Care Home: 28 Newland Street

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What the care home does well The staff team were working well with people in the way they express themselves that may present difficult challenges and place the person at risk. Support guidance had been developed that identified the difficult situations that people faced and informed staff how to work with people so that they remained safe and also continued to take part in activities they enjoyed. Examples of this guidance was seen in relation to community activities where one person described how much they enjoyed going to the local shops but did get upset when it was busy. She was very pleased that she had decided, with the staff`s help, to get her hair cut and wanted to show her friend where she had been. Guidance recorded how staff worked with that person to reduce their anxiety.The management and staff team had continued to work with people in a person focused way to find out what was important for them and the way that they wanted to be supported. Another person also said how much they enjoyed shopping and domestic tasks around the house and that staff had listened to her with suggestions for healthy eating at meal times. Care plans set out in detail how staff were to interact and respond to people in the way that they wanted. In addition, the staff team had worked with people to develop clear ways of understanding each other through improved communication. Tools such as pictorial planners and picture books were used to help people express their choices and feelings and decisions. The staff team had worked closely with a Speech and Language Therapist to find out the best ways of supporting a person`s communication skills and had used several new techniques such as facial massage to help a person to develop their communication skills. An area that the home continues to work hard was maintaining people`s general and mental health. The home supported people to access local general health services such as the G.P. dentist, chiropodists, etc. The home had made sure that people received support from specialist mental healthcare services and had worked with those services to monitor and maintain people`s health. People were receiving one to one support through the day from a stable and consistent staff team reflected in the increase in the quantity and range of activities that people experienced and enjoyed. People were able to express themselves through the different activities that they enjoyed and showed when they were happy and excited about the things that they were doing. What has improved since the last inspection? The previous key inspection report highlighted a number of areas that required improvement and action from the management and staff team. From the evidence seen during the site visit and information gathered in the inspection process the improvements required have been made and were being sustained. These included: A great deal of the work that the home does well and the improvements made since the last key inspection can be attributed to the management and staff team. They have developed a consistent and stable team of core staff who know the people well and have developed the skills, knowledge and values needed to support them in a positive and affirming way. Improvements to the way that the management and staff team manage the medication administration system to make sure that it is safe and people receive the medication they needed at the right time.Ongoing improvements in the quality of the care planning and risk assessment process to show that the staff team and management understand what people need and how to support them. The environment that people lived in and that staff worked in had improved. This made the home feel more modern and homely reflecting more the personality of the people living there. What the care home could do better: Some recommendations have been made as good practice issues to consider in the provision of the service to the people supported. These look further at areas such as person centred planning, the environment and medication management. To show that the improvements made to the service continue The Regard partnership Ltd have been asked to send us the reports of the monthly inspections they must carry out. CARE HOME ADULTS 18-65 28 Newland Street 28 Newland Street Crumpsall Manchester M8 5RY Lead Inspector Steve O`Connor Unannounced Inspection 13th May 2008 13:00 28 Newland Street DS0000021706.V363433.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 28 Newland Street DS0000021706.V363433.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. 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 28 Newland Street Address 28 Newland Street Crumpsall Manchester M8 5RY 0161 740 9785 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) Southfields Care Homes Limited T/A The Regard Partnership Limited Zoe Anne McCall Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th November 2007 Brief Description of the Service: The home is a terraced house situated in the Crumpsall area of Manchester with easy access to local facilities e.g. shops, services, and places of worship, pubs and local transport. The home provides accommodation for 2 people with mental health problems. Fees are based on individuals’ level of support needs. 28 Newland Street DS0000021706.V363433.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 inspection report is based on information and evidence we (the commission) gathered since the last key inspection in May 2007. Additional information, which has been taken into account, included incidents notified to the commission by the agency and information provided by other agencies. Before visiting the home, we asked the agency to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helped us to determine if the management of the home viewed the service they provide the same way that we see the service. Before the visit to the home people who use the service, their relatives and members of staff were sent surveys and were asked to comment on the agency. By the time of the visit 2 staff returned surveys. During the inspection site visit time was spent talking to the two people who live at the home, to the manager and staff. Documents and files relating to people and how the agency was run were also seen. