Care Home: 18 Water Gate

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What the care home does well The people live in comfortable, spacious and well designed accommodation. Each person is encouraged and supported to be as independent as possible and encouraged to take part in meaningful activities. They are also offered choices about what they wish to do and to make decisions about how they spend their lives. They are encouraged and supported to have control over their lives. People living in the home are cared for and supported by a caring, educated and committed team of staff.They are in turn lead by an experienced manager who although new to this home has extensive knowledge about the needs of people who experience sensory difficulties. There is a comprehensive programme of education and training provided for staff, which ensures that staff know how to care and support the people who live at the home. The staff feel valued by the management and feel part of a team to improve, help and support the people living in the home. What has improved since the last inspection? The garden has been further developed to make it more attractive with colourful flower beds and patio furniture. A new more comfortable people carrier has been provided. A more suitable and accessible cooker has been provided. A large flat screen television has been provided in the large lounge. A new central heating boiler has been provided. What the care home could do better: There were no requirements or recommendations from this inspection. Where improvements were identifies, they were already being addressed by Sense, the acting manager or staff in the home. Sense carry out regular quality assurance monitoring audits. As a result of discussions during this inspection they have agreed to update information about us to include our Cambridge Regional office address. The acting manager has also agreed to purchase a suitable controlled drug cupboard. CARE HOME ADULTS 18-65 18 Water Gate Quadring Spalding Lincolnshire PE11 4PY Lead Inspector Tobias Payne Unannounced Inspection 2nd September 2008 3:00 18 Water Gate DS0000067455.V370627.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 18 Water Gate DS0000067455.V370627.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. 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 18 Water Gate Address Quadring Spalding Lincolnshire PE11 4PY 01778 382230 01778 380078 susan.bush@sense.org.ok www.sense.org.uk Sense, The National Deaf blind and Rubella Association An acting manager was appointed in July 2008 who has applied to be registered by the CSCI. Care Home 4 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) Category(ies) of Learning disability (4), Physical disability (4), registration, with number Sensory impairment (4) of places 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 18 Watergate is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Learning Disability, Physical Disability and Sensory Impairment under 65 years of age. The maximum number of persons to be accommodated at 18 Watergate is 4. 4th September 2006 2. Date of last inspection Brief Description of the Service: 18 Watergate is part of a group of homes in the area, managed by Sense. The home was first registered in May 2006 to provide personal care for up to 4 people with dual sensory impairments. The home is a 4 bedroom detached property with separate single storey warehouse. In the house, accommodation is to ground and first floors. All bedrooms are single and are en-suite (toilet, basin a bath). The property is located in the village of Quadring 8 miles from the day service facilities at Pinchbeck, which is owned and operated by Sense East. There is a large lawn with enclose garden areas with a gated entrance to driveway, which provides off road parking for several vehicles. The stated aims and objectives are to provide a safe and supportive environment, based on best care values for people who are deaf/blind, to promote a presence in the community through the use of local amenities and services and to build and maintain good relationships and a positive image. The home’s statement of purpose confirms that the minimum staffing ratio of the home is one staff member to 2 people during the day and at night one wakeful member of staff and one who is sleeping in and on call. The fees at the inspection visit on the 2/9/2008 ranged from £1,188,64p to £1, 942,26p each week. All information about the home including the statement of purpose, service user’s guide and copy of the last inspection report can be obtained from the manager of the home. 18 Water Gate DS0000067455.V370627.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 3 stars. This means the people who use this service experience excellent quality outcomes This key inspection was unannounced and started at 3 pm. It was undertaken using a review of all the information available to the commission about 18 Watergate. It took place over 3½ hours. In order to be sensitive to the communication needs of the 4 people living in the home, we used our observations between staff and the people who live there, information provided by the acting manager, staff members and records as evidence as to whether standards were being met. This observation also ensured we could use our evidence to judge whether the outcomes experienced by people were what they wanted. We spoke with 3 members of staff including the acting manager. The main method of inspection used during our visit was called “case tracking”. This involved selecting one person and tracking the care they received through the checking of records, discussions with the care staff and observation of how staff responded to their needs and that of the other people who lived there. We also looked closely at the annual quality assurance assessment (AQAA) that was sent to us by the acting manager before this key inspection. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the home. It was very clear and detailed. Before making our visit we asked the people who live there to send us comments about the support they receive. We receivedsome feedback from 4 people living at the home. These were completed with the assistance of their key workers. The feedback provided was very positive. We also received positive comments from 2 relatives and 3 staff. What the service does well: The people live in comfortable, spacious and well designed accommodation. Each person is encouraged and supported to be as independent as possible and encouraged to take part in meaningful activities. They are also offered choices about what they wish to do and to make decisions about how they spend their lives. They are encouraged and supported to have control over their lives. People living in the home are cared for and supported by a caring, educated and committed team of staff. 