Care Home: 55 Drubbery Lane

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What the care home does well People like living at the service and get on well with the staff. People have good care plans that show people`s needs and how they want then to be met. People also have person centred plans that are full of pictures and show the hopes, wishes and goals of the people that live at the service. Staff work with the people to develop their own plans and they often discuss their care needs and talk about what it is like to live at the service. The staff are very aware of each person`s needs and are aware of how people communicate. Staff promote people`s independence and support people to make choices about their life. People have good accommodation. People have made their bedrooms their own with lots of personal belongings. The service`s communal areas are decorated in a domestic way and provide comfortable accommodation. The service is fully accessible to people that use wheelchairs.The service has a robust recruitment process. All of Mencap`s staff have the checks that are required before they start work. Staff have training to do their job. The service checks the service to make sure that it is giving people a service that meets their needs. As part of this the views of the people that live there and the views of relatives are gathered. The service has a plan to make the service better. What has improved since the last inspection? Since the last time we visited the service there have been some improvements. The radiators that could harm people are now covered. Staff are now taking part in fire drills to make sure they know what to do if there is a fire. Also the service has plans about how to support each person if they have to leave the service in an emergency. The service has also addressed most of the recommendations we made. What the care home could do better: Although the service is providing good outcomes for the people that live there the service needs to make sure that it increases the number of permanent staff. At the moment the service is using a lot of agency staff and they are not able to do all the tasks that permanent staff can do. This has meant that staffing cannot be used flexibly to cover busy times and people cannot go out as much as they used to. We also made some recommendations that could improve the service. CARE HOME ADULTS 18-65 55 Drubbery Lane 55 Drubbery lane Blurton Stoke on Trent Staffordshire ST3 4BH Lead Inspector Jane Capron Key Unannounced Inspection 1st April 2008 09:30 55 Drubbery Lane DS0000008245.V361245.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 55 Drubbery Lane DS0000008245.V361245.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. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 55 Drubbery Lane Address 55 Drubbery lane Blurton Stoke on Trent Staffordshire ST3 4BH 01782 311324 F/P 01782 311324 h6026@mencap.org 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) Royal Mencap Society Mrs Julie Hawley Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 Brief Description of the Service: 55 Drubbery Lane is registered to provide care for 5 adults with learning disabilities and associated physical disabilities, although the current design and usage is suitable only to accommodate 3 people in single bedrooms (there were previously 2 double bedrooms). The future of the service is now certain until at least March 2009. There are currently 3 service users; two have lived at Drubbery Lane since it opened 15 years ago. The service is managed by the Mencap Homes Foundation. The service is a spacious and carefully adapted bungalow situated in extensive grounds. All 3 service users have wheelchairs for mobility and all areas of the service and grounds are easily accessible. The service is situated in a residential area with good access to all main towns. 2 people-carriers adapted for wheelchair users are available. There are 3 spacious bedrooms one has large en-suite facility, all have adequate space for wheelchair use, hoist etc. There is a large lounge/dining area overlooking the garden. There is a communal bathroom with assisted facility and separate toilet areas. There is a large kitchen area, a laundry and office accommodation. Furniture, fittings and equipment are to a generally high standard. 55 Drubbery Lane DS0000008245.V361245.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 This inspection took pace over a one-day period and the service did not know we were visiting. The inspection included discussions with the people that live there, staff and the manager. Before we visited the service we sent surveys to relatives, people that lived there and health and social care staff to gain their views about the service. The service sent us a document called an annual quality assurance assessment (AQAA). This documents gives the service the opportunity to tell us what they are doing well and where they feel they can make the service better. During the inspection we looked at the care people are getting and whether people are provided with choice about their lives and are supported to do as much for themselves as possible. We looked at whether the service is listening to people and keeping them safe by looking at how they recruit and train staff, by looking at the number of staff available to support people and whether staff are aware of the care people need. Since the last inspection there have been no complaints. We have visited the service as part of the process to consider deregistering the service although this did not occur. What the service does well: People like living at the service and get on well with the staff. People have good care plans that show people’s needs and how they want then to be met. People also have person centred plans that are full of pictures and show the hopes, wishes and goals of the people that live at the service. Staff work with the people to develop their own plans and they often discuss their care needs and talk about what it is like to live at the service. The staff are very aware of each person’s needs and are aware of how people communicate. Staff promote people’s independence and support people to make choices about their life. People have good accommodation. People have made their bedrooms their own with lots of personal belongings. The service’s communal areas are decorated in a domestic way and provide comfortable accommodation. The service is fully accessible to people that use wheelchairs. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 6 The service has a robust recruitment process. All of Mencap’s staff have the checks that are required before they start work. Staff have training to do their job. The service checks the service to make sure that it is giving people a service that meets their needs. As part of this the views of the people that live there and the views of relatives are gathered. The service has a plan to make the service better. 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. 55 Drubbery Lane DS0000008245.V361245.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 55 Drubbery Lane DS0000008245.V361245.