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the agency and to decide how much work we need to do with then in the future. What the service does well: The staff team were working well with people in the way they express themselves that may present difficult challenges and place the person at risk. Support guidance had been developed that identified the difficult situations that people faced and informed staff how to work with people so that they remained safe and also continued to take part in activities they enjoyed. Examples of this guidance was seen in relation to community activities where one person described how much they enjoyed going to the local shops but did get upset when it was busy. She was very pleased that she had decided, with the staff’s help, to get her hair cut and wanted to show her friend where she had been. Guidance recorded how staff worked with that person to reduce their anxiety. 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 6 The management and staff team had continued to work with people in a person focused way to find out what was important for them and the way that they wanted to be supported. Another person also said how much they enjoyed shopping and domestic tasks around the house and that staff had listened to her with suggestions for healthy eating at meal times. Care plans set out in detail how staff were to interact and respond to people in the way that they wanted. In addition, the staff team had worked with people to develop clear ways of understanding each other through improved communication. Tools such as pictorial planners and picture books were used to help people express their choices and feelings and decisions. The staff team had worked closely with a Speech and Language Therapist to find out the best ways of supporting a person’s communication skills and had used several new techniques such as facial massage to help a person to develop their communication skills. An area that the home continues to work hard was maintaining people’s general and mental health. The home supported people to access local general health services such as the G.P. dentist, chiropodists, etc. The home had made sure that people received support from specialist mental healthcare services and had worked with those services to monitor and maintain people’s health. People were receiving one to one support through the day from a stable and consistent staff team reflected in the increase in the quantity and range of activities that people experienced and enjoyed. People were able to express themselves through the different activities that they enjoyed and showed when they were happy and excited about the things that they were doing. What has improved since the last inspection? The previous key inspection report highlighted a number of areas that required improvement and action from the management and staff team. From the evidence seen during the site visit and information gathered in the inspection process the improvements required have been made and were being sustained. These included: A great deal of the work that the home does well and the improvements made since the last key inspection can be attributed to the management and staff team. They have developed a consistent and stable team of core staff who know the people well and have developed the skills, knowledge and values needed to support them in a positive and affirming way. Improvements to the way that the management and staff team manage the medication administration system to make sure that it is safe and people receive the medication they needed at the right time. 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 7 Ongoing improvements in the quality of the care planning and risk assessment process to show that the staff team and management understand what people need and how to support them. The environment that people lived in and that staff worked in had improved. This made the home feel more modern and homely reflecting more the personality of the people living there. 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. 28 Newland Street DS0000021706.V363433.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 28 Newland Street DS0000021706.V363433.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed prior to them coming to live at the home. EVIDENCE: There had been no new admissions to the home since the previous inspection. The organisation that owns and manages the home (The Regard partnership Ltd) has a referral process and a specific referral team, although the manager stated that she and the staff team would be fully involved in the referral, assessment and admission process. Pre-admission assessment information from the purchasing authority had been made available prior to people coming to live at the home. 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff and management team understand and provide the support and help that people need on a day-to-day basis. EVIDENCE: The previous key inspection report highlighted how the management and staff team had begun to review and update people’s care plans. Since that inspection people’s needs and support had been reassessed to make sure that all the information was up-to-date. The two people’s care plans and files were seen and it was found that the staff team and management had identified and recorded further information about their needs and the level of support given to help them. The manager stated that all the staff team were involved in working with people to find out the information such as their likes and dislikes, what a person’s strengths are and a summary of the person’s general, social, personal and emotional needs. 