Care Home: 30 Lower St Helens Road

Similar services:

• Hillview Farm
• Dalewood Respite Care
• Orchard,The
• REACH Upton Court Road
• Fairways
• Treloar College
• Kestrel House, St Anne`s Opportunity Centre,
• Pinta

What the care home does well There are good systems to assess the needs of service users before they move into the home and assessments are comprehensive. The home provides a homely and welcoming environment and the home was pleasantly decorated and service users rooms were personalised. Service users are encouraged and supported to participate in the day-to-day living arrangements, through regular meetings and consultation. What has improved since the last inspection? Since the last inspection the care plans for service users have been improved and these contain information about how staff meet service users` needs and these plans are reviewed regularly. The recruitment practices have been improved to ensure that all relevant checks are carried out before staff starts work at the home. What the care home could do better: This report will make 1 requirement to the home and other points which need to be addressed to help improve the service provided for service users are contained within the main body of the report, general observations were: It was noted that care plans contained a lot of information that was not current and there is a need to remove old information to avoid confusion for staff. Currently the home does not have its own "in house" medication policy. This issue was discussed with the deputy manager and it was explained that it would be beneficial to staff to have a simple policy which gave staff information on how medication procedures were managed in the home and this procedure should include a protocol regarding "when required" medication and should include information on when this should be considered or given. There was 2 complaints made to the area office about the home, however these complaints had not been recorded in the complaints log at the home. The inspector discussed this issue with the acting manager who will get the details of these complaints and ensure they are appropriately recorded The home has infection control procedures in place, however there is no information for staff on the procedures to be followed when dealing with any soiled items and the home needs to establish a procedure for this to provide clear information for staff. Generally service users are well supported, however the current staffing arrangements potentially puts service users at risk and the home must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. The home must also ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. CARE HOME ADULTS 18-65 30 Lower St Helen`s Road Hedge End Hampshire SO30 0LX Lead Inspector Michael Gough Key Unannounced Inspection 9th October 2007 10:00 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 30 Lower St Helen`s Road DS0000059969.V347445.R02.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. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 Lower St Helen`s Road Address Hedge End Hampshire SO30 0LX 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) 01489 787449 ILIACE Limited Miss Joanne Copp Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007 Brief Description of the Service: 30 Lower St Helen’s Road is registered to provide care and accommodation to four people between the ages of 18 and 65 years with learning disabilities. The home is owned by Iliace ltd and is a four bedded detached property situated in a residential area of Hedge End, approximately half a mile from the shops and village amenities. All service users have their own bedroom and share the use of the kitchen, lounge / dining room and garden. The manager reported in a pre-inspection questionnaire that the range of fees at the home is £1416.42 to £1935.95 per week, depending on the needs of the service users and service users are responsible for paying for their own toiletries, hairdressing and items of a personal or luxury nature. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at 30 Lower St Helens Road and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out on the 12 December 2006. The inspection took into account the comments received in inspection questionnaires; and comment cards received from 1 staff member and 1 relative. The homes Annual Quality Assurance Assessment (AQAA) was returned prior to the visit and information contained in the AQAA was also used. Included in the inspection was an unannounced site visit to the home, which took place on the 9 October 2007. Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and service users. It was not possible to speak with any of the homes permanent staff members but the inspector did speak with one agency staff member and also the homes acting manager who assisted the inspector during the visit. The home is registered to provide support for 4 service users and at the time of the inspection there were 4 service users living at the home. What the service does well: What has improved since the last inspection? What they could do better: 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 6 This report will make 1 requirement to the home and other points which need to be addressed to help improve the service provided for service users are contained within the main body of the report, general observations were: It was noted that care plans contained a lot of information that was not current and there is a need to remove old information to avoid confusion for staff. Currently the home does not have its own “in house” medication policy. This issue was discussed with the deputy manager and it was explained that it would be beneficial to staff to have a simple policy which gave staff information on how medication procedures were managed in the home and this procedure should include a protocol regarding “when required” medication and should include information on when this should be considered or given. There was 2 complaints made to the area office about the home, however these complaints had not been recorded in the complaints log at the home. The inspector discussed this issue with the acting manager who will get the details of these complaints and ensure they are appropriately recorded The home has infection control procedures in place, however there is no information for staff on the procedures to be followed when dealing with any soiled items and the home needs to establish a procedure for this to provide clear information for staff. Generally service users are well supported, however the current staffing arrangements potentially puts service users at risk and the home must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. The home must also ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. 