Care Home: 6 Albion Terrace

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What the care home does well What has improved since the last inspection? The home had confirmation that the building work, to convert one large bedroom into two separate rooms, had been approved by building control and the fire service. The woodwork, on the outside of the building, had been repaired and painted. Four bedrooms had been redecorated to the person`s choice. The second floor kitchen that had peeling wallpaper and the lounge, on that floor, had dampness on the ceiling/wall in the corner of the room. The lounge had been redecorated and the kitchen was in the process of being decorated. The laundry wall had peeling paintwork and that had also been decorated, as had the chipped paintwork of some doorframes. A shower had been renovated and an old boiler had been replaced. The home had bought new furniture, for both lounges and the dining room. New carpets had been fitted in a lounge and three bedrooms. New cupboards had been fitted in a kitchen. There was a larger television that had `freeview`. The back garden had been improved but was not quite finished. There was an attractive `decked` area that had accessible seating and new lighting had been installed. What the care home could do better: The home must have a registered manager, so that the home meets the registration requirements. The planned quality assurance and quality monitoring system should be put into practice, so that people are involved with the improvements and developments of the service. CARE HOME ADULTS 18-65 6 Albion Terrace Strathallen Saltburn-by-Sea TS12 1JN Lead Inspector Brenda Grant Key Unannounced Inspection 15 January & 25th February 2008 09:20 th 6 Albion Terrace DS0000000124.V356903.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 6 Albion Terrace DS0000000124.V356903.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. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 6 Albion Terrace Address Strathallen Saltburn-by-Sea TS12 1JN 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) 01287 622813 M C Independent Care Initiatives Position Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th February 2007 Brief Description of the Service: Situated in the centre of Saltburn, 6 Albion Terrace is a three-storey Victorian terraced house in keeping with other properties in the area. It is close to local shops and has easy access to bus services and the railway station. There are nine single bedrooms that do not have en-suite facilities but bedrooms have a hand wash basin. There is an enclosed private garden to the back of the home, it has an attractive ‘decked’ area that has accessible seating. Strathallen is registered to provide accommodation for 9 people with a learning disability. The fees, at the time of the inspection, range from £398.27 to £713 per week. The fee depends on a person’s individual assessed needs. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment that had been completed by the manager and we carried out three visits to the home. On the first visit there was no one at the home. Therefore the ‘site’ visits took place over two days, five hours and twenty minutes in total. Discussion and observation took place with three people who used the service, three staff, and the manager. We looked around the home as well as examining a number of records which included those for: people who used the service and staff files, health and safety and maintenance checks, complaints, accidents and medication. The findings from the inspection were of the manager and staff providing a good care service, creating a comfortable, homely atmosphere and making every effort to meet the people’s needs. What the service does well: The acting manager and staff worked well to deliver a caring service that benefited the people who lived at 6 Albion Terrace. People enjoyed living the lifestyle they chose and they were supported in a way they preferred. People were treated as individuals. The manager and staff encouraged people to be independent and staff gave suitable support, when it was needed. One person told us, “I like living here. I can do everything I want to and I like cooking and keeping my room tidy”. There was a good relationship between people who worked and lived at the home. One service user commented about the staff, “They are all nice”. Management and staff were obviously enthusiastic with all aspects of their work and they clearly enjoyed caring for the service users. In surveys, comments from people who used the service were: • “I like it here” • “I go to college and it is what I want” • “My family and social worker found me this place. I came to stay for a few days and I liked it”. In surveys, comments from people’s relatives were: • “My son/daughter has improved his/her ability to communicate and has widened his/her experiences in life” 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 6 • • • “People live their lives as they choose and there is support for people to live independently” “Staff have a positive attitude” “My son/daughter always seems to have things to do whether it is social events or going to college to learn new skills”. In surveys, comments from social workers and a health professional were: • “Healthcare needs are closely monitored and there is good liaison with health professionals” • “The home provides pro-active support” • “The residents needs, wishes and wants are always the most important aspect to the staff team” • “The home treats each individual with a sense of friendship and