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 11 In addition, information about people’s daily personal routines such as personal care, accessing the community, shopping and social activities had been developed that contained a very good range of personal information that focused on the person and how they wanted to be helped. The information contained clear guidance on issues such as communication, body language, risk situations and also very positive comments about what the person can do rather than problems. As well as the reviews carried out on an annual basis by the purchasing authority regular reviews are carried out of people’s support and changing needs. It was noted that at times people’s changing support/needs had not been reflected in their care plan so it is recommended that care plans and guidance are updated on an ongoing and regular basis to reflect changes in the way that people were supported. Evidence was seen that the staff team had started to work with people to develop their own ‘person centred plan’ that would set out their own dreams, wishes and personal goals in the way that they want to. It is recommended that the home continue to develop and implement the person centred planning approach to how people identify their own needs, goals and the help they need to achieve them. To help people to make meaningful choices and decisions the staff team and management have worked with people and other specialist agencies to help develop a better understand of the way that people communicate their choices and needs. Both people have a pictorial planner that they use with staff to help devise a weekly routine and planner of the activities they wish to take part in. Also, as people express themselves in different ways guidance for staff had been recorded that highlighted how a person’s behaviour reflected what they felt and how staff can help people to express themselves in a more positive way. The previous key inspection of May 2007 highlighted that work had just begun on reviewing and updating any relevant risk assessments. From the samples of work seen the staff team and management had put a lot of effort and time into working with people to identify the areas of their lives that can cause them problems and to develop ways of working that reduce these risks and still support them to take part in activities that they enjoy such as social and leisure activities. The majority of the staff team had attended training in how to work with people who presented a challenge to them and the service, and in crisis prevention techniques. To show that they had read and understood the risk assessment guidance each member of staff signs a recording sheet to confirm this. 28 Newland Street DS0000021706.V363433.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to make their own choices and decisions about the lifestyle they lead and the activities they want to participate in. EVIDENCE: People living at the home receive support on a 1:1 basis between 9am and 5pm during the week. The aim of this support was to enable people to take part in activities that are meaningful and valued by them. This could be social and leisure activities or skills development, such as education or employment. The previous key inspection report raised the issue of the type of support and activities that people were taking part in. The staff team and management had worked further with people to find out what they enjoyed and valued and so how best to support them. A member of the staff team had the role of co28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 13 ordinator to work with people to develop a weekly planner of activities to give people a clear base of what they will be doing and when. This planner was not a strict routine and people decided whether they wanted to take part in a particular activity or not. People also have opportunities to take about the things they want to do at the regular house meetings. Records of what activities people were participating in were being maintained by the staff team to be able to show people’s attitude and feelings about certain activities and their progress in developing skills such as food preparation and other domestic skills. At the time of the visit a person was being supported to attend a health appointment and later a person was supported to go to the hairdressers, which they said they had really enjoyed. People were encouraged and supported to maintain and develop links with their families and friends based on people’s own wishes. An example was seen where a person’s wishes in respect to contact with family had been supported and action taken to make sure the contact was as the person wanted. People decide on a weekly basis what shopping to get and what meals they would like. General principles of a balanced nutritional diet were followed and an example was seen where a person had raised the issue of healthy eating at a house meeting. 28 Newland Street DS0000021706.V363433.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): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs were known and they were supported to maintain their health. The systems for supporting people’s medication needs were in place to make sure they took the medication they required. EVIDENCE: Since the last key inspection people’s personal care needs had been reviewed and updated to reflect their current needs. Clear and detailed guidance had been developed that set out what help people wanted and the best way that they wanted to be helped. The example of the guidance seen was person focused and clearly reflected how the staff and management team had worked with people to gather this information. People’s general and emotional health needs had been clearly identified through the assessment and care planning process. Records were maintained of people’s contact with general and mental health professionals and the outcome of these appointments. 