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. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 30 Lower St Helen`s Road DS0000059969.V347445.R02.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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a detailed assessment of their individual needs before they move into the home and have information about their terms and conditions of residence. EVIDENCE: Any potential new service users are seen by a placement team from the organisation and also the homes manager. Their individual needs are then assessed. There has been one new service users to the home since the last inspection, this service user moved into the home in August 2007. There was a comprehensive assessment and this included information on health and personal care, self help skills, communication, domestic skills, academic skills, activities, social and community skills, personal relationships and sexuality and environment. The assessment also had a breakdown of staff hours and there was a scale i.e. 1-1 meant 1 staff member to 1 resident, 2 – 1 was 1 staff member to 2 residents and 3 – 1 was 1 staff member to 3 residents. A needs assessment was also looked at for another service user. This assessment was not as comprehensive as this person moved into the home from another of the organisations homes, however there was a plan to ensure that the transition between homes went as smoothly as possible. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 9 Contracts for service users were not available as the inspector was informed that these are held at head office, however conditions of terms and conditions of residence were contained in individual files. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users assessed needs and personal goals are reflected in a plan of care and service users are supported to make decision about their lives with assistance give by staff. Risk assessments are in place to enable them to take responsible risks as part of an independent lifestyle. EVIDENCE: Care plans were seen for 2 service users and these were comprehensive documents that gave staff clear information on what support was required and how and when this should be given. The inspector was informed that service users have input into their care plans and are involved in the bi monthly reviews and also annual reviews. Care Plans seen were written clearly and could be followed easily. One service user has epilepsy and there was a separate care plan for this. Other information in the care plan gave expanded details of the information contained in the needs assessment and also provide information on the level of support required. One care plan stated that the service user thrived on a consistent approach and that she had a high level of support needs. There was information that the service user needed 1-1 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 11 support for some tasks. Another care plan seen was also detailed and gave clear information for staff. It was noted that care plans contained a lot of information that was not current and the need to remove old information was discussed with the acting manager who understands the need to remove out of date information to avoid confusion for staff. Recording was clear and there were a number of different sheets where recording takes place, there were separate sheets for GP & Health visits and for nighttime recording and also for recording other specific information. There were also recording sheets for staff to complete at the end of each shift and these gave information on what support had been given and what the service users had been doing during the day, however the form used for this recording did not always provide sufficient space for any detailed recording and this was discussed with the acting manager. Care plans were reviewed Bi Monthly and annual reviews take place. Review notes were in service users files and one service user had her care reviewed in the week prior to the inspection, however these notes were not yet available. The inspector was informed that as a result of this review it was agreed to have the service user’s needs re-assessed as her needs had changed, this review of needs will be taking place in the next few days and appropriate changes will be made if necessary. Staff supports service users to make their own decisions about their lives as much as they are able and there are regular weekly service user meetings with appropriate records kept. These meetings are used to plan menu’s and to arrange activities, the acting manager said that staff support service users to make decisions about their day to day lives and that there wishes and views are respected and taken into account. Service users are also able to have the support of an independent advocate from a local advocacy service and currently they are supporting one service user to resolve a sensitive issue. Risk assessments were in place in service users files and these were clearly written and gave information to staff on what support was required to minimise any potential risks. All assessments are reviewed as part of the bi monthly review of care plans. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to be part of the local community and to be involved in appropriate activities and they benefit from support to maintain social contacts. Daily routines at the home respect service users rights and responsibilities and meals at the home are flexible and service users benefit from a balanced diet. EVIDENCE: Each service users has a weekly plan of activities and this details what they are participating in each day. 2 of the service users attend a local day service where activities include art, cooking, drama and leisure activities. 2 service users attend a local college to learn independent living skills. There are gaps in these services and the home provides activities for service users during the times they are not at day service or college, these activities includes, shopping, hairdressers, bowling, trips into town for lunch, however these are dependant on sufficient numbers of staff being on duty as all service users require staff support to go out into the local community. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 13 Service users are supported to maintain family relationships and 1 service user is supported to phone her mother each day. The home has a visiting policy and this is flexible and visitors are welcome at any time. Daily routines in the home promote independence as much as possible. Staff were observed knocking on doors before entering and seeking permission to visit bedrooms. Staff were observed interacting with service users and their preferred form of address was used. Mail is given to service users unopened and staff support individuals with their mail. Service users are able to access all areas of the home. Menus at the home are made up each week at the weekly service user meetings and staff are involved to ensure that nutritional needs are met. Service users are offered a choice of cereals and toast at breakfast and lunch is normally a snack type meal with the main meal being in the evening. The menu is flexible and allows for change at short notice and this gives the opportunity for service users to choose a take away if they wish. Service users are encouraged to help prepare meals at the home as much as their abilities will allow and they assist with making drinks and laying and clearing the table. Service users are encouraged to eat their meals at the dining table however they can eat elsewhere if they wish. Records of food consumed are kept by the home and food shopping normally takes place twice a week with top up shopping being done on a day-to-day basis. Service users are encouraged to go with staff to buy shopping for the home. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and service users physical, emotional and health needs are generally met. The home has a satisfactory system for storing and administering medication. EVIDENCE: Care plans for individual service users give information on personal care needs and this is offered by care staff of the same gender wherever possible. The staff team are flexible round the times when service users want their personal support however there is a daily routine for service users to help with consistency. Service users at the home are registered with 2 different surgeries and have different GP’s. Service users have specialist input from the local learning disability team, from district nurse’s, occupational and speech therapists and physiotherapists. Dental checks and treatment are provided by a local dental clinic and other health care professionals are arranged through a GP referral. There was information in service users care files of hospital and GP appointments and on the day of the inspection the deputy manager supported a service user to attend a health care appointment. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 15 The organisations medication policy and procedures are currently being reviewed. The home does not have its own “in house” policy, this was discussed with the deputy manager and it was explained that it would be beneficial to have a simple policy which gave staff information on how medication procedures were managed in the home and this procedure should include a protocol regarding “when required” medication and should include information on when this should be considered or given. The home supports one service user who has epilepsy and there is a clear procedure laid down for staff. The home operates a monitored dose system from a local pharmacist and all staff has received training in the administration of medication. The medication administration sheets were inspected and there were no gaps and there was a clear record of medication administered. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a simple, clear and accessible complaints procedure and the homes policies and procedures protect service users for any form of abuse. EVIDENCE: The home has a clear complaints procedure and has been supplied to all service users in an accessible pictorial format. All relatives are given a copy of the homes complaints procedure and a copy of this procedure is displayed on the notice board at the home and this contained all of the required information and gave details of how to contact the CSCI. The acting manager told the inspector that there have been no complaints made to the home since the last inspection, however there was 2 complaints made to the area office and these concerned the home and are being dealt with by the area manager. The home has a complaints log; however these 2 complaints were not recorded and the inspector discussed this issue with the acting manager who will get the details of these complaints and ensure they are recorded at the home. A staff member who completed a survey confirmed that they were aware of the homes complaints procedure. The home has a copy of the Hampshire Adult Protection procedure and staff also receive training with regard to adult protection and POVA. The acting manager said that staff were aware of the action they should take and she demonstrated a clear understanding of her responsibilities in this area. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely and comfortable environment and the home is clean and hygienic and free from offensive odours. EVIDENCE: The inspector toured the home and all areas were clean and pleasantly decorated and homely in appearance. The homes AQAA indicated that new furniture was required in the lounge, elsewhere furniture and fittings were of good quality and the service was clean and hygienic and there were no offensive odours. There is a separate laundry, which is situated just off the kitchen and has washable floors and walls. There is a domestic washing machine, which is able to wash clothing at appropriate temperatures and also a domestic tumble drier. Service users are encouraged to bring their own laundry down to the utility room and staff support service users to do their washing. There is information on the kitchen door which reminds of the need to not bring any items of clothing through the kitchen when food is being prepare however there is no information for staff on the procedures to be followed when dealing with any soiled items. This issue was discussed with the 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 18 acting manager who will ensure that a procedure is drawn up to provide clear information for staff. The home has an infection control policy and staff have received training in this area. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports and encourages staff to undertake relevant care qualifications and service users are supported by trained staff and service users are protected by the home’s staff recruitment procedures. However the current staffing arrangements potentially puts service users at risk. EVIDENCE: Currently the home has only 5 permanent staff members and 2 are currently undertaking NVQ2 and two are undertaking NVQ3. The acting manager stated that the organisation supports all of its staff to undertake relevant qualification once they have been employed for over 6 months. On the day of the inspection the acting manager was not available for the first 30 minutes as she was supporting a service users to attend a medical appointment. When the inspector arrived he was met by an agency staff member who was supporting one service user who was at the home. The homes staff rota was examined and this showed that there are 2 members of staff on duty between 7.30am to 10pm and there is one member of staff on waking night duty from 9.30pm – 8am. The issue of staffing was discussed with the acting manager when she returned to the home and she informed the inspector that the home was actively recruiting new staff member as 3 had 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 20 recently left and one of the current staff members was due to leave shortly. She informed the inspector that cover is provided by bank staff and other carers who work for the organisation at other local homes and do extra shifts at 30 lower St Helens road. Agency staff also backs up the staff team. The inspector was told that agency staff are familiar with the home, however the agency staff member on duty did not have any knowledge of where care plans were kept or what information was contained in them. One comment card received back from a staff member said that there were not sufficient staff on duty at the home and a comment card received from a relative was concerned at the staffing levels in the home. The home supports 4 service users some who have behavioural problems. The care plan for one service user said that she needed a high level of support for some tasks and that a consistent approach was needed. Another service user is quite shy and likes to stay in her room and all of the service users require staff support to go out into the community. Currently there are only 5 permanent staff members and two of these staff work night shifts, this leaves 3 members of staff to support the service users and give guidance to bank and agency staff. The inspector viewed an incident form that was completed and this had evidence that a relative returned her daughter to the home after a visit to her parents and it was found that there were only 2 members of staff on duty and these were both agency staff. The relative was not happy with this arrangement and reported it to the organisation who arranged more suitable cover. The current staffing arrangements potentially puts service users at risk and the home must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users and they must also ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. Staff records were inspected for 3 staff members. All files seen contained all of the required information including photograph, CRB/POVA and 2 x references. Files also contained training certificates and supervision notes. The organisation has a training co-ordinator who arranges training for all staff. Staff undertake induction training and foundation training and mandatory training is carried out in; moving and handling, fire safety, adult protection, first aid, health and safety, food hygiene and infection control. Staff have also received training with regard to foot health, autism, communication skills, medication administration, epilepsy, Strategies for Crisis Intervention and Prevention (SCIP) and makaton. The acting manager confirmed that staff receive a good induction and said that there was a training calendar was produced each year with a range of courses they could request to go on and for refresher training and updates. Any training requests and needs were discussed at supervision sessions and there was a matrix of training dates and also dates for refresher training so that the manager could monitor training needs. 30 Lower St Helen`s Road DS0000059969.V347445.R02.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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are suitable management arrangements in place at the home and service users can be confident that their views are taken into account when developing the home. The homes policies and procedures promote and protect the health safety and welfare of service users and staff. EVIDENCE: The homes registered manager is currently on Maternity leave and is expected to return to work in February 2008. The organisation has put a temporary manager in place and she is experienced and has worked at the home for some time she said that said she receives good support and is able to seek advice and support whenever she needs to and she said that she has regular supervision meetings with the area manager. There were a range of quality assurance measures in place, and these included, staff meetings, resident meetings and regular contact with relatives. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 22 The organisation has also recently employed a quality assurance manager who will be co-ordinating quality assurance arrangements. The fire logbook was inspected and there was a fire risk assessment and appropriate checks are made of the fire alarm system and the equipment. The gas system was checked in March 07 and portable electrical appliances were checked in July 07, with fixed wiring checked in February 2004. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 30 Lower St Helen`s Road DS0000059969.V347445.R02.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. 1. Standard YA33 Regulation 18 (1)(a)(b) Requirement The current staffing arrangements potentially put service users at risk and the home must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users and they must also ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 25 No. Refer to Standard Good Practice Recommendations 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 30 Lower St Helen`s Road DS0000059969.V347445.R02.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!