Care Home: 54 Monks Dyke Road

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What the care home does well The home is spacious, clean, tidy and comfortably furnished and has the necessary equipment available to meet people`s individual needs.There is a varied range of opportunities for people to experience and participate in differing recreational, social and leisure activities both in the home and local community. Staff are kind, caring and treat people who use the service with respect. The service is being well managed. What has improved since the last inspection? This is the first key inspection of the service since it has changed its registration from providing a service to children to younger adults. It is however noted that the matters identified as needing addressing when it was last inspected as a children`s service, which also relate to adult services have been addressed. These matters include ensuring information and records about people who use the service are available for staff to refer to should they need to, staff records being kept securely and ensuring that people who use the service have the opportunity to participate in individual activities should they wish. What the care home could do better: Ensure that care plans show that consideration has been given to people`s capacity to make decisions more explicitly. Whilst there is information in the home about the Mental Capacity Act staff may benefit from some training to ensure they fully understand its implications in the work they do. Ensure that meal times are better managed so that people who use the service who may need to have a meal at a different time can be assured it will be served hot. The manager also recognises that she needs to ensure that the formal staff supervision system in place is achieved on a more regular basis as this is a means of ensuring good standards are maintained. CARE HOME ADULTS 18-65 54 Monks Dyke Road 54 Monks Dyke Road Louth Lincolnshire LN11 9AN Lead Inspector Sue Hayward Unannounced Inspection 4th August 2008 14:00 54 Monks Dyke Road DS0000064051.V369562.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 54 Monks Dyke Road DS0000064051.V369562.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. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 54 Monks Dyke Road Address 54 Monks Dyke Road Louth Lincolnshire LN11 9AN 01507 609332 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) margaret.greenfield@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Margaret Greenfield Care Home 4 Category(ies) of Learning disability (4), Physical disability (4), registration, with number Sensory impairment (4) of places 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only:Care home only - Code PC To people of the following gender: Either Whose primary needs on admission to the home are within the following categories:Physical disability - Code PD Learning disability - Code LD Sensory Impairment - Code SI The maximum number of people who can be accommodated is 4. 2. Date of last inspection 3rd April 2006 Brief Description of the Service: Monks Dyke Road is situated in the small market town of Louth. The property is owned by Linx Housing and leased by Sense East. The home has a large open plan kitchen/diner, a lounge and a sensory room. There are four large single downstairs bedrooms with full en-suite facilities. All bedrooms are decorated to reflect the individual preferences and interests of each young person. There is an upstairs guest bedroom adjacent to the office with access to a shower and toilet. The home provides care for four young people with dual sensory impairment, profound learning disabilities and associated medical problems. This service was until December 2006 registered as a care home for children but on account of the young people living in the home becoming adult it became a service for younger adults and is required to meet different standards and regulations. There has been a change to the management arrangements, Margaret Greenfield becoming the registered manager in May 2007. The care home has a statement of purpose, which sets out the resources of the home and the facilities offered. Information about the day-to-day operation of the home and fees, as well as a copy of the last inspection report, is available from the manager. The current range of fees is £ 134000.00 to £141372.32 per year. Hairdressing, newspapers and clothing are additional costs. 54 Monks Dyke Road DS0000064051.V369562.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. Throughout this report the terms ‘we’ and ‘us’ refer to The Commission for Social Care Inspection (CSCI). This was an unannounced visit and it formed part of an inspection, focussing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. It is the first key inspection since the service has changed it registration from Children’s to Adults’ services. The main method used to do this was through a process we call “case tracking”. This includes following the care of a sample of two people through their records and assessing their care. We met all four people who use the service and saw their rooms. In addition we spoke to four staff that were on duty. The visit started in the afternoon and lasted 5 hours. It took into account information we already hold on our files, which was used to plan the visit and produce this report. Prior to the visit the manager had completed a questionnaire. This gave us important information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. In view of the needs of the people who use the service surveys were not sent out to them. Instead, time was spent during the visit observing staff working and the information this gave us is also included in the report. Since the last key inspection we have received surveys from three relatives of people who use the service and their comments are also included in the report. We also undertook an annual review of the service on 13th December 2007, which indicated that the service was providing positive outcomes for the people using the service. There was discussion with the manager who was present for part of the visit. She was telephoned after the visit to clarify further some information and the general outcomes of the visit were also discussed with her. What the service does well: The home is spacious, clean, tidy and comfortably furnished and has the necessary equipment available to meet people’s individual needs. