Care Home: 13 Wilbury Gardens

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What the care home does well The home and its staff are committed to supporting the people who use the service in accordance with their needs and goals. This was evidenced throughthe care plans, which detailed the areas of support that the person who uses the service needed and how this support is provided by the staff. The people who use the service that were communicated with indicated that they were very happy at the home, that they are able to chose and have control over there own lives with the in the home with the support of the staff. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of `best practice` operational systems. Evidence supports that she puts the needs of the people who use the service first and is very supportive of staff. Some of whom themselves are deaf. The AQAA (Annual Quality Assurance Assessment) was completed by the manager and was seen to be of a high quality. This gave the inspector a greater insight into what the home considers it does well, what we could do better, what has improved within the last 12 months and plans for improvement. The home is an older property but was in good decorative order and kept very clean throughout. Improvements to some areas are planed and this will enhance the home further. What has improved since the last inspection? The RNID has provided residence with a contract which shows who is responsible for the fees and gives the terms and conditions of there stay. The home has changed the layout of the garden to make it more accessible to service users who are unsteady on their feet. The manager purchased new much smaller vibrating pillows, a new call system has been installed making it easier for service users to call staff in the case of illness or emergencies. What the care home could do better: No requirements have been made during this inspection process. The home through the AQAA has made the following statements showing some of the areas they have identified for improvement. To access new activities and different environments on a more frequent basis. We will ensure that the staff team are up to date with any new policies & procedures that are issued around equality & diversity.Continue to regularly review our systems ensuring that we stay up to date with any changes in legislation, which might affect service delivery. Compile accessible formats for service users to use in all circumstances to aide with their understanding and comprehension. All new staff to attend POVA and MAPA training and any other relevant training that will help increase awareness and for existing staff to ensure they maintain current knowledge. CARE HOME ADULTS 18-65 13 Wilbury Gardens Hove East Sussex BN3 6HQ Lead Inspector Sally Hall Unannounced Inspection 17th March 2008 09:30 13 Wilbury Gardens DS0000014115.V359084.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 13 Wilbury Gardens DS0000014115.V359084.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. 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 13 Wilbury Gardens Address Hove East Sussex BN3 6HQ 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) 01273 205044 01273 771891 sue.arnold@rnid.org.uk www.rnid.org.uk RNID Care Services Susan Ann Arnold Care Home 8 Category(ies) of Sensory impairment (8) registration, with number of places 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The maximum number of service users to be accommodated is eight (8) Service users must be aged between forty five (45) and sixty five (65) years on admission Service users with sensory impairments only to be accommodated To admit, from time to time, service users who are aged under fortyfive (45) years on admission To admit one named service user with physical disabilities. Date of last inspection 26th June 2006 Brief Description of the Service: 13 Wilbury Gardens is registered to provide care, accommodation and support for up to eight adults aged 45 years and over with hearing impairments and physical disability. The home is run by the RNID (Royal National Institute for Deaf People). Another RNID home is located close by at 32 Ferndale Road, Hove which caters for younger adults with hearing impairments and mental health difficulties. The service is located in a three-storey detached house in a quiet area of Hove. The home is in close proximity to local transport, shops and other amenities. Accommodation is provided in single rooms, none of which have en suite facilities. There is a lift to all floors. There is a large garden and conservatory to the rear of the building, which people who use the service enjoy during the warmer months. The home is well maintained and has a very welcoming atmosphere. Current fees for the home range from £700.00 to £2,300 per week. 13 Wilbury Gardens DS0000014115.V359084.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 the people who use this service experience good, quality outcomes. The Inspector agreed and explained the inspection process with the Senior Carer present at the start of the inspection. Later the Inspector was joined by the Registered Manager. The focus of the inspection was to assess 13 Wilbury Gardens in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an annual quality assurance assessment questionnaire, which was received prior the site visit to the home. This provided the Inspector with information relating to what the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. Survey questionnaires were sent to the home prior to the inspection. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, menus, rota’s, training records and recruitment records. In addition an environmental tour took place. The Inspector identified three people who use the service for case tracking, speaking with one of them whilst assessing the available information held in the home pertaining to the care provision for them. In addition the Inspector met with the other People who use the service, which gave her a good opportunity to observe the quality of care within the home and quality of life enjoyed. What the service does well: The home and its staff are committed to supporting the people who use the service in accordance with their needs and goals. This was evidenced through 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 6 the care plans, which detailed the areas of support that the person who uses the service needed and how this support is provided by the staff. The people who use the service that were communicated with indicated that they were very happy at the home, that they are able to chose and have control over there own lives with the in the home with the support of the staff. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems. Evidence supports that she puts the needs of the people who use the service first and is very supportive of staff. Some of whom themselves are deaf. The AQAA (Annual Quality Assurance Assessment) was completed by the manager and was seen to be of a high quality. This gave the inspector a greater insight into what the home considers it does well, what we could do better, what has improved within the last 12 months and plans for improvement. The home is an older property but was in good decorative order and kept very clean throughout. Improvements to some areas are planed and this will enhance the home further. What has improved since the last inspection? What they could do better: No requirements have been made during this inspection process. The home through the AQAA has made the following statements showing some of the areas they have identified for improvement. To access new activities and different environments on a more frequent basis. We will ensure that the staff team are up to date with any new policies & procedures that are issued around equality & diversity. 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 7 Continue to regularly review our systems ensuring that we stay up to date with any changes in legislation, which might affect service delivery. Compile accessible formats for service users to use in all circumstances to aide with their understanding and comprehension. All new staff to attend POVA and MAPA training and any other relevant training that will help increase awareness and for existing staff to ensure they maintain current knowledge. 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. 13 Wilbury Gardens DS0000014115.V359084.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 13 Wilbury Gardens DS0000014115.V359084.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): 2,5 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Service user’s can be confident that their needs will be properly assessed prior to moving to the home. EVIDENCE: Records held showed that people who use the service have an assessment, which identifies their individual needs prior to or on admission to the home. The people who use the service, their families and health provide the information / social care professionals. This is then reflected into the care plans and these are developed in agreement with the individual. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnicity and diversity needs of the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. In the files sampled contracts, which had been signed by the people who use the service, were seen, these are also available in an easy read version that is 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 10 easier to understand. These contracts included terms and conditions and who is responsible for paying any fees. 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The people who use the service benefit from having clear care plans that identify their individual needs, aspirations and goals and give clear guidance to staff. The people that use the service are treated with respect and their dignity and independence is promoted. EVIDENCE: The home and its staff are committed to supporting the people who use the service in accordance with their needs and wishes. This was evidenced through the care plans, which detailed the areas of support that the people who use the service needed and how this support is provided by the staff. The people who use the service have some communications difficulties, staff have developed there skills so the people who use the service can express easily their own choices. The way each service user is able to communicate is clearly documented so that staff are able to understand when the person is happy or not happy with what is occurring. The plans also included guidelines in respect 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 12 to routines and behaviour. In the files sampled it was evident that their link worker regularly reviews the care plans with each individual person who uses the service. Each individual persons likes and dislikes have been recorded and have been used to formulate the person centred care plans. Staff have the necessary training and skills to support and encourage the individual to be fully involved. Because the people who use the service are deaf, staff are skilled in using sign language. A link worker system provides additional support enabling one to one involvement. Care plans include a comprehensive risk assessment. Management of risk takes into account the specialist needs and age of people who use the service, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, it is in the person’s best interest. Any limitations are fully documented and reviewed on a regular basis to ensure their ongoing relevance. The risk assessments included every day type risks such as mobility but also risk assessments were seen for the holidays taken last year to Spain and Dorset. 13 Wilbury Gardens DS0000014115.V359084.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): 12,13,15,16,17 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they are offered a wide range of opportunities for personal development and to learn new skills and feel part of the wider community. People who use the service engage in an good level of activities, which are appropriate to their needs and capabilities. Those people who use the service with family and friends are supported to maintain contact, which ensures they continue to receive stimulation and emotional support. The person who uses the service’s benefit from the appetising meals and balanced diet offered at the home. EVIDENCE: 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 14 People who use the service are enabled to participate and contribute to meeting their own self-care needs and day-to-day chores around the house where possible. Discussion with the Registered Manager and staff confirmed that the level of activities were of a high level and good quality for people who use the service. They enjoyed an excellent level of stimulation through leisure and recreational activities both inside and outside the home. The home sees community presence as a priority along with choice and opportunity for personal development. People who use the service have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining the garden, last year 2 people who use the service tried growing vegetables as they have a special interest in gardening. Another has a particular interest in art and has his own work station where he draws and paints pictures. It was confirmed that people who use the service are enabled to maintain contact with relatives and friends where they wished to do so. Examples of such included provision for relatives to visit the home and support