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 15 Staff had access to clear and detailed information about people’s emotional and mental health needs and how to identify and respond to behaviour and changes in their emotional health. The previous three key inspection reports had all highlighted that people’s medication was not being administered or managed safely. After the key inspection of May 2007 a further random inspection was made in November 2007 to assess the progress in improving the medication administration system. From information provided and from talking to a member of staff and management during that site visit in November 2007, it was confirmed that staff had received additional training in the medication administration system. In addition, an audit was being undertaken and recorded of the medication levels to show that people had taken all their required medication. However, it was found that there were still issues around the administering of PRN medication and requirements were made for the management to improve this. The medication administration system was checked during this site visit and it was found that the recording was accurate and that regular physical checks and audits were taking place to make sure that people were receiving the medication they need. The PRN medication guidance had been clarified with the prescribing doctor and clear guidance was now in place. However, the administering of PRN medication was being recorded on two sources, one with the exact time and the other on a recording sheet provided by the pharmacist that did not record the exact time administered. It is recommended that one record of administering PRN medication is maintained that records clearly the exact time that medication was administered. It was also found that when two staff were on duty at the time that medication was given then administering medication had to be observed by the second staff member and they had to sign for this action on the Medication Administration Record (MAR) under the signature of the staff member who actually administered the medication. It was established, through discussion with the area manager of The Regard Partnership, that this had been set down by the purchasing authority in response to a medication incident at another care home operated by The Regard partnership. It is recommended that the management and staff team follow the guidance set out by the Royal Pharmaceutical Society for administering medication in social care settings. It is also recommended that the policies and procedures 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 16 relating to the administration and management of medication be reviewed to make sure that they meet the required standards of good practice set out in the guidance. 28 Newland Street DS0000021706.V363433.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place and were being followed by staff who had the required knowledge to protect people. EVIDENCE: People were given the opportunity to express any concerns through talking to their own keyworker, through the regular meetings they have with staff and also directly to the manager who visits the home on a regular basis. Both people are able to express themselves and have raised concerns and complaints through formal reviews. The AQAA, provided information that over the last 12 months one complaint had been received and investigated. The management and staff team follow a clear complaint policy and procedure that has set time frames for action. People were provided with an easy read version of the complaint procedure. Since the last key inspection the management and staff have had to deal with one incident that related to people’s safety and make a referral to the local authority under the local safeguarding procedures. The manager was able to describe these events and the process they followed. The two staff on duty were asked about their understanding of adult protection issues and were able to describe the training they had received and the procedures they would follow in the event of an incident or allegation. Through the discussions with the staff it is recommended that they be provided with 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 18 information as to what happens when referrals are made through the local safeguarding procedures and the role of the local authority in investigating such referrals. Staff support people to manage their personal finances and benefits. Records were maintained of all spending transactions and regular checks and audits were carried out to make sure the balances were correct. 28 Newland Street DS0000021706.V363433.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in an environment that is generally clean and homely in nature. EVIDENCE: The key inspection of May 2007 judged that the condition of the home and the environment that people lived in was poor and required a level of investment to refurbish the home. In November 2007 a random inspection checked on the progress in improving the environment. A tour of the premises found that kitchen units and worktops had been replaced. The living room and hallway had been decorated and people’s bedrooms had new bedroom furniture. People had been involved in choosing the colours and materials used in the refurbishment. During the site visit it was found that the shower had been repaired and the lounge had been personalised and made to feel more homely by people and 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 20 the staff team. The kitchen had been re-tiled and was now looking light, comfortable and more homely. The bathroom had not yet been fully redecorated and it was noticed that the windows at the front of the building were showing signs of needing repair. It is recommended that an updated action plan of refurbishment for the house be undertaken in consultation with the people living at the home. The laundry facilities are located next to the kitchen area and are suitable for people’s needs. 28 Newland Street DS0000021706.V363433.