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): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with information about the service so that they know what to expect if they live there. Prior to moving to the service people’s needs are assessed therefore making sure that the service can meet their needs. EVIDENCE: People living at the service are provided with information about what the service provides. This is provided in easy read and pictorial format. Copies of the Service user guide are present on people’s files. The information does not contain information about the fees. One person spoken to said that they had been given information about the service before they moved there and had visited beforehand to decide whether they wanted to live there. Although no one has moved to the service for several years the service’s admission process includes the completion of an assessment of people’s needs. We saw copies of assessments completed prior to the current people moving to the service and we are aware that assessments have been completed to consider people’s future care needs. People living at the service were involved in the assessment process and were supported by advocates to make sure their views were heard. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service has a clear support planning process that includes the wishes and gaols of the people living at the service and the information needed to meet people’s needs. The service supports people to make decisions about their lives and to be involved in running the service. EVIDENCE: Case tracking shows that people living at the service have support plans and Person Centred Plans. The support plans contain the information needed by staff to provide people with the support in the way they wish. They cover personal care and health care needs and social care needs. The Person Centred Plans are full of pictures and give a comprehensive view of the person including their social history, their daily routine, likes and dislikes and their hopes and wishes for the future. Short term and longer terms goals are identified. Plans are developed with the person concerned through regular meetings and reviews. Plans belong to the person and are kept in their 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 10 bedroom. One person told us that they talked to their key worker about their care and the things they wanted to do. We also saw the service manages risks. Risk assessments are developed and are updated and reviewed when situations change. These cover such areas as managing money, mobility, bathing, use of vehicles and the use of wheelchairs. Assessments are in place to cover such practices as straps to make sure that people are safe in wheelchairs. People are encouraged and supported to make choices about their lives. A survey from one of the people living there said that they are provided with choices about what they did. One person also told us they have choice over going to bed and getting up. They said ‘ I go when I am tired’ and ‘I get up when I want and tell staff if I don’t want to get up yet’. We talked to staff about how they promote people’s choices and they are aware of how each individual is able to express their likes and dislikes and methods of supporting people in decision making. Methods include showing people different foods and showing people leaflets of theatre shows and pictures of holiday places as a way to help them make choices. Staff are also aware of people’s non-verbal means of communicating their likes and dislikes, for example pushing food away and the use of facial expressions. One person also told us that staff take them shopping to choose new clothes and to buy their own toiletries. People living at the service are supported to participate in helping to run the service. They are involved in staff meetings, fire drills and we saw photographs showing them cooking, baking and helping to clean their bedrooms. People’s views of the service are sought during meetings with their key worker. People are also involved in recruiting staff to the service. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 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 take part in activities of their choice although there is scope for this to be further developed. People are supported to maintain and develop relationships. The service meets the dietary needs of the people that live there providing them with a varied menu based upon their choices. EVIDENCE: Everyone at the service is attending a day centre one day a week undertaking such activities as art and crafts, dance and taking part in trips out of the centre. One person attends college twice a week taking part in floristry, gardening and basic skills. This person told us how they enjoy college and meeting the friends they have there. They also said that the service is having a greenhouse so that they can start growing plants. People’s plans identify the activities people enjoy and each person has a daily schedule showing the type of activities that should take place and a record showing the actual activities that have taken place. Records also show that 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 12 the service consults people about the thing they want to do. Although the staff try to make sure that activities are provided the current staffing situation, relying on relief and agency staff does not always make this possible. However people do undertake some activities both in and out of the service. There are trips out to for example the theatre, shopping, bowling, meals out and day trips out to places like Chester Zoo. People also go out with staff to do the food shopping, go to the bank to draw out their money, pay their rent and go shopping for personal items including clothes. In the service the staff support people to do arts and crafts and there are pictures on the wall they have done. People also have their own televisions and faculties to play music. The service also supports people to be as independent as possible supporting them to do baking, help with preparing meals and with keeping their bedroom clean. People go on holiday and last year they went to Derbyshire. This year discussions are taking place with each person to decide where they wish to go and which staff they would like to support them. The service has its own transport that the people living at the service contribute towards. The service promotes inclusion and the human rights of people living there supporting people to access local resources, supporting one person to exercise their right to vote, supporting one person to attend a local church and promoting the use of advocates. The manager works with the local authority to promote access to public facilities for people with disabilities. People tell us they are encouraged and supported to maintain and develop the type of relationships they want with family and friends. Visitors are able to see people in the communal areas or in their bedroom depending on the person’s choice. Friends are encouraged to visit and one person told us that they had a meal with a friend recently. This person also said that they are supported to telephone and write to their relative. In order to try and reestablish a relationship for one person the service placed an advert in a