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 6 There is a varied range of opportunities for people to experience and participate in differing recreational, social and leisure activities both in the home and local community. Staff are kind, caring and treat people who use the service with respect. The service is being well managed. 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. 54 Monks Dyke Road DS0000064051.V369562.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 54 Monks Dyke Road DS0000064051.V369562.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. This judgement has been made using available evidence including a visit to this service. There are good systems in place to introduce and assess people who use the service to ensure their care needs are identified and can be at the home prior to admission. EVIDENCE: Information about the home is available in the form of a statement of purpose and a brochure, which tells people about the service. It can be made available to people in other forms such as audiotape, Braille or larger print if needed. It makes a statement, which includes acknowledging and respecting the “unique” and differing needs of people. The manager confirmed that although such information is available in alternative forms, people who use the service have very different and individual communication needs and levels of understanding and people may need information providing in different ways. For example people who use the service have opportunities to visit and have overnight stays so they can experience and become familiar with what living in the home is like. This also assists in the assessment of each person to ensure the home is suitable for his or her needs. The manager said people are also told about 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 9 the service in a way, which is meaningful to each individual if other ways of providing information is not suitable. Previous inspection reports are available in the office should people wish to see them. The organisation has an assessment procedure, which includes involving other relevant people such as relatives and carers, social workers and medical professionals. Records were in place in both files checked on this occasion to demonstrate this and to show that there had been assessments made of individuals needs from which a plan of care had been developed. A range of information is obtained during the assessment, which includes matters such as health and hygiene, recreational, religious and social needs. A relative made a comment, which indicated that they and the person who now uses the service had had the opportunity to visit the home a few times and meet staff before moving in. Staff confirmed their understanding of the admission process and had a good knowledge of the needs of the young people asked about. Records were also available which demonstrated that each person had been issued with a form of agreement telling them about the conditions of residency. Currently all people living in the home are sponsored by a local authority. From observations made on the day people who use the service had had their needs assessed appropriately and staff knew what these were. They had had appropriate equipment provided where necessary to ensure their assessed needs could be met, for example hoisting aids were in place and bedrooms seen were decorated and furnished in different styles reflecting the individuality of the young people who live at the home. 54 Monks Dyke Road DS0000064051.V369562.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. People who use the service are supported to make choices and decisions about their lives. Staff have a good knowledge of peoples needs and how to meet them, which contributes to ensuring peoples health and wellbeing. Care plans do not clearly show whether consideration has been given to people’s capacity to make decisions. EVIDENCE: Both service users files checked had care plans in place, giving staff sufficient information about the needs of people and the care required to meet them. Other information was also in place such as risks assessments where there had been risks identified and guidelines for staff to follow in relation to matters such as how to manage behaviour, which may be challenging or how to manage specific dietary requirements. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 11 A matter was raised at the previous inspection of 30th September 2006 in relation to ensuring that records and care plans about people who use the service were available for staff to refer to at all times. This has been addressed. Discussion with staff indicated that they knew where records were kept and they could read them when they wished. Care records seen did contain some information general to all people who use the service to demonstrate how staff would include people in decision making but care plans did not specifically record peoples capacity to make decisions or not. This is important in view of recent legislation, which has come into force to ensure there is no infringement of peoples’ rights. This was discussed with the manager who agreed to ensure that such information was added to care plans. There was however information available about the Mental Capacity Act for staff to refer to if needed. Reviews are held a minimum of twice yearly and records and discussion confirmed that relatives and other professionals such as funding authorities are invited to attend. Staff discussion and observations indicated that they were aware of the needs of the young people and of ways in which people who use the service are given choices in the home. For example, it was said that some people are given different items to feel to help them make a choice when choosing what clothes to wear. Staff