Care Home: 199 Doseley Road

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What the care home does well People living at Doseley Road enjoy a full and stimulating lifestyle and have structured daily and weekly routines. They are provided with imaginative and varied opportunities to develop and maintain their social and recreational interests. The home is managed in the best interests of the people using the service. The manager has a clear vision for the service and is well supported by her team. Staff spoken with considered the service is well managed and that the manager is open, approachable and service user focused.A survey received from a relative stated `The home provides a safe loving environment and also promotes dexterity and encourages our relative to carry on with his craft, lessons, this providing a healthy stimulus to his everyday wellbeing`. The building is well equipped and soft furnishings are of good quality and provide people with a comfortable and homely place to live. People have personalised their own bedrooms and it is evident that staff respect people`s own space. Observations made and discussions held clearly evidence that staff have developed working relationships with the people they support, their relatives and other agencies. What has improved since the last inspection? The home now has a registered manager in place and the requirements made as a result of the last inspection are considered met. The use of agency staff has significantly reduced providing continuity of care for the people using the service. A number of permanent staff have been recruited and the management team have restructured to ensure people have access to a senior member of staff on duty. Staff files are now more readily available for inspection. Files seen were well presented and contained all the information required to demonstrate that the provider has robust recruitment procedures in place to safe guard people using the service. A staff-training matrix has been developed which includes training courses individuals have undertaken. Staff have received training in safe working practices in addition to training specific to the people they support to include epilepsy and autism. What the care home could do better: The findings of this inspection indicated that the service is currently performing well. It is hoped that the service can sustain its performance and continue to provide positive outcomes for people. The homes quality assurance processes require further development in order to regularly review the quality of care provided to people living at the home. CARE HOME ADULTS 18-65 199 Doseley Road 199 Doseley Road Dawley Telford TF4 3BA Lead Inspector Rebecca Harrison Key Unannounced Inspection 17th April 2008 09:00 199 Doseley Road DS0000066727.V361911.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 199 Doseley Road DS0000066727.V361911.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. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 199 Doseley Road Address 199 Doseley Road Dawley Telford TF4 3BA 01952 506105 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) www.dimensions-uk.org Dimensions (UK) Ltd Miss Claire Louise Downing Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2007 Brief Description of the Service: 199 Doseley Road is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of five adults with a learning disability. The home currently has one vacancy. Dimensions (UK) Ltd is the registered service provider and the responsible individual is Mr David Nance. The registered manager is Ms Claire Downing. The home is located in Doseley, Telford approximately two miles from Telford Town Centre and offers access to local amenities and public transport. The property is detached and is in keeping with the local community. Accommodation is provided over two floors comprising a lounge, kitchen, dining room, conservatory, single bedrooms and an enclosed garden to the rear. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged were not available in the Service User Guide as required however it was reported fees prior to April were £1554.00 per person per week. Therefore the reader may wish to obtain more up to date information direct from the service provider. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. The inspection was unannounced and took place on 17th April 2008 by one inspector over 6 hours. A range of evidence was used to make judgements about this service to include discussions with the manager and staff on duty, surveys received from four people who use the service, two relatives and seven staff, a tour of the home, a review of quality assurance processes and observation of care experienced by people using the service. We also looked at a number of records to include care records held on behalf of two people receiving a service, complaints and protection, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The manager completed this and some comments have been included within this inspection report. The purpose of the inspection was to assess ‘Key’ National Minimum Standards for Younger Adults and to review the two requirements made as a result of the previous inspection undertaken on 25th April 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: People living at Doseley Road enjoy a full and stimulating lifestyle and have structured daily and weekly routines. They are provided with imaginative and varied opportunities to develop and maintain their social and recreational interests. The home is managed in the best interests of the people using the service. The manager has a clear vision for the service and is well supported by her team. Staff spoken with considered the service is well managed and that the manager is open, approachable and service user focused. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 6 A survey received from a relative stated ‘The home provides a safe loving environment and also promotes dexterity and encourages our relative to carry on with his craft, lessons, this providing a healthy stimulus to his everyday wellbeing’. The building is well equipped and soft furnishings are of good quality and provide people with a comfortable and homely place to live. People have personalised their own bedrooms and it is evident that staff respect people’s own space. Observations made and discussions held clearly evidence that staff have developed working relationships with the people they support, their relatives and other agencies. 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. 199 Doseley Road DS0000066727.V361911.