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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are support by an established staff team with the numbers, skills and knowledge to meet people’s needs. EVIDENCE: The current management team consisted of the manager who divides her time with two other small homes owned by The Regard partnership Ltd and a deputy manager who has been allocated some hours from her work schedule to help the manager with the management of this and the two other homes. Previous inspection reports had raised issues about the staff team including the quantity and quality of the staff team, the stability of the team and the use of agency staff. Since the last key inspection the manager has made a number of changes and the staff team now consists of a core team of around 5 members of staff who provide the bulk of the support. In addition staff who work at the other small care homes the manager has responsibility for also provide cover for shifts, holidays, training and sickness. This gave the management and staff team 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 22 more consistency, flexibility and allowed staff to develop the knowledge and skills needed to support people. The manager stated that no agency staff had been employed since the last inspection. The Regard Partnership Ltd provided an in-house training programme and had a dedicated training manager who arranged and provided a range of events including an Induction Programme. Staff were asked about the training they had participated over the last year and were able to describe events such as working with challenging behaviour, crisis intervention and various events looking at different aspects of mental health such as personality disorder. Staff also accessed core training such as Protection of Vulnerable Adults, Health and Safety, Food Hygiene, Fire Prevention and First Aid when they required refresher training. From the staff team, around 75 have achieved the NVQ Level 2. Many of the staff were undertaking the Level 3 qualification and some staff have accessed management training to add to their development. Staff files were being sampled at a national level to assess whether all the required checks and documentation required through the recruitment process had been obtained. Files had been seen with completed application forms, references received and a contract of terms and conditions. 28 Newland Street DS0000021706.V363433.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team and operational systems were in place to seek peoples’ views of the service and to maintain their health and safety. EVIDENCE: The manager has several years’ management experience working with people who present a challenge to the service and completed her Registered managers Award in 2003. The previous inspection of May 2007 identified the need for her to apply to become the registered manager as required under the Care Homes Regulations 2005. Since then she had gone through the application process and was now the registered manager with the full roles and responsibilities that the position 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 24 holds. They had worked with people and the staff team over the past 12 months to make the necessary changes in the way they work with people that was much improved and gave people a more consistent and valued level of support. To find out people’s views of the service house meeting had been introduced to talk about issues that impact on people and their life at the home. A meeting was help in April 2008 where people raised issues such as further decoration, meals, activities and medication. In addition, the staff who act as keyworkers still spend time with each person to talk to them about their concerns and worries and how to reduce those. The Regard Partnership Ltd have their own quality assurance system, including surveys, and a Quality Assurance manager who carries out the Regulation 26 visits to the home. To make sure that the company are addressing the issue of maintaining the quality of the service they must provide us with copies of the Regulation 26 visits until further notice. A fire log is maintained for visual checks and fire drills. A fire risk assessment had been reviewed. Up-to-date environmental risk assessments had been undertaken in relation to the health and safety of the home. Records for monitoring temperatures of the hot water and fridge/freezer were being maintained. 28 Newland Street DS0000021706.V363433.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 3 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 4 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 28 Newland Street DS0000021706.V363433.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. 1 Standard YA39 Regulation 26 Requirement To make sure that the company are addressing the issue of maintaining the quality of the service they must provide us with copies of the Regulation 26 visits until further notice. Timescale for action 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that care plans and guidance are updated on an ongoing and regular basis to reflect changes in the way that people are supported. It is recommended that the home continue to develop and implement the person centred planning approach to how people identify their own needs, goals and the help they need to achieve them. 2 YA20 It is recommended that one record of administering PRN medication is maintained that records clearly the exact time that medication was administered. DS0000021706.V363433.R01.S.doc Version 5.2 Page 27 28 Newland Street It is recommended that the management and staff team follow the guidance set out by the Royal Pharmaceutical Society for administering medication in social care settings. It is also recommended that the policies and procedures relating to the administration and management of medication be reviewed to make sure that they meet the required standards of good practice set out in the guidance. It is recommended that the staff team be provided with information as to what happens when referrals are made through the local safeguarding procedures and the role of the local authority in investigating such referrals. It is recommended that an updated action plan of refurbishment for the house is developed and undertaken in consultation with the people living at the home. 3 YA23 4 YA24 28 Newland Street DS0000021706.V363433.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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