newspaper. There is a relaxed atmosphere at the service and routines are quite flexible in line with the wishes and needs of the people living there. Times for getting up and going to bed are up to the individual person. There are no set mealtimes and people tell us that there is always a choice of food. The records show that at times all the people living there have different meals. People can spend time in their room or in the communal areas and all areas of the service are wheelchair accessible. The service involves the people that live there in developing the menus making sure that their preferences are taken account of whilst trying to provide people with a healthy diet. Meal times are flexible and breakfast is taken when people get up. Breakfast is a choice of cereals, toast and fruit with hot and cold drinks. The main meal is in the early evening and includes a main course and pudding. Lunch tends to be a lighter meal such as soup, cheese on toast 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 13 or sandwiches followed by fruit or yoghurts. People are able to have a choice of meal and records show that at times all the people living there have different meals. The service takes account of people’s dietary needs and involves a dietician if needed. People’s independence in eating is promoted through the use of non-slip mats, spoons rather that forks if necessary and cutting up food if needed. We saw that meals time are a social time when people living there and staff eat and chat together. 55 Drubbery Lane DS0000008245.V361245.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): 18,19/20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care provided is based on each person’s individual needs and these needs are met in partnership with the person concerned and through multidisciplinary working. The service’s medication practices are making sure people receive the medication they need. EVIDENCE: Support plans and person centred plans identify the health and personal needs of the people that live at the service. Plans and records demonstrate that people are involved in issues about their personal care needs including how they want this care to be provided. Records of one to one meetings show discussions over such issues as hoisting methods. One person said that the staff meet their needs and listen to what they want when undertaking personal care tasks. People’s oral and hair care needs are met. People either went to the hairdresser or a hairdresser visited them in the service. One person told us that they are supported to choose their own clothes and go out with staff to buy new clothes. There is evidence of people going to the dentist and we saw that people have toothbrushes and toothpaste in their bedroom. Observation showed that staff are sensitive to people’s personal care needs and respond to them sensitively and ensure that people’s privacy and dignity is respected. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 15 The General Practitioner’s in the responses to our surveys felt that the service respected people’s privacy and dignity. People at the service have access to regular chiropody, and to the optician. People are supported to access the doctor when they are ill and records confirm that staff are alert to any deterioration in people’s medical conditions and ensure that people receive medical support appropriately. The service supported people to access specialist health care services including psychiatrists, physiotherapists, and Occupational Therapists. There are procedures in place to monitor people’s weight and this is generally well maintained. However we would recommend that where this cannot be undertaken they discuss with people if there are ways to achieve this as significant weight changes may indicate the need for medical intervention. The responses to our survey of the General Practitioners were positive. They felt that the service was meeting people’s healthcare needs. The service’s medication is making sure that people receive the medication that is prescribed. There is a medication procedure in place and people living at the service have medication reviews. The service uses a monitored dosage system. Medication is kept securely and there is a system in place to record medication received and returned ensuring that the system can be audited and monitored. We watched the service’s process for administering medication and this is being completed appropriately. The staff member undertaking this was aware of their responsibilities and of the correct procedures. Medication Administration Records are completed correctly and an explanation provided when medication is not administered. Staff are aware of each person’s medication and the reasons for it. Information about possible side effects is recorded as well as a protocol for administering PRN medication. A homely remedies policy is in place and is signed by the doctor. One of the people living at the service has difficulty swallowing and arrangements are in place for them to have their medication in a liquid form. One person is having a vitamin supplement and the details of this need always to be fully recorded on the Medication Administration Records. 55 Drubbery Lane DS0000008245.V361245.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): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People that live at the service are supported to express their wishes and to have their views acted upon. The staff’s knowledge and practices are making sure they are protected. EVIDENCE: The service listens to the views of people that live there. Regular one to one meetings are held with each person to ascertain their views of the service, to identify any concerns and to discuss their care. The service’s complaints procedure is provided in a number of formats including on audiotape and in pictures. As well as the service’s own complaints procedure it provides people with the procedures for the local authority and the CSCI. Due to some specialist communication needs the service involves advocates to support people to express their views and advocates were involved when the service was recently being considered for closure. Also staff are aware of how people express upset and distress non verbally. Discussions with 2 people living at the service told us that they know how to complain. Since the last inspection no complaints have been received. The service has a safeguarding and whistle blowing procedure and staff have received training to understand these procedures. The staff we spoke to are aware of safeguarding issues and able to describe possible symptoms of abuse and know how to refer an incident. They are aware that incidents of aggression can be a person’s method of communicating that something is wrong. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 17 The service has procedures in place to safeguard people’s money. Support plans show the level of support people need to manage their money. Everyone has a bank account. People’s money is securely stored. One person told us that they always go to the bank to draw out their money and go out to pay their rent and to buy personal items. A check on one person’s money confirm that an accurate record is being kept and that receipts are obtained for expenditure. 