comments indicated that they also use their knowledge of individual ways in which people who use the service communicate as a method used to judge their preference and wishes as well as observations of peoples reactions to ensure they are happy. The manager confirmed that all of the current people living in the home need support to manage their personal finances. The organisation has a procedure for staff to follow about this. Records are kept of any transactions and staff signatures obtained to demonstrate when these have occurred. Staff were noticed to check the money which they have access to to ensure it was correct and said they made daily checks to ensure the accuracy of money held in safe keeping. Discussion and records checked showed that the manager also carries out regular audits. The storage arrangements for any money or valuables are satisfactory. Checks made on items held in safekeeping of both people whose care was being followed on this occasion were accurate and up to date. People who use the service looked well cared for and it was noticed that staff offered them choices for example as to which staff helped them with their personal care. A relative commented, “ X loves his life at the home”. 54 Monks Dyke Road DS0000064051.V369562.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to experience and participate in a range of activities within the home and community which enables them to have a varied social life. People are provided with meals which cater for their individual preferences and dietary requirements but the arrangements for serving meals is not sufficiently satisfactory to ensure that people are always served their meal hot. EVIDENCE: Care records contained information about people’s recreational, social and religious needs and documented for example when they had taken part in shopping trips, craft sessions, watching television or listening to music. It was also observed during the visit that one young person had been taken out shopping, another was having a rest in his room and one was using the 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 13 sensory room. Staff discussion and records confirmed that people who use the service can attend a day centre facility also operated by the organisation and this provides further options, which people can pursue. There was discussion with the staff team, which indicated that people do have opportunities to participate in a range of activities and leisure interests. They are also able to keep in contact with family and friends and go on holiday. Records kept also confirmed this. A relative who had completed a survey made a comment, ”when I visit I leave feeling easy about the situation, X is happier and healthier now than at any time previously in his life”. Staff commented and observations made during the visit confirmed that there is generally sufficient staff to support people individually or as a group to pursue their interests. There is a minibus available to take people out. Some young people who use the service were noticed to be with the staff whilst they were preparing the evening meal and menus showed that the meals provided take into account peoples known individual preferences and specific dietary needs. Staff said that they generally decided on the menus but tried to ensure that healthy meals were provided. Whilst it was noted that there is flexibility about meal times it was noticed that one person’s hot meal was served up well in advance of the person coming to have his meal and there was not the option of this being reheated or provided with an alternative hot meal. This matter was discussed with the manager who agreed to address the issue so that all people who use the service are able to have their meal served hot. Staff had a good knowledge of people’s individual dietary needs and were noticed to provide appropriate support to people who needed assistance whilst enabling people to have their meals as independently as possible, for example ensuring those who needed it had the appropriate equipment. 54 Monks Dyke Road DS0000064051.V369562.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 – 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive care that promotes their health and welfare. They are protected by the medication procedures in place. Any errors are appropriately dealt with to ensure the safety of people who use the service by prompt action being taken to improve the systems in place. EVIDENCE: Staff were seen to assist people who use the service appropriately when providing care and were attentive to them, such as ensuring they had the support of a staff member of their choice when they needed assistance with personal hygiene. Staff knew people’s different ways of communicating and were seen to treat them with respect. A staff member said that there is always a mixture of male and female staff on duty so that people who use the service can have assistance from people of the same sex. There is a “key” worker system in place giving specific staff responsibilities for specific service users. Staff comments indicated that they had a good knowledge of the needs of people who use the service and how to meet them. Care records included 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 15 sufficient information about peoples health needs for staff to refer to if necessary. For example any specific allergies, manual handling and dietary needs had been recorded. Records also demonstrated when visits to or from health professionals such as dentists’, doctors and chiropodists had taken place. People who use the service looked well cared for. A comment from a relative was that “X is happier and healthier now than at any time previously”. On both files checked there were individual guidelines for staff to follow about any specific needs such as when risks to people’s health and safety had been identified. We have been notified of incidents that have the potential to affect the welfare of people who use the service. We were told of an error, which occurred when staff failed to ensure medication was administered. Steps have been taken to address this issue by ensuring two staff sign an additional record after medication has been taken. There have been no further errors notified to us since. Storage arrangements for medication were satisfactory. The local pharmacist visits the service and advises on the medication systems in place. The most recent report of 15/03/07 did not identify any problems. Records checked and discussion with staff indicated that they had had training prior to being able to administer medication. There are also organisational policies and procedures in place relating to the storage, administration and disposal of medication and protocols in relation to the use of homely remedies. All current service users need assistance from staff with the administration of medicines. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23u. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The robust policies, procedures and practices in place help to ensure that people who use the service are protected. EVIDENCE: The home has a satisfactory complaints procedure, which is available to people in symbol form if necessary. It is included in the information, which is given to people who use the service or their relatives. The manager said no complaints have been received in the past twelve months and records checked also confirmed this. People who use the service looked comfortable and relaxed and were responsive to staff. Records showed that family and other professionals are invited to attend formal reviews, which provide another opportunity for any matters to be raised should anyone have any concerns about the service. In view of the different ways that people use to communicate with staff, they may not easily be able to make any concerns known, however staff said they would rely on their own observations and knowledge of ways in which each person communicates, as well as observing any changes in behaviour to determine their well being. Records and discussion with staff confirmed that all members of staff have received training about safeguarding adults. There are organisational procedures in place to guide staff on what action to take in the event of them having any suspicion of abuse taking place. There is an up to date copy of Lincolnshire County Councils Safeguarding Adults procedure in the home for 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 17 staff to refer to if needed and those staff asked knew of the different forms of abuse that can occur and of their responsibility to report such matters. There are satisfactory arrangements in place for people who wish to have their money or valuables kept safely by in the home and those records checked were accurate and up to date. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 18 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 excellent. This judgement has been made using available evidence including a visit to this service. People live in a safe and comfortable environment that is suitable for their needs. EVIDENCE: All bedrooms were checked on this occasion as well as the lounge, dining kitchen, sensory room, laundry facilities and staff office and guest room. People’s rooms seen were spacious, comfortably and individually furnished and equipment had been provided where needed to assist people. For example, signs are on room doors to help people identify them, and pictures, which people who use the service had created, were on display. All rooms have full en-suite facilities. The home is spacious, well maintained, clean and comfortably furnished and gardens are kept neat and tidy. Some maintenance work was being carried out at the time of the visit and staff comments indicated that generally any matters are attended to promptly. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 19 People who use the service have opportunities to assist in some domestic tasks to increase their independence and receive support from staff to do so, for example with meal preparation. A relative made the comment “It is absolutely the right place for him”. There were records kept of risk assessments, which had been done to identify any risks that the environment may pose to the people who live there. Records showed that they were regularly reviewed, for example the fire safety risk assessment was last reviewed on 31st July 2008. Written information provided prior to the visit confirmed that equipment such as hoists and fire detection and fire fighting equipment had been serviced within the past year. The service has visits periodically from the Environmental Health officer and Fire Safety officer. The last visit from an Environmental Health officer took place on 25th January 2007 when a kitchen safety inspection was carried out. This inspection was satisfactory overall with only a couple of recommendations made. Information provided prior to the visit confirmed that there are policies and procedures in place for staff to refer to, to ensure they know about good hygiene and infection control practices. It was observed that there were stocks of protective equipment available and a staff member was seen to wear protective gloves when assisting a service user with a specific procedure. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a team of staff who have had relevant training and who are employed in sufficient numbers to meet their current needs. EVIDENCE: Both male and female staff members work at the home. This enables people to have some choice as to who undertakes their personal care. On the day of the visit 4 staff were on duty and discussion with them, the manager and rotas checked confirmed that during the day this is the usual staffing level. Where possible two wakeful night staff are on duty, although the manager did say there were occasions such as unplanned sickness of night staff when if unable to cover the vacancy there would be a wakeful staff member and one on the premises who was able to be called to assist if needed. On occasions agency staff cover any shortfalls in staffing, which cannot be covered by the staff team. During this visit an agency staff member was working, who was complimentary