being provided to enable services users to visit with relatives outside the home. With in the home the people who use the service do need different support regarding religious and cultural wishes. These have been recognized and people who use the service have been enabled to access churches and festivals regarding their religions. Customs around food and prayer have also been supported through care planning. From observation, records viewed it was evident that people who use the service were offered a choice of menus at breakfast and tea time. The meals through the day meet their dietary needs and individual preferences. Meal times are flexible to suit the service users’ activities and schedules. Service users are able to choose where to eat, and also have the facility to make drinks, and snacks for themselves with staff support should they wish. Person who uses the service’s are to be given a better choice at dinner time, which until now offered a meal for all, which an alternative was only offered if they did not like what was on offer that day. 13 Wilbury Gardens DS0000014115.V359084.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 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People who use the service feel supported by the level of help given and that their healthcare needs are addressed. The people who use the service can also feel confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. EVIDENCE: Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different people who use the service daily routines. All people who use the service were able to make their own choices with regards to what they wished to wear, and this was evident by their individual appearance. The inspector observed excellent interaction between staff and people who use the service. The documentation seen in the form of a separate folder just about their individual health needs confirmed that all people who use the service have a GP and visits from other health professionals are arranged and enabled. The file contains there past medical history, there wishes regarding chiropody and 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 16 other current areas which need to be monitored for example. The health care issues and visits from health care professionals were also seen recorded in the daily record. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. MAR sheets which are an integrated part of the blister pack system used in the home were seen to be completed correctly and medication was stored appropriately. Quality assurance systems confirm that policy is put into practice. PRN or as required medication protocols were written up. The home could demonstrate that as required medication is given following an agreed protocol. The home has one person who uses the service who is undertaking management of their own medication. Procedures are in place to ensure this is done in a safe and monitored way. The manager confirmed that all staff that dispenses medication has received the appropriate training. The Royal Pharmaceutical Society of Great Britain (RPSGB) has recently launched a new publication, The Handling of Medicines in Social Care, which provides professional pharmaceutical guidance for people working in every area of social care to improve the safety and quality of medicines. The manager had secured a copy of this for the home. The home’s current medication policy is reviewed to ensure that it follows current guidance. 13 Wilbury Gardens DS0000014115.V359084.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): 22,23 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People who use the service know that their concerns and complaints are taken seriously and are protected from the risks of abuse EVIDENCE: A copy of 13 Wilbury Gardens complaints procedures was reviewed at the last inspection. The procedure included details of how to complain, timescales for response and information for referring a complaint. They are available in every people who use the service room and are in an easy read and picture format. The complaints procedure highlights the importance of complaining or making suggestions for improvement. No complaints have been received since the last inspection. The home’s Policy for the Protection of People who use the service and staff “Whistle blowing” procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. A copy of the Local Authority protocols were not available but these were printed off during the inspection and arrangement made for staff to be made aware of them. Full training is provided in adult abuse. Courses are always planned to ensure all staff receive the training required to protect people who use the service from abuse evidence was seen in the training file. 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 18 The home promotes an open culture where People who use the service feel safe and supported and enable relatives to share any concerns in relation to their protection and safety. At all levels the service is very clear when an incident needs external input, and is open in discussing incidents with external bodies (CSCI, Social Services) to clarify difficult judgements. Staff are trained to respond appropriately. All staff have had training in handling challenging behaviour they understand the techniques that can be used to calm the situation etc. Individual assessments were completed which involve the individual, other professionals such as the care manager or GP to promote the least invasive intervention. All staff working within the service have a CRB (Criminal Records bureau check) and have been cleared by POVA (Protection of Vulnerable Adults Register). The Manager is aware of her obligations with regard to ensuring the safety of Service users and protecting them from abuse. 13 Wilbury Gardens DS0000014115.V359084.