interests and preferences. In discussions with staff it was clear that they respected residents’ privacy, which as we observed was not difficult, as residents were very particular about their own private space. Residents have keys to their own room and a lockable facility inside it. Staff can access all bedrooms in the event of an emergency. We noted the warm and friendly interactions between residents and staff, with plenty of good- humoured banter on both parts. In discussions with residents they confirmed that they share responsibility for various household chores. One in particular was helping out with a variety of tasks in the kitchen, while the evening meal was being prepared. This was done willingly and with good humour. Residents keep two cats in the home that are cared for by everyone. No residents’ smoke, and staff respect that by not smoking in the home. Meals – During the site visit we asked residents about meals. They said they were very happy with the food provided and confirmed that for the most part the type of food they enjoyed enabled them to prepare their own meals. On Sundays meals tend to be communal. On days that they attend a day centre they take a packed lunch with them, and eat a hot meal in the evening. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 15 • • • • Supporting clients in maintaining relationships. All clients have good relationships with people. Could do better at finding employment Have improved helping clients to access the community. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 16 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 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Personal support – Personal plans developed with the residents identify the support and/or encouragement they need from staff. Both residents are currently fully independent and need only prompts or encouragement with their personal care. From discussions with them and staff it was evident that residents choose their own clothes and styles, which reflect their personality. One in particular is very conscious about appearance. Daily recording on personal plans showed there is flexibility around times for getting up and going to bed and it was noted that respect for dignity was an important issue, especially in the area of privacy. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 17 Healthcare – Care records showed that residents’ health care needs are regularly addressed. They receive checks from the GP, dentist, optician and specialist health care professionals. All health care needs of the residents are identified in their personal plans and were noted to have up to date reviews. The manager said that all residents have their own GP in Portsmouth and liaison with the practices is very good. Medication The manager and staff confirmed that currently neither resident is in receipt of medication. This was confirmed in discussions with the residents. In the event that medication is required they are assessed as being able to manage the process themselves. Risk assessments are in place. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • We are good at supporting clients with our core values and supporting them to attend medical appointments/dieticians etc. Currently no clients are on any medication. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 18 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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse. EVIDENCE: Complaints The home has a clear complaints policy and procedure in place. However, residents said they would speak to the manager if they had any worries or concerns. In discussions with staff they said that both residents were very assertive, and would not hesitate to report anything they were unhappy about. They confirmed that minor issues are dealt with immediately and anything more serious would be reported to the manager and recorded. No concerns were raised. Safeguarding adults The home has a ‘whistle-blowing’ policy for staff, and an adult protection policy and procedure that follows locally agreed multi-agency protocols as regards the reporting of incidents. Staff training covers abuse and records showed that refresher training in this subject was provided in August 2007. Residents have the cognitive ability to manage their own monies, with some support from staff. They both have lockable facilities. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 19 Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • Good at protecting clients from abuse with robust policies. No complaints 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The home’s premises are suitable for their stated purpose. They are reasonably comfortable, safe and maintained. However, some decoration is needed and furniture in one bedroom must be upgraded. On the day of the site visit the home was clean, hygienic and free from unpleasant odours. EVIDENCE: Premises 112 Henderson Road is a three bedroom terraced house, much like others in the road. The front of the building was noted to be generally in need of redecorating, the front first floor window sill in particular showed signs of peeling paintwork. During the site visit we looked at all areas of the building with the manager and individually with the two residents. It was noted that in general terms the 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 21 house is suitable for its stated purpose; accessible, as both people are mobile, safe and reasonably well maintained. All three bedrooms are for single occupancy, and are located on the first floor. Residents have chosen not to have sinks in their bedrooms. The sizes of the lounge and dining room are adequate for the numbers of residents and staff, with enough seating and space for relaxation and activities. There is a kitchen, bathroom with toilet, and separate toilet with wash hand basin. All had been upgraded in the last year. The dining room at the front of the house was in the process of being redecorated. A discussion was held with the manager about the appropriateness of a staff sleep-in bed being located in the dining room. The manager confirmed that she would review the situation and hold talks with the providers about it. The premises are reasonably decorated and comfortable and it was apparent that some ongoing refurbishment had taken place in the last year, especially in the lounge, which had new furnishings, wall lights and had been redecorated. Rooms looked to reflect the personalities of the residents and were clearly decorated according to their individual tastes. The manager said that new floor surfaces were being laid in identified areas the following week. One resident’s room was in need of new furniture, which was showing clear signs of wear and tear. Outside is a small enclosed garden, which is mainly laid with gravel. Cleanliness We noted all areas to be clean, reasonably tidy and free from unpleasant odours. Support workers undertake the domestic tasks; an arrangement that seems to work well in what is essentially a domestic style setting. Laundry is carried out in the kitchen. However, given the needs of the residents there are no soiled articles to contend with. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • • The home provides a safe, comfortable, clean family style environment. Clients are very happy with their home. Plans for this year: Redecorate new client’s bedroom, new carpet, redecorate dining room. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 22 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 and 35 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and are deployed in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staffing levels The staff team consists of three support workers and one registered manager. Staff rosters showed that staffing is flexible, and responsive to the needs of the residents. There are several other services in the Bayrose Ltd group, and staff work flexibly between the services at times when there are shortfalls due to holidays and sickness etc. These staffing levels are considered appropriate for the current needs and numbers of people in the home. The manager confirmed that when the new service user joins the home staffing levels would be increased in line with needs. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 23 Staff recruitment Since the last inspection there have been no new staff recruited to the home. In fact all staff have been employed for at least five years. With this in mind staff recruitment records were not checked on this occasion. Staff training, development and competencies We looked at the staff training plan and a selection of training certificates. The plan sets out the dates for statutory training scheduled for 2007. Additional service specific training includes: • • • • • • Autism Asperger’s syndrome Bereavement Epilepsy Communication Risk assessments Two of the three staff have achieved the National Vocational Qualification (NVQ) at level 2 and the other is currently working towards it. The care support worker spoken with during the site visit confirmed the Company has a very good training package, which equips them well for work in the home. Some scheduled refresher training for 2007 had already been carried out. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • Good at training and retention of staff – looking after staff (being flexible) Will be providing epilepsy training for all staff. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 24 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 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 and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Management The manager has many years experience of working with people with learning disabilities and has managed 112 Henderson Road for nearly three years. As regards qualifications she has achieved the NVQ at levels 3 and 4, and also the Registered Managers Award (RMA). Staff spoken with at this and previous inspections regarded the home as being well run, with regular staff meetings and formal supervision. They confirmed 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 25 that the morale of staff was good and the manager was approachable and supportive. A discussion was held with the manager about the home’s assessment, which was not returned to the Commission promptly and lacked detail in all areas. The manager recognised the failings in the assessment, explaining that she had completed it hurriedly without fully understanding that it is the main way of letting us know how well the service is delivering good outcomes for the people who use it. She confirmed that care would be taken in the completion of future assessments. Quality assurance The home is relatively small and domestic in scale. In discussions with the manager she outlined the steps taken to monitor the quality of service at Henderson Road, which includes: • • • • • Written quality assurance feedback from residents (available for inspection). Monthly reviews of personal plans. Annual care/support reviews involving residents, families, key workers, representatives from day services and social services. Staff meetings and supervisions. Monthly statutory visits to monitor the conduct of the home. The manager and staff member made the point that with so few residents it was possible to have a comprehensive knowledge of the ongoing views of the people who receive the service. Health and safety All care support staff undertake statutory training, which includes health and safety awareness, food hygiene, first aid, manual handling and fire training. During the site visit we looked at a sample of records, including fire logs, records of weekly carbon monoxide tests, public liability insurance and portable appliance tests (PAT), all of which were found to be in order. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • We provide a well run home with good relationships between management, staff and clients. We have happy clients and good retention of staff. 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 26 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 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 23 Requirement To ensure that people live in a home that continues to be well maintained: • The outside front of the building must be redecorated. • Furniture must be renewed in the resident’s bedroom identified during the inspection. Timescale for action 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 112 Henderson Road DS0000067309.V347486.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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