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 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is good People who may use the service and their representatives have the information needed to choose a home that will meet their assessed needs and are provided with a contract, which tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides people with information about the service in its Statement of Purpose, which has been updated to reflect the change in managerial arrangements since the last inspection. Service User Guides have been developed for all individuals and have been produced in a pictorial format. There have been no new admissions to the home however the homes assessment processes have previously been assessed as satisfactory. All individuals are provided with a copy of their Terms and Conditions of residency, which have been produced in an easy read format and approved by an independent advocate in conjunction with relatives. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9 Quality in this outcome area is good Staff are provided with detailed information to ensure peoples individual needs are met and regularly reviewed. The people who use the service are supported to make decisions and enabled to take responsible risks to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All care documentation held on behalf of two people was examined. Support plans were found person centred, detailed and covered all aspects of the persons individual needs with evidence of review with significant others. Staff spoken with considered that they are provided with sufficient information to meet the assessed needs of the individuals they support. Designated ‘key workers’ are in place for continuity of care and are responsible for monitoring and reviewing the individual needs of the person on a monthly basis and compiling a report. Staff spoken with had a clear understanding of the individual needs of the people they support. Individual reactive management 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 10 plans have been developed with significant others and these were detailed with evidence of review. The management team have recently attended training in person centred planning and aim to develop individual plans with people shortly. Throughout the inspection staff were seen to communicate well with the people they support and demonstrated a good understanding of peoples preferred communication styles. Observations made throughout the inspection evidence that individuals are encouraged to take part in decision-making processes as much as their needs allow. Staff offered people choices in terms of meals, social activities and daily routines. It was reported that families play an active role in representing their relative’s best interests. The home is currently sourcing an independent advocate for one individual. People using the service are supported to take responsible risks both in their home and in the community. Detailed risk assessments were available on the two files examined with evidence of review. All staff sign to say they have read and understood each assessment. The self-assessment completed by the provider indicates that all staff will receive training in risk assessment in the next twelve months. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15,16 and 17 Quality in this outcome area is excellent People living at Doseley Road are provided with imaginative and varied opportunities to develop and maintain their social and recreational interests and are enabled to keep in contact with family and friends. People receive a healthy, varied diet according to their dietary requirements and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The self-assessment completed by the provider states the ‘The people we support are encouraged to make choices in their every-day lives and are provided with opportunities to access the wider community, develop life skills and gain confidence and independence’. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 12 The findings of this inspection clearly evidence that individuals living at Doseley Road enjoy a full and stimulating lifestyle and have structured daily and weekly routines. When at home people are encouraged to share the domestic tasks and take part in basic meal preparation based on their ability. During the inspection everyone accessed the community at different times to partake in activities to include multi-sensory, hydrotherapy and a local walk. One individual attended a day service provided through the local authority and it was reported that one person continues to enjoy a work placement two mornings per week. Two people currently attend educational courses at the local college and staff have supported people to attend a recent open evening to identify future courses. Pictorial activity plans have been developed and prove a useful tool with helping individuals plan their lifestyle. Staff work flexibly to accommodate peoples leisure interests, for example plans to support one individual to the theatre in London are being arranged in addition to holidays based on individual’s preferences. It was reported that people access public transport in addition to their own vehicles or the vehicle provided by the home. Staff gave examples of how family support is encouraged by the home and people are supported to stay in touch with regular visits, social evenings and birthday events where both families and friends are made welcome. Contact details were available on the two files examined and visits recorded in daily records. Surveys that we received from relatives were positive and indicate that they are satisfied with the service provided, that they are kept informed of important issues and that staff and managers are caring, supportive and approachable. Plans for the forthcoming twelve months are ‘to encourage people to widen their circle of friends’. The menus seen appeared healthy, balanced and provided choice. It was reported that people using the service are involved in menu planning and are supported to develop their skills by purchasing provisions locally and partaking in basic meal preparation. Likes and dislikes were seen on the two files examined in addition to a record of meals eaten. The mealtime observed was flexible and relaxed and staff offered assistance where required. It was reported that none of the individuals have special dietary requirements however one person continues to follow a healthy eating programme. A number of comments from people who have visited the home were seen in the homes compliments book in relation to meals and include: ‘Food excellent as always’ ‘’Fantastic food (beautiful)’ ‘The food is lovely…’ 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. People who use the service are safeguarded by the home’s improved systems for handling, storing and administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preferences in relation to support requirements were available on both files examined, which is essential given the communication limitations of the people living at the home. Observations made clearly evidence that the delivery of personal care is consistent and that staff respect privacy and dignity. Records seen indicate that individuals are encouraged to be independent and are supported to take responsibility for their personal care needs as much as possible for example by undertaking personal care tasks under close supervision. Health records seen evidence people are supported to access health appointments and outcomes are now much more clearly recorded. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 14 Health plans have been developed to monitor the health needs of individuals and records evidence the home has sought external professional input following the increased behaviours of one individual. Medication procedures appeared satisfactory at the time of the inspection. A detailed medication policy and procedure has been developed following requirements made at the previous inspection. The manager was able to demonstrate a clear understanding of her role and responsibilities in relation to how this is managed. It was reported that all staff have attended an in-house training course in medication and have commenced accredited training via the distance-learning route through a college. Staff competency assessments in handling and administering medication have been developed and implemented as required by the previous inspection and an example of this was seen. The manager stated that there have been no medication errors since the last inspection. Records evidence that an appropriate healthcare profession regularly undertakes medication reviews. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good The home has is a complaints procedure in place and people using the service are provided with pictures and symbols if they wish to express their concerns. Procedures to safeguard people from potential abuse are in place although managers must ensure these are effective to ensure people are not placed at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at the home and their representatives have access to a complaints procedure, which has been developed in a format appropriate to the people living at the home. The manager reported that a copy of the procedure has recently been distributed to relatives to ensure they are familiar with the process. No complaints were found recorded in the complaints log and the manager confirmed that no complaints have been received by the home. We have not received any concerns or complaints in relation to this service since the last inspection. The self-assessment completed by the provider identifies plans for the forthcoming twelve months, which state that ‘Staff are to be trained to understand how they should view and use the complaints procedure as well as the value of complaints’. The service has received a number of compliments from visitors and external agencies since the last inspection and comments received include: 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 16 ‘I enjoyed my visit…lovely home atmosphere’ ‘…I visit the home on a regular basis; all staff are polite, sociable and contribute to a friendly homely atmosphere. I look forward to each visit’ ‘I was really impressed to see X accessing the health spa during lunch time, he was having a thoroughly good time…I do not know the support worker but he was doing a cracking job, please pass my appreciation and thanks to the team and specifically to the support worker’ The manager has obtained the revised copy of the local multi-agency safeguarding adult policy and procedure. Staff spoken with confirmed they have received training in adult protection and the management of actual and potential aggression. Records indicate that all staff employed have received this training. No referrals under safeguarding adult procedures have been made however records seen on one file suggest that given a number of incidents by one service user against another, a referral should have been made. However the manager was able to evidence that external professional input was sourced and measures put in place to safeguard the individual concerned and a risk assessment developed and implemented as seen during the inspection. It was reported no person has been subject to physical intervention or restraint since the last inspection. The home has a policy in place for the management of service users’ finances and all people have their own bank accounts. Financial procedures were discussed with a member of staff and the manager who considered these to be robust and safeguard both people using the service and staff. Managers undertake regular audits. 199 Doseley Road DS0000066727.V361911.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): 24 and 30 Quality in this outcome area is good People living at Doseley Road are provided with a comfortable, safe and wellmaintained environment to live with good infection control procedures in place to protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a purpose built detached property situated in Doseley, Telford and provides good access to community facilities and services. The accommodation is provided over two floors consisting of comfortable, bright and spacious rooms. Bedrooms seen were personalised and the home provides a relaxed and homely atmosphere. The lounge suite has been replaced with one more appropriate to the needs of the people accommodated. The manager has an allocated budget for the renewal and replacement of furnishings. The self-assessment completed by the provider states ‘People are encouraged to keep their home in good order and are assisted in developing skills to carry out the every day tasks in order to achieve this’. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 18 The home was found clean at the time of this unannounced inspection. An odour was detected in one bedroom although it was reported that attempts have been made to eliminate this in addition to the possibility of replacing the floor covering. Cleaning schedules are maintained and all staff have received training in infection control procedures. Substances hazardous to health are appropriately stored and assessments and data sheets readily available in addition to personal protective equipment. An external specialist has recently undertaken an infection control audit and the minor issues identified have been actioned. A comment was seen in the homes compliment book stating ‘I was welcomed into the home when coming to do the infection control audit. The home has a pleasant atmosphere and for a small home achieved a good audit’. 