55 Drubbery Lane DS0000008245.V361245.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): 24,26,27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service provides people with safe, well maintained and comfortable accommodation. EVIDENCE: The home is single storey building located in a service residential area of Blurton in Stoke-on-Trent. It is indistinguishable from other domestic properties in area. Externally there is a large rear garden with sitting areas and provision for parking at the front. The service has suitable communal areas for the people living there having a large lounge/ dining room and a domestic style kitchen. Bedrooms are of a good size with one being extremely large. They provide good private accommodation. Bedrooms have suitable storage area and are decorated in a modern style and have wooden floors making them easy for wheelchair use. One bedroom has ensuite facilities. The service also has a bathroom with an 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 19 assisted bath and a separate toilet. All areas of the service are wheelchair accessible. The service is clean and tidy throughout and there are cleaning schedules in place. The service is suitably heated and the radiators that previously could have caused a risk had been covered. The service has a small laundry area that is adequate for the service’s laundry needs. There are infection control procedures in place but the service needs to make sure that written documentation clearly identifies the temperature that is needed to launder soiled linen. People living at the service have equipment to aid their independence and to support staff with moving and handling. The service is expecting two new electric hoists. Corridors were wide enough to accommodate wheelchairs. All the people living at the service have been provided with suitable wheelchairs although one person is awaiting an electric wheelchair that will increase their independence. 55 Drubbery Lane DS0000008245.V361245.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): 32,33,34 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service needs to reduce its reliance of agency staff so that people receive a consistent service and there is more opportunity to use staff flexibly to meet people’s needs. The service’s recruitment of permanent staff is robust and provides people with protection. EVIDENCE: The service provides adequate staffing levels to meet people’s needs. 2 staff are on duty throughout the day and 2 staff on duty overnight one of which is a waking staff member. However due to the uncertainty over the future of the service last year a number of staff have left the service. This has resulted in the service needing to rely on agency staff. Although the service has tried to ensure that there is consistent agency staff these staff cannot undertake the full tasks required. This situation has reduced the opportunities for people to access the community and has meant that the service has not been able to use staff flexibly. Sampling of staff files shows that the service has a robust recruitment procedure. All the required staff checks were completed including obtaining 2 references and a Criminal Records check. The agency staff used are obtained 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 21 through Mencap’s relief bank of staff and the manager confirmed that Mencap made sure these people had the necessary employment checks and training. We would recommend that the manager obtain information herself to confirm that these checks have been undertaken. The service supports staff to be trained and gain the knowledge needed to support the people that live there. Staff undertake induction training when they start work and complete a range of relevant training. More than 50 of the permanent staff have completed NVQ training. 55 Drubbery Lane DS0000008245.V361245.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): 37,38,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is well led in the interests of the people that live there. EVIDENCE: The manager has been in post several years and has now completed a management qualification but still needs to complete her level 4 care qualification. She has the knowledge and skills to effectively manage the service. She promotes the rights of the people living there and is working with the council to promote access rights for people with a disability. Staff report that she is supportive and listens to their views and the views of the people that live there. She is reported to have an open management style. There are systems in place to monitor and develop the service. Monthly visits are completed by the Area Service Manager and the manager undertakes a 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 23 range of monthly audits. These cover such areas as Health and Safety, care planning, risk management, medication and the environment. Yearly surveys take place of relatives and people that live there to ascertain their views. This process could be developed to include the views of other professionals that have contact with the service. Health and safety procedures are in place. The service has fire risk assessments and is undertaking regular fire checks. The service has also responded to the recommendations made by the fire service. Staff are trained in areas of Health and Safety including fire, moving and handling, food safety and first aid. The service undertakes a range of other checks to maintain a safe environment. 55 Drubbery Lane DS0000008245.V361245.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 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 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 25 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 Requirement The home needs to reduce the use of agency staff so that people have a more consistent service and that staff can be are used more flexibly to meet people’s needs. 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. 2. 3. 4. Refer to Standard YA14 YA20 YA20 YA40 Good Practice Recommendations The service should provide people with more activities so that they have a more varied lifestyle. Staff should work with people to support them to have their weight monitored as changes in weight may indicate the need for medical intervention. All details of medication should be recorded on Medication Administration Records so that the likelihood of errors is reduced. Further efforts should be made to produce relevant policies and procedures in a format that service users can easily understand. The service must have evidence that agency staff have the DS0000008245.V361245.R01.S.doc Version 5.2 Page 26 5. YA34 55 Drubbery Lane 6. YA30 required employment checks to make sure that people are protected. The laundry procedures should clearly state the temperature required to wash soiled laundry. This will reduce the likelihood of the spread of infections. 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 55 Drubbery Lane DS0000008245.V361245.R01.S.doc Version 5.2 Page 28 - 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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