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 6 They are in turn lead by an experienced manager who although new to this home has extensive knowledge about the needs of people who experience sensory difficulties. There is a comprehensive programme of education and training provided for staff, which ensures that staff know how to care and support the people who live at the home. The staff feel valued by the management and feel part of a team to improve, help and support the people living in the home. 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. 18 Water Gate DS0000067455.V370627.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 18 Water Gate DS0000067455.V370627.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): Standards 1, 2 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Where a person is referred to the home they receive a comprehensive assessment to ensure that their needs can be met. People receive clear and detailed information in many forms to suit their needs to enable them or their relatives/advocates to make an informed choice as to whether or not they wish to live in this home. EVIDENCE: There was a statement of purpose and service user’s guide. The information was very clear and detailed and included Sense’s mission statement, values, aims and objectives together with specific aims and objectives for 18 Watergate. This information was clearly displayed on a table outside the kitchen/dining room on the ground floor. We noticed that our address and phone number referred to our old Lincoln address. We asked that all information now referred to our Cambridge Regional office. The acting manager agreed to act on this as soon as possible. The acting manager told us that she is also further improving this information by providing it in different formats in order to make all the information simpler and easier to understand for anyone who wanted to use it. 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 9 There is an established group of people currently living at the service and it was confirmed that no person had been admitted since 2002. Where a person was admitted Sense had very clear procedures to ensure that a detailed assessment would be carried out to ensure that they could meet all the assessed needs of that person. The acting manager confirmed that, where appropriate all those involved in the person’s life would be consulted to ensure a smooth transition took place. Each person had a contract/terms and conditions of residency. This contained Sense East terms and conditions. This was clearly outlined in the statement of purpose and service user’s guide. The fee included all costs, rent, utility charges, personal care, laundry, food, and comprehensive programme of choices, activities inclusive of a 7-day holiday or equivalent. 18 Water Gate DS0000067455.V370627.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, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is detailed care planning, which includes risk assessments. People enjoy choices about what activities they want to get involved and have a varied social programme. People are encouraged to make decisions for themselves and be independent with the support and guidance of staff. EVIDENCE: Each person had a detailed care plan outlining his or her care and support. The care plan had been produced wherever possible with the involvement of the person, their family/advocate and other relevant people. Care plans were very detailed and included an information sheet with photograph, terms of residence, description of the premises, what the fee includes, furniture provided by Sense, layout of the room, inventory of their personal belongings their background/family, birthday, mobility, health and professional involvement, personal care, eating and drinking, communication, social and emotional, making choice and specific needs including religious and cultural needs. 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 11 Since our last inspection care plans have been further improved and now included a capacity assessment for each person. Each person also had information about how staff could help with individual needs. There were also very detailed risk assessments covering all aspects of their life. A compressive “My Health Record” was kept for each person, which had details about their health needs and any specialist equipment required. These plans were available for each person to access if needed. Sense had detailed policies and procedures concerning accessing personal records, confidentiality and data protection. Training records also showed staff were trained to respect confidences. Choice and decision making was clearly shown in the care plans. The people were given choice concerning their interests activities and lifestyle. Staff received training to assist and support them. The care records were very detailed, person focussed and reviewed regularly. Reviews took place every 6 months. These included wherever possible the person and their family/advocate, people who provide daytime support outside the service, their key worker and acting manager for the home. Before this there was a meeting to obtain all information concerning the person. We looked at the financial records for the people living in the home. They were well maintained with receipts and signatures. They were also checked every month. There are currently no formal group meetings with the people living in the home. However staff ensured individual support was given, and time taken to obtain feedback so that that the people living in the home were involved in running the home wherever possible. The acting manager also confirmed they used the advice/support of a behavioural therapist who visited the home every 6 months. The acting manager and staff had received training in order to manage challenging behaviours. There were also detailed policies and procedures. We saw that records were kept securely. This makes sure peoples personal information about their needs is private and only used by the staff team to meet their needs 18 Water Gate DS0000067455.V370627.