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): 24,30 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People who use the service benefit from living in a clean comfortable home, which is suitable for their needs. EVIDENCE: The home is on three levels and has a passenger lift to each floor. A tour of the building was undertaken and a few people who use the service bedrooms were viewed. These were personalised and contained the furniture and equipment required on an individual basis. As people who use the service in the home are deaf there are alarms in the form of flashing lights and at night time vibrating pillows alert people who use the service to an emergency. The manager has purchased new much smaller vibrating pillows, following complaints from the people who use the service that ther old ones were to bulky and uncomfortable. A new call system has been installed making it easier for service users to call staff in the case of illness or emergencies. The are bathroom and toilet facilities suitable for the number of people in the home. for 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 20 people who use the service with mobility problems there is currently a specialised bath that they can access easily. The home does however have the funding and plans to adapt a step up shower facility into a wet room which will make the shower accessible to all. In general terms the home is well maintained and very clean with no offensive odours detected throughout. The communal space on the ground floor consisted of two lounges, one of which has a through dining area. The rooms are furnished and decorated in a way that gives a homely feel and some period features of the old house have been retained giving the area character. There is also a conservatory that leads out to a terraced garden. They have changed the layout of the garden to make it more accessible to service users who are unsteady on their feet. There is a kitchen off of the dining area and the home has a separate laundry. The laundry a small but it is suitable for use and people who use the service use the area to do their ironing. 13 Wilbury Gardens DS0000014115.V359084.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): 32,34,35 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People who use the service’s care, social and emotional needs are promoted by the employment of trained staff in sufficient numbers with the skills that they need to support people who use the service’ individual needs. The people who use the service are protected by the homes recruitment and employment policies and procedures. EVIDENCE: From discussions with the Registered Manager, observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the service users needs. The home provides a ratio of two members of staff to one particular person who uses the service during the day where ever that person who uses the service is, then there are other staff on duty for the remaining people who use the service. At night there is just one sleeping member of staff. staffing levels are kept under review and will be increased if it is found necessary to meet any changing needs of the people who use the service. The home does have an agency it can use for extra staff when the need arises. 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 22 A wide range of training has been identified for all staff over and above core skills courses. Most staff have been trained to NVQ Level 3 in Care and some are now doing level 4. The Registered Manager has the benefit of being supported by a deputy manager and senior carers. It was noted that all of the required training / updates to maintain qualifications had been undertaken for all staff. This includes First Aid, Health and Safety Awareness, Medication; fire Safety, Epilepsy, Infection Control, Signing, Food Hygiene and other courses. The inspector viewed details of the Home’s recruitment procedure and a number of records relating to staff members recruited. The Home undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of I.D and copies of qualification certificates, seeks written references. All staff appointments are subject to a probation period, which is subject to review. All staff have a contract of employment and job description. As part of the recruitment process checks are carried out to ensure that the staff employed have a good philosophy towards equality & diversity, they try to employ a very diverse staff team. RNID have very clear policies & procedures to guide staff if they feel there are poor practices around race, gender, disability etc. 13 Wilbury Gardens DS0000014115.V359084.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): 37,39,42 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People who use the service benefit from living in a well run and managed home. People who use the service can always feel fully confident that their health/safety, and welfare is protected by robust policies and procedures, which includes regular safety checks. EVIDENCE: The registered manager confirmed she has the required RMA (Registered Managers Award) plus an National Vocational Qualification level 4 in care. Her management skills have been proven in the competent way the home is run. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems. 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 24 Evidence supports that she puts the needs of the people who use the service first and is very supportive of staff. Quality assurance was discussed and the views and opinions of heath professionals and relatives is sought. People who use the service also complete surveys and these were seen, they were very positive about the service they receive. T o further improve quality assurance within the homes, within the past year RNID have formed a new Quality Support group, the focus of this group is to improve the Quality Assurance procedures for the organisation as a whole and to imrove its policies and procedures. A representative of the registered provider of the home does visit the home and completes what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). Such visits focus on outcomes for the people who use the service with regard to quality of care, staffing, adult protection, staff training, Activities, along with speaking to staff. The manager explained procedures and records were viewed relating to maintenance and servicing, and risk assessments for the home. Of the certificates viewed it evidenced that the necessary checks and servicing had been carried out and risk assessments were in place. Evidence was seen that checks and servicing of fire safety equipment, emergency lighting and fire log book had been undertaken, a fire risk assessment was in place The manager completes an annual operational plan, to identify areas for improvements and to sets goals for the future of the service. The staff are kept involved in this as part of their annual appraisal and they each have clear objectives for the year that are linked to the homes operational plan and the 3 year plan for RNID Care services as a whole. All staff have undertaken all staff training pertaining to health and safety issues and all certificates are in date. 13 Wilbury Gardens DS0000014115.V359084.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 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 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 26 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. Refer to Standard Good Practice Recommendations 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 13 Wilbury Gardens DS0000014115.V359084.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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