Care Home: 12 Queens Terrace

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What the care home does well The home provides good information about the home for prospective residents and their families, which is also available in formats that may be easier to understand if necessary. There are systems in place whereby the management of the home would carry out a thorough assessment of need of a prospective resident before they moved into the home. The prospective resident would also visit the home to make sure it was the best place for them, and they liked it. Assessments areall based on each individual`s different needs, to make sure the right care and support is given. We saw that the information held by the home creates a clear picture of the person and how to best care for them. The manager and team coordinator who were on duty at this visit were clearly very knowledgeable on the individual preferences of each resident, and the residents we saw all had their own interests and stimuli that they were encouraged to follow and develop. The survey returned from a resident was very positive, stating that they usually made their own decisions on what they did. We saw the staff going about their work always having time to talk to residents and involving all of the residents in what was happening in the home. The manager stated in the information sent to us that ` Individuals are encouraged to take an active role in the daily maintenance of their home and pursue varied activities`. We saw that daily records gave evidence of a variety of activities residents enjoyed, plus any contact they had with family members. Residents can get up when they wish for breakfast, although staff said they are encouraged to get up if they need to be somewhere at a certain time. During this visit one resident got up mid morning, as it was his `day off`. He was obviously very comfortable in his surroundings, and was helped with getting breakfast by the manager of the home. We saw residents freely making it clear what they did and did not want to do, or like, and joint decisions were made with staff on the outcome. The home is warm, comfortable and clean, and the manager told us of the plans to redecorate and update rooms in the house. We noted that regular services to all household appliances and equipment were up to date. 60% of the staff hold a National Vocational Qualification (NVQ). There is good communication within the staff team. All of the systems in the home are being updated so as to be more structured, with complete and easy to find records. What has improved since the last inspection? The key to the medication cabinet is held more securely in a locked cupboard.Comprehensive risk assessments are in place for all activities the residents take part in. These give clear instruction to staff on how to reduce the risks involved. We saw that daily records are made for each person by staff. These produce a full picture of people`s lives, giving evidence of the constant care provided, and background information for any future incidents. Staffing levels are being constantly addressed, according to whatever event is occurring, to make sure residents have the appropriate support. The recruitment of an experienced team coordinator has been a great benefit to the home, as she is using her knowledge and abilities to help improve and restructure the policies and procedures used in this home. Staff and management training has been increased, with staff meetings and supervision being regular, causing staff to be more motivated and involved in the development of the service. This also leads to improvements in the standard of support staff give to residents. General housekeeping routines have been put in place, with staff keeping the home clean and tidy. All records in the home were available for inspection by us. CARE HOME ADULTS 18-65 12 Queens Terrace 12 Queens Terrace Fleetwood Lancashire FY7 6BT Lead Inspector Ms Jenny Hughes Unannounced Inspection 14th September 2008 10:00 12 Queens Terrace DS0000009984.V367138.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 12 Queens Terrace DS0000009984.V367138.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. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Queens Terrace Address 12 Queens Terrace Fleetwood Lancashire FY7 6BT 01253 876386 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) Ms Maria Elizabeth Gilchrist Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 Date of last inspection 13th September 2007 Brief Description of the Service: This home is situated on the promenade at Fleetwood overlooking the port. It is situated in close proximity to local amenities including shops, public transport and public houses. It is registered to accommodate four adults who have a learning disability. All accommodation is single with one bedroom being provided on the ground floor and the other three on the first floor. There are two bathrooms on the first floor. There are two lounge areas, a dining room and a dining kitchen. The laundry facilities are situated in the basement. At the rear of the property there is a large garden. The range of fees are set by the Local Authority, currently at £627 to £940 depending on the individual’s needs. Further details are available from the manager. 12 Queens Terrace DS0000009984.V367138.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 star. This means that the people who use this service experience good quality outcomes. This was an unannounced visit to the home, meaning that the manager or staff did not know that the visit was to take place. This site visit was part of the key inspection of the home. A key inspection takes place over a period of time, and involves gathering and analysing written information, as well as visiting the home. During the visit we (Commission for Social Care Inspection) spent time speaking to residents, and the team coordinator and manager, who were the staff on duty. Every year the registered manager is asked to provide us with written information about the quality of the service they provide, and to make an assessment of the quality of their service. It also asks about the registered manager’s own ideas for improving the service provided. We use this information, in part, to focus our assessment activity. Surveys were sent to residents and staff from the home and any responses are included in this report. During the site visit, staff records and resident care records were viewed, alongside the policies and procedures of the home. We also carried out a tour of the home, looking at both private and communal areas. Everyone was friendly and cooperative during the visit. What the service does well: The home provides good information about the home for prospective residents and their families, which is also available in formats that may be easier to understand if necessary. There are systems in place whereby the management of the home would carry out a thorough assessment of need of a prospective resident before