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 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People continue to be involved in meaningful and appropriate activities, which include educational and recreational activities. People also enjoy varied and nutritious meals. EVIDENCE: People who live at the service attend an activity centre called Glenside Resource Centre at Pinchbeck operated by Sense Monday to Friday between 9.30 am and 4 pm. People are transported in a newly purchased airconditioned people carrier with comfortable seating for 8 people. A wide range of activities are available at the centre, which include cookery, pottery, horticulture, creative art, office skills, personal and social development, music, numeracy and literacy, local history and citizenship. Activities outside the resource centre had included swimming, bowling, visiting friends, BBQ’s, church services, pubs, wall climbing, horse riding, yoga, 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 13 rambling, gym, kayaking, horse riding and local clubs. The home actively welcomed visitors at any reasonable time. People had also been on holiday supported by staff. We observed that the care team also worked closely with families and arranged for the people to visit them. To enable this to happen, staff were available to give support as needed. The staff had established close relationships with relatives of the people who because of distance found it difficult to visit. The staff in the home regularly phoned them to give up to date information about the person living in the home. Risk assessments we looked at showed how people were supported safely and were guided in activities to promote more independence for example, housework, which included cleaning, laundry and cooking. Staff said that this has been made easier as a result of the purchase of a new more suitable cooker. When moving into the home the care team showed how they obtain details about each person’s food preferences, likes and dislikes. There was a rotating 5 weekly menu. They also chose daily what they wished to eat and the staff monitored the nutritional content. At breakfast there was a choice including a hot meal. At lunch, when attending the resource centre there was a packed lunch and an evening meal provided a hot meal including a choice. Meals were taken in the dining area in the lounge on the ground floor. All staff members help and support meal preparation and all had food hygiene training provided. 18 Water Gate DS0000067455.V370627.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 excellent. This judgement has been made using available evidence including a visit to this service. People benefit from being fully involved in identifying their own needs and choices. Clear care plans, created from assessments of need help to ensure that people’s health and welfare needs are fully met. Medication is safely given by staff who know what they are doing. EVIDENCE: Care records showed that any health or emotional needs were being met either by staff, specialist staff from Sense East or by the GP. Close working relationships had been established with the local GPs and they were working with the community physiotherapist. When needed, with permission from the person, people were referred to their GP, Community Nurse, Continence Nurse, Dentist and Optician and Podiatry. Sense also had access to a behavioural therapist and physiotherapist. There were also 6 monthly audiology and dental checks. Where required, staff accompanied the people to these services. Each person had an annual health check. One of the people was being assessed in a hospital unit and had been 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 15 supported by daily visits from staff from the home to assist and support the person and the staff in the hospital. The acting manager showed she has key worker system in order to provide consistent support with communication and to give a specific member of staff responsibilities for each person. All of the people living at the service needed support in order to take their medicines safely. Sense had a very detailed and clearly written medication policy. Since our last inspection visit we had been made aware by the home of one medication error, which did not put any person at risk. The manager told us she had taken action and assessed each staff member responsible for supporting people with their medicines and monitored their practice. Procedures have recently been reviewed and medication is covered more fully during induction. The acting manager confirmed they had also introduced checks at each shift of medication in the home. Records were very clear and detailed. As a result of this no further errors had occurred. We did observe that there was no controlled drugs currently needed for people and that at present the acting manager has not needed to use a separate secure cupboard for this purpose. We advised that the law now required a care home to have this facility whether or not there were any controlled drugs in the home. The acting manager agreed to act on this immediately. 18 Water Gate DS0000067455.V370627.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. People are supported by staff to enable them to raise concerns and feel that staff will listen to their views. The care team know how to respond to a complaint and how to act in order to protect people from abuse. They are protected from abuse by correct recruitment procedures. EVIDENCE: Sense East had produced a “Resolving Issues” policy, which gave written and pictorial guidance concerning how any person could raise any issues. This could be provided in Braille, tape or other languages other than English. No complaints or safe guarding adults’ issues had been received by the commission and the home since the last inspection. We asked, and it was agreed that the acting manager would amend the complaints procedure with our new contact address. The acting manager showed she had an adult protection policy and all staff as part of their induction received abuse training. There was also a copy of Lincolnshire County Council’s adult protection procedures available and staff new about this and how it should be used. They also received yearly refresher training programme in the form of a questionnaire about safeguarding people at their appraisal. Staff knew about abuse and clearly described what they would do if they suspected abuse. 18 Water Gate DS0000067455.V370627.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, 25, 26, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a safe, clean and well decorated comfortable home suitable for their needs. EVIDENCE: Accommodation was of a high standard and well maintained throughout. All 4 bedrooms were single and were en-suite (toilet, basin, bath and extractor fan). The bedrooms reflected each persons individuality. The accommodation was designed to enable easy access for people with mobility difficulties and those who had a visual needs making good use of colour and texture contrasts in décor and furnishings, tactile information and specialist lighting. One bedroom on the ground floor had an en-suite with an over head tracking hoist to help support individual mobility. Two people with specific mobility needs lived in the 2 bedrooms on the ground floor. We observed that this 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 18 helped ensure people had more opportunities to access the support needed. Each bedroom had a lock to enable people to be private if they chose to. There was a large lounge with comfortable chairs and settees and a large kitchen and dining/sitting area. This room had doors to the garden. The lounge area also had comfortable chairs one of which was raised specifically to make sitting easier for one person. There was a utility room with a washing machine with a tumble dryer. A new more suitable accessible cooker had been provided to enable the people to get more involved in cooking with the support of staff. There was a very attractive garden at the back of the home overlooking a fence to open fields. This laid to lawn, with colourful flower beds with wooden patio furniture. This could be accessed easily for people from the kitchen/dining area. 18 Water Gate DS0000067455.V370627.