about the service provided at 54 Monks Dyke Road. There are 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 21 some staff vacancies but generally there is a consistent staff team. The manager said she worked additionally to the staff rota on the whole. Staff said they felt that 4 staff during the day were sufficient to meet the needs of the people who use the service and to enable some flexibility to meet individual needs. For example on the day of the visit one staff member was out in the community with one of the young people and other staff remained in the home with those at home. With the current staffing levels they felt people who use the service had a choice of whether they participated in activities and leisure interests or not. The recruitment records for two members of staff provided evidence that there is a satisfactory process in place, which includes taking up references, a criminal records bureau and protection of vulnerable adults check prior to staff working in the home. One person’s records were not available as she had transferred from another service within the organisation, and her records had not yet been transferred. The manager has provided written confirmation since the visit to confirm that the same checks as previously stated were carried out prior to her employment with the organisation. Staff said that they received a range of training to assist them to carry out their work including, basic sign language skills, manual handling, medication administration, basic food hygiene, fire safety and safeguarding adults for example and courses are updated periodically. Information provided prior to the visit showed that out of 19 staff 3 had achieved a nationally recognised vocational qualification in care and 6 were working towards it. New employees participate in an induction-training programme over thirteen days. A staff member spoken to said that she found this to be comprehensive and that she had felt competent after it to carry out the duties expected of her. Staff were observed for short periods of time whilst carrying out their work and it was noticed that there was a good rapport with people who use the service and staff were kind and caring. Staff confirmed that they felt well supported by the manager through staff meetings, and formal supervision sessions although there was some variation in how frequently these occurred. The manager said she recognised that she needs to ensure that formal staff supervision sessions occur on a more regular basis. This will help to ensure the service is being well monitored. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 22 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 home is well managed. There are good systems in place to monitor the quality of the service to help ensure the health and welfare of service users. EVIDENCE: Since the last key inspection there has been a change of registered manager. The current manager has completed a registered managers award and is in the process of working to achieve a nationally recognised vocational award in care at level 4. She also confirmed that she attends the same refresher training sessions as the staff team to ensure she is kept up to date. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 23 Staff members said they felt well supported by the manager. It was said that the manager could be called at any time but if unavailable there is an organisational on-call system in place. The manager said she was aware that the frequency of formal staff supervision sessions had lapsed recently and would address this. The manager was also noted to address any matters raised with her on the day promptly, such as ensuring the statement of purpose was amended to show the correct address where we could be contacted. There are various ways that the quality of the service is monitored. For example records were in place to show that a representative of the organisation visits the service on a monthly basis at different times of the day and checks various matters such as care records, complaints and concerns and maintenance issues. In addition records demonstrated there are staff meetings held. Other means that are in place to monitor the service are through quality monitoring systems such as health & safety audits and reviews of people who use the service at which significant people such as funding authorities and relatives are invited to attend as well as the person who uses the service if able. A report of the 6 monthly review of the service undertaken in December 2007 was available and showed that various areas had been identified where improvements could be made for example health, mobility, induction training and support and staff supervision. Information provided prior to the inspection indicated that there are organisational policies and procedures in place relating to health & safety issues and staff knew where to locate these. Of the sample checked on this occasion fire and environmental risk assessments were in place, regular checks were being made of fire alarm systems including the emergency lighting system and records were kept which indicated that a fire drill was held in March 2008. 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 24 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA17 Regulation 16 (2)(i) Requirement Timescale for action 30/09/08 2. YA6 15[2] b & c Mental capacity Act 2007 There must be arrangements in place to ensure cooked meals are served hot to people who use the service unless they request otherwise. This will ensure that people’s choice and wishes are respected and hot meals can be provided flexibly to people who use the service. Care plans must be reviewed and 30/09/08 must take into consideration the Mental Capacity Act 2007 in order to ensure people are not deprived of their rights. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 54 Monks Dyke Road DS0000064051.V369562.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 54 Monks Dyke Road DS0000064051.V369562.R01.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. 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