they moved into the home. The prospective resident would also visit the home to make sure it was the best place for them, and they liked it. Assessments are 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 6 all based on each individual’s different needs, to make sure the right care and support is given. We saw that the information held by the home creates a clear picture of the person and how to best care for them. The manager and team coordinator who were on duty at this visit were clearly very knowledgeable on the individual preferences of each resident, and the residents we saw all had their own interests and stimuli that they were encouraged to follow and develop. The survey returned from a resident was very positive, stating that they usually made their own decisions on what they did. We saw the staff going about their work always having time to talk to residents and involving all of the residents in what was happening in the home. The manager stated in the information sent to us that ‘ Individuals are encouraged to take an active role in the daily maintenance of their home and pursue varied activities’. We saw that daily records gave evidence of a variety of activities residents enjoyed, plus any contact they had with family members. Residents can get up when they wish for breakfast, although staff said they are encouraged to get up if they need to be somewhere at a certain time. During this visit one resident got up mid morning, as it was his ‘day off’. He was obviously very comfortable in his surroundings, and was helped with getting breakfast by the manager of the home. We saw residents freely making it clear what they did and did not want to do, or like, and joint decisions were made with staff on the outcome. The home is warm, comfortable and clean, and the manager told us of the plans to redecorate and update rooms in the house. We noted that regular services to all household appliances and equipment were up to date. 60 of the staff hold a National Vocational Qualification (NVQ). There is good communication within the staff team. All of the systems in the home are being updated so as to be more structured, with complete and easy to find records. What has improved since the last inspection? The key to the medication cabinet is held more securely in a locked cupboard. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 7 Comprehensive risk assessments are in place for all activities the residents take part in. These give clear instruction to staff on how to reduce the risks involved. We saw that daily records are made for each person by staff. These produce a full picture of people’s lives, giving evidence of the constant care provided, and background information for any future incidents. Staffing levels are being constantly addressed, according to whatever event is occurring, to make sure residents have the appropriate support. The recruitment of an experienced team coordinator has been a great benefit to the home, as she is using her knowledge and abilities to help improve and restructure the policies and procedures used in this home. Staff and management training has been increased, with staff meetings and supervision being regular, causing staff to be more motivated and involved in the development of the service. This also leads to improvements in the standard of support staff give to residents. General housekeeping routines have been put in place, with staff keeping the home clean and tidy. All records in the home were available for inspection by us. 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. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. No service user moves into the home before having their needs and aspirations assessed and being assured that these will be met. EVIDENCE: The Statement of Purpose for the home states that an assessment is made of the individual before the decision is made as to whether the home is the right place for them to be. There have been no admissions since the last inspection in September 2007. The team coordinator told us that prospective residents would be assessed prior to admission to ensure the home could meet the needs of the individual. This assessment would be carried out together with the prospective resident and all relevant people, such as families, friends and other professionals. We saw that the pre-admission assessment procedures were in the process of being developed further to make sure full information would be obtained at this stage. The information would identify the needs, choices and preferences of each resident. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make decisions in their lives meaning that individual needs and choices are met EVIDENCE: We examined the files of the four residents living at the home. We saw that a new format is being introduced for all the residents through the assessment and risk assessments, to produce person centred care plans. These plans focus on the individual and create a detailed picture of who the person is and what they want to do with their lives, empowering them to achieve their goals. The individual files have been re-organised in a logical order and information is easy to find. The manager told us that the staff handbook encourages the promotion of person centred support. We saw new care support plans for each resident that 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 11 were clear and told staff how to best look after each person, giving information which included areas covering their physical and mental health needs, dietary needs, and a personal profile. The information creates a clear picture of each resident. We saw that the manager and team coordinator are reviewing the systems used so that they are more structured and easy to keep updated and person centred. The manager confirmed that any plans are always devised in partnership with relevant people, such as families, friends, or other professionals. We saw that daily records are made for each resident by staff. These produce a full picture of resident’s lives, giving evidence of the constant care provided, and background information for any future incidents. Residents are supported to make their own decisions about their lives. New risk assessment procedures enable a full assessment of any risks regarding activities, allowing staff to know what action to take so that residents can follow their chosen activities safely. We saw that the risks are discussed with the resident at the time of the assessment and when they are reviewed. We saw that all residents are in the process of completing, with help, a ‘Listen to Me’ booklet. In this they express their needs, wishes and aspirations. These are then incorporated into their support plans. We saw that residents had an Action Plan, which developed their individual lifestyles. One resident enjoyed being taken in a car and going through the automated car wash, and at the time of this visit was anxiously waiting for the time to go to this with the staff. Another was happy to watch carefully all that was happening in the home, staff making sure he was always involved. Another chose to be in his own space, clearly comfortable in his surroundings. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ decisions are respected and daily routines promote independence. Residents benefit from being able to keep good links outside the home. EVIDENCE: The manager stated in the information sent to us that ‘ Individuals are encouraged to take an active role in the daily maintenance of their home and pursue varied activities’. We saw that daily records gave evidence of a variety of activities residents enjoyed, plus any contact they had with family members. There were photos of residents and their families in the home, which added to its homely appearance. The manager told us they had all recently returned from a caravan holiday in the Lake District, and one resident showed us photographs of themselves horse riding, and with their celebrity hero. They told us of plans to go to the 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 13 theatre. The manager told us that staff discuss the activities residents have participated in, and how they can be further motivated. She added that one resident was trying Salsa dancing classes. All of the residents enjoy lunch outings, and on this day three residents were looking forward to going to a local hostelry for lunch. Other activities we noted had been enjoyed were crazy golf and swimming. A resident’s survey noted, ‘I go to Larkholme Lodge Monday to Thursday, Friday is my day off and I do my banking, shopping and go horse riding’ The manager said that they plan to encourage residents to think about taking part in a wider variety of activities, and feels that the new person centred procedures they are introducing have helped the staff to be better at listening to what support residents actually want. All foods eaten are monitored and recorded. Special diets are catered for. For example one resident needs a gluten free diet. We were told about the need for different foods for different residents at meal times, for example finger foods, which were more suitable for one of the residents. Residents had a snack mid morning at the friendly kitchen table, and drinks were plentiful. Main meals are eaten at the large dining table in the dining area. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the resident’s support needs. The medication at this home is well managed, promoting good health. EVIDENCE: The individual support plans we viewed were seen to be comprehensive in providing clear guidance for staff on how to assist a resident in the way that best suits their needs. The manager and team coordinator were on duty at this visit, and clearly knew the support needs of all of the residents, who were happy to go where they wished in the home, and join in whatever was happening, all while being tactfully supported by staff. Residents were seen to come and go to their rooms, some choosing to stay there for a while to play music, look at their possessions, or just spend time on their own. Medication is stored in a locked metal cabinet, with the unmarked key stored in a locked cupboard. The team coordinator confirmed that further security 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 15 measures are planned regarding this so that the person in charge at any time would hold the key. Medication records we viewed were up to date and accurate. The team coordinator is in the process of reviewing all the medication in the home, both that prescribed for individuals, and the medication procedures used by staff. All stock has been reviewed, and a formal returns sheet used to send unwanted stock back to the pharmacist. The team coordinator has arranged in-house medication training for staff as a refresher, and they are to attend formal accredited training about handling medication in November. PRN (when required) medication information is being developed so staff are clearer about when it is to be administered. Patient information leaflets are held by the home regarding the medication taken by the residents. An audit of the medication is done every week. The manager told us that she is going to initiate Health Action Plans for each person, and provide training for staff in keeping them updated. A Health Action Plan is an individual plan that belongs to a particular person, explaining their health needs. It shows the actions needed to meet those needs and keep the person healthy. These plans will enable residents to understand health issues and access the health services they need. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents who live at Queens Terrace are protected from abuse by the policies and practices within the home. EVIDENCE: Neither the home nor the Commission for Social Care Inspection have received any complaints since the last inspection in September 2007. There is a clear complaints procedure available for all who use the service, and it is included in the Service User Guide that is provided to them. The manager said that the procedure is explained to the people supported by the service. The four people accommodated would probably not be able to make a formal complaint, but staff said they are aware of behaviour changes and gestures that may indicate a person is not happy with something. There are opportunities on a daily basis for residents to make their wishes and opinions known. The manager and team coordinator were clear on what to do regarding safeguarding vulnerable adults from abuse, and all staff have Prevention of Harm training provided through social services. The manager was able to give an example of when the Whistleblowing procedures in the home were used correctly by staff to protect the people living in the home. This is whereby staff are encouraged to report if they suspect some form of abuse may be taking place. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a homely, comfortable and safe home. EVIDENCE: In the information provided to us the owner said that there were plans to have property repairs carried out, and some general decorating of communal areas. There is a large lounge/dining room, a second lounge and a large kitchen/diner to which all residents have access as they wish. None of the bedrooms have en-suite facilities, however there are two large bathrooms situated on the first floor. The home is generally well maintained, although some parts at the last visit seemed to need more thorough cleaning. We saw that this task has now been addressed and the home was clean and safe. There is an action plan for household tasks, and a rota for each day’s household duties. Each resident is 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 18 encouraged to help in routine tasks. A survey response from a resident said that the home is always fresh and clean. We viewed the rooms in the home and the manager told us of plans to update and refresh the décor. New furniture has been purchased for the dining area. The home has a bright, homely and comfortable appearance. Residents’ bedrooms are full of their possessions, and one person was keen to show us where his collections were stored in his room, and photographs that took pride of place on his wall. Other photographs of friends and family of the residents around the house made it each person’s home. Residents may hold a key to their room. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clear recruitment and induction procedure means that only people suitable to care for vulnerable people are working at this home. EVIDENCE: Through the day there are either two or three staff on duty to care for four people. At this visit one resident was at Larkholme Lodge day centre, and the manager and team coordinator were on duty to look after the three residents at home. All three residents had attention from the staff. One preferred to follow and watch everything the staff did, one preferred to stay in a different room, and one was due to have a trip out. All the residents chose what they wanted to do and were supported in a way that created an inclusive atmosphere in the home. At present one staff member is on duty in the evening, and the manager said that dependent on what event was happening she would staff the home accordingly, to ensure residents had the right support. For example, more staff are on duty if there is an evening activity. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 20 There is a good mix of staff. Some are long term, some new, there are different age groups, and one male staff in the team. Staff files were available to be examined. We saw that the recruitment procedures of the home include obtaining a Criminal Records Bureau disclosure (CRB), and a Protection of Vulnerable Adults (POVA) clearance, prior to staff starting employment. References from previous employers are also obtained. The manager commented that they plan to include residents more in the recruitment process where possible. Residents are asked their opinion of new applicants. The manager told us that all new staff have to complete the Learning Disabilities Award Framework (LDAF) Common Induction Standards, which is done over a six-month period. All staff attend core training. This includes equality and diversity, the Mental Health Act, communication and medication. Specific training is accessed as needed, for example epilepsy awareness. We saw that staff files are being re-structured, and inductions and further training being developed. The manager said that she has noted that this has caused staff to be more motivated and enthusiastic, and this is also helping to develop the standard of support the home can give to people. Three of the five staff employed hold National Vocational Qualifications (60 ), which is above the requirement of 50 the National Minimum Standards for Care Homes asks for. The team coordinator holds NVQ Level 4 Registered Managers Award, which the manager is presently due to attend. Regular support is given to staff, and we saw evidence of a recent meeting where suggestions from staff were discussed on how to improve the support to the residents. There is a planned programme of individual staff supervision sessions every six weeks, and annual appraisals. Staff are supported in their day-to-day work. One resident had behavioural problems in reaction to certain events, so the team coordinator decided to support the resident herself in order to make sure the risk assessment was correct and the resident and staff safe to continue the activity. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home that is well managed and where their health, safety and welfare are of paramount importance EVIDENCE: The manager is long term and experienced, and is due to commence further training to achieve NVQ Level 4 Registered Managers Award (RMA). She has recently recruited an experienced team coordinator to assist at management level. The team coordinator holds the RMA. The information we asked for about the home was sent to us on time. We discussed with the manager how this information could be improved with more detail about how procedures, linked to the National Minimum Standards for care homes, work in this home, with examples if possible. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 22 The present residents are all well established at this home. The residents were all relaxed and choosing to do whatever they wanted, clearly telling or signalling the staff about what they did or did not want to do. This ongoing feedback is dealt with immediately, and recorded for future reference. The ‘Listen to Me’ booklet, which all residents are being helped to complete, will be clear on likes and dislikes, and what makes each person happy. The team coordinator said that she plans to develop a forum for the residents, with communication simplified by the use of pictures to clarify people’s opinions. She was able to show us how this would be set up. At the last visit we advised that excess resident’s money should be banked regularly, and we were shown that this is done weekly. A resident commented that on a Friday ‘I do my banking’. All financial records are clear and signed and dated. We saw that there is a programme of weekly, monthly and quarterly auditing carried out. For example, alarms and fire systems are checked weekly, water temperature is checked weekly, wheelchairs are checked monthly. General house maintenance is prompted with the daily planner for staff, which identifies who is to do the task, and what is due to be checked, so it is not missed. All staff are instructed on what to do in case of fire, with regular fire drills. All accidents are recorded on file. We saw that all equipment is maintained regularly. The systems used in the home are being gradually updated. Records are easy to find and well structured. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 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 3 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 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA20 YA37 YA37 YA37 Good Practice Recommendations Plans to further address the security of the key to the medication cabinet should continue so that it remains the responsibility of the person left in charge at the home. The registered provider should achieve the Registered Managers Award as stated in the National Minimum Standards for Care Homes for Adults (18-65) The updating and restructuring of procedures in the home should continue to ensure the standard of the service provided at the home is maintained. The manager should complete the self-assessment document (AQAA) to include more detailed information about how the home operates in relation to the care standards. 12 Queens Terrace DS0000009984.V367138.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection N W Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ 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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