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): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a safely recruited, well-trained, supported staff team available who have the skills to meet the varying needs of the people living in the home. EVIDENCE: The manager showed that she had made sure there were enough staff available each day to support people safely and promote their independence. Recruitment and training records showed they were experienced and competent to care for people who had sensory needs. There was occasional use of agency staff but a separate file was available giving them information about the home and each of the people living in the home. At night there was one wakeful and one sleep in member of staff who was available if required. Records showed how the dependency and needs of the people in the home were monitored regularly and where needed additional staff provided. 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 20 Each new member of staff was recruited correctly with a check by the Criminal Records Bureau. They had a 13-day induction programme to prepare them for their role. They then completed a Skills for Care certificate and post induction training in the first six months. They also received monthly supervision sessions and an annual appraisal. All staff had been trained to communicate using total communication skills and to understand each person’s differences and needs by signing. Training over the past year had included moving and handling, fire prevention, adult protection, infection control and medication. In addition, staff were encouraged to study for a nationally recognised qualification in care (National Vocational Qualification). Three members of staff had an NVQ level 2, one was studying and one is waiting to start. There were 4 staff without this qualification. Sense had achieved the Investors in People award as a result of its commitment to staff education and development. Staff spoke of the support they received and of the supervision and appraisal systems in place. All staff were responsible for care, catering, domestic and laundry duties. They were therefore responsible for all services in the home. The staff felt they could meet the needs of people and felt they had sufficient time. This was observed during our visit by staff taking particular time to communicate with the people in a calm, kind, friendly and sensitive manner. Staff members spoke of the support they received and of working as a team. Comments we received from staff included, “all training was informative, we receive 6 weekly supervisions and there is an open door policy, we provide a safe and caring environment encouraging independence and support where needed”. 18 Water Gate DS0000067455.V370627.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, 38, 39, 40, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and staff benefit from the positive leadership of the management team. Management record systems show that residents’ health, welfare, safety and choices are promoted. The management team ensures that the people living in the home with the support of the staff, relatives, and staff have the opportunity to share their views and opinions. The management uses feedback from questionnaires and quality assurance systems to make improvements. EVIDENCE: Since July 2008 there had been a new person appointed to be manager of the home. This person had extensive knowledge about the needs of people with sensory impairments. The acting manager confirmed she is in the process of formally registering with us. She was being supported in her role by a newly appointed deputy manager who was on his induction and about to start 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 22 training provided by Sense for this post. The acting manager also told us she is working to obtain a nationally recognised qualification to help develop her skills as a manager. Despite these recent changes staff we spoke with felt confident in the management. There were detailed policies and procedures, which enabled staff to deliver care and support the people in the home. Sense had a policy on equality and diversity. Monthly meetings were held with staff. They told us that they felt they valued and supported. Staff were seen to support people in a confident, knowledgeable, and sensitive manner. Our observations confirmed they clearly knew the needs of each person and demonstrated excellent communication skills. Throughout our visit there was a relaxed atmosphere. We received comments which included, “they always make me welcome whenever I visit, if my relative is happy and safe that is good”, “the level of caring for our daughter is so high as to be best be described beyond the normal call of duty” and “the service that this home provides should be replicated across the whole of the country”. Records showed that Sense made monthly unannounced monitoring visits. We looked at the reports written about the visits made and found them detailed and well maintained. There had been no concerns. Records throughout our visit were available, up to date and well maintained. Sense had comprehensive health and safety policies, which also included detailed and up to date risk assessments. These included risk assessments covering all aspects of daily living activities. A detailed fire risk assessment had also been carried out. There were regular tests of the fire system as well as regular fire drills. 18 Water Gate DS0000067455.V370627.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 4 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 X 28 3 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 4 3 3 4 3 LIFESTYLES Standard No Score 11 4 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 2 3 3 3 3 3 X 18 Water Gate DS0000067455.V370627.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. Refer to Standard Good Practice Recommendations 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 18 Water Gate DS0000067455.V370627.R01.S.doc Version 5.2 Page 26 - 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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