199 Doseley Road DS0000066727.V361911.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): 32,33,34,35 and 36 Quality in this outcome area is excellent People living at Doseley Road are supported by a well-trained, enthusiastic and committed staff team who are sufficient in numbers and have a clear understanding of their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the inspection staff were accessible and communicated well with the people using the service. They appeared motivated and discussions held with them clearly evidenced they are committed to their work and have developed positive working relationships with the people they support. Staff spoke positively about their role and responsibilities and of their good training opportunities. It was reported of the eight permanent support staff employed, three hold a recognised care award known as a National Vocational Qualification at level 2 and three further staff are currently working towards their award. The team consists of a registered manager, two seniors and six support workers. The home currently has three support worker vacancies and interviews for these positions have recently been held. Records evidence the 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 20 use of agency staff has significantly reduced thus providing more continuity of care for people living at the home. The current staffing ratio is a minimum of two staff to four people with a third staff member covering a middle shift during the day, which was an accurate reflection of the staff rota seen. Staff spoken with confirmed staffing is appropriate to meet the individual needs of the people they support and spoke very positively about their work. One staff member stated ‘It’s absolutely brilliant here, staff are caring, considerate and do a great job…morale is really good and its one of the best jobs I’ve ever had’ Since the last inspection three staff have been appointed. All three files were examined, were well presented and contained all the documentation as required by Schedule 2 of The Care Homes Regulations, as amended. The manager reported that a service user was involved in recent staff interviews and discussions with him indicate that he enjoyed this process. A newly appointed member of staff spoken with considered the organisation’s recruitment procedures robust and safeguards the people using the service. We received seven surveys completed by staff who are employed at the home and all staff indicated that they receive training relevant to their job role which helps them to understand and meet the needs of the people they support and keeps them up to date with new ways of working. Staff spoken with during the inspection reported they are provided with good training opportunities that cover health and safety and other training appropriate to their job role such as epilepsy and autsim which was seen on the team training matrix. Staff training needs are identified through staff supervision. All new staff complete induction training and a six month probationary period is a requirement of the job. Some staff have attended training in record keeping and report writing. Staff spoken with confirmed they receive formal supervision at the required frequency as recommended by the previous inspection. A matrix to record dates of staff supervison is maintained and staff meetings are held monthly. 199 Doseley Road DS0000066727.V361911.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): 37,38,39 and 42 Quality in this outcome area is good People living at Doseley Road benefit from a service, which is effectively managed. Quality assurance requires further development to assess performance and evaluate outcomes for people using the service. The home is managed and maintained in a manner, which ensures the safety of people using the service and the staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 22 Ms Claire Downing has been managing the service for twelve months and her application for registration was approved in February 2008. Records seen and discussions held with the manager evidence that the she has attended a number of training courses relevant to her role and has completed NVQ level 4 Award in Health and Social Care and is aiming to commence the Registered Manager’s Award shortly. Discussions with the manager evidence that she promotes equal opportunities and was able to share an example of this with the inspector. Staff spoken with stated that the manager is approachable and supportive. One person stated ‘the manager is very good, always listens and follows things through. She cares about the service users and staff and is one of the best manager’s I’ve worked for’. The Annual Quality Assurance Assessment (AQAA) forwarded to CSCI was detailed and reflects both the strengths and areas of improvement for the service. The manager has not yet had the opportunity to distribute satisfaction surveys in order to gain peoples views about the service provided or developed an annual development plan, which reflects aims and outcomes for service users. Monthly visits and reports required under Regulation 26 have been undertaken but not at the required frequency. It was reported that the organisation has developed a new Quality Manager post that will take on responsibility of Quality Assurance. Matters pertaining to health and safety appeared satisfactory at the time of the inspection. Risk assessments for the management and safe working practices in the home are in place with evidence of review. The service meets the requirements of the fire and environment health departments. Certificates for the servicing of equipment are maintained and safety checks are undertaken at the required frequency. Training records evidence that staff now receive training in safe working practices at the required frequency. Staff have access to policies and procedures, which are regularly reviewed and updated. 199 Doseley Road DS0000066727.V361911.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 3 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 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 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 2 x x 3 x 199 Doseley Road DS0000066727.V361911.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 Refer to Standard YA39 Good Practice Recommendations The homes quality assurance processes require further development in order to regularly review the quality of care provided to people using the service. 199 Doseley Road DS0000066727.V361911.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 199 Doseley Road DS0000066727.V361911.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. 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