kindness”. What has improved since the last inspection? The home had confirmation that the building work, to convert one large bedroom into two separate rooms, had been approved by building control and the fire service. The woodwork, on the outside of the building, had been repaired and painted. Four bedrooms had been redecorated to the person’s choice. The second floor kitchen that had peeling wallpaper and the lounge, on that floor, had dampness on the ceiling/wall in the corner of the room. The lounge had been redecorated and the kitchen was in the process of being decorated. The laundry wall had peeling paintwork and that had also been decorated, as had the chipped paintwork of some doorframes. A shower had been renovated and an old boiler had been replaced. The home had bought new furniture, for both lounges and the dining room. New carpets had been fitted in a lounge and three bedrooms. New cupboards had been fitted in a kitchen. There was a larger television that had ‘freeview’. The back garden had been improved but was not quite finished. There was an attractive ‘decked’ area that had accessible seating and new lighting had been installed. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 7 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. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 The individual aspirations and needs, of people who use the care service, are assessed before they are admitted to the home. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The manager informed us that all people who used the care service had assessments before they were admitted to the home. We examined a sample of people’s files. They contained assessment documentation that included details of health and social care needs and the person’s likes and dislikes. There were also Risk Assessments, detailing how risk would be managed. The assessments included people’s views, showing that they were fully involved with the assessment process. In a survey a person informed us, ‘My family and social worker found me this home’ and continued with, ‘I went to stay for a few days and liked it’. In surveys, eight people told us, they had information about the home and they visited 6 Albion Terrace before moving in. All eight people confirmed, they were asked if they wanted to live at the home. The Annual Quality Assurance Assessment gave information that admissions were planned. There was a full ‘introductory programme’ which would assist the person with 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 10 preparing to move to the home. A record was kept of all visits and over night stays and Care Plans were started at this point. A representative from the home also visited people in their work placements, to find out extra information and the person’s likes and dislikes. In a survey, a Care Manager informed us, ‘The home has assessments before anyone is admitted’. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 11 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): Standards: 6, 7 & 9 The home has individual Care Plans for each person and the plans are regularly reviewed. The plans contain Risk Assessments that include how risks are managed. People’s files inform how they are supported and assisted with making decisions and living their lives independently, within their capabilities. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: A sample of Care Plans was examined. They had details about each person’s care needs, how people wanted to live their lives and their likes and dislikes. The Annual Quality Assurance Assessment informed us, individuals were provided day care packages that reflected the person’s needs, aspirations and goals. People were given the opportunity to voice their opinions, preferences, wants and wishes and their views were recorded in the Care Plans. In a survey a member of staff told us, ‘The resident’s needs, wishes and wants are always 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 12 the most important aspect to the staff team’. Care Plans had evidence that people were involved with, and agreed with, the plans. Care Plans also included Risk Assessments, which gave information about how risks would be managed, to minimise risks to an acceptable level. In a survey a member of staff informed us, “There are always Risk Assessments and action plans” and another member of staff wrote, “Individuals can choose what they want to do within the restrictions of the Risk Assessments”. Risk Assessments were discussed with individuals, to make sure they understood the measures that were being taken to make sure their safety was maintained. The Risk Assessments and Care Plans, we looked at, had been regularly reviewed and updated. Staff said, they supported people with making decisions about their lives and staff assisted individuals with contacting an independent advocate, when it was needed. People we spoke with confirmed, they decided what they wanted to do each day and a relative wrote, ‘People live their lives as they choose’. Staff told us, people were supported with managing and spending their own money, within the limitations that were recorded in Care Plans. The home kept a record and receipts of all transactions of people’s money. The manager told us, there was one person who looked after his/her own money. S/he told us, “I look after my own money and I spend it on the things I want”. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 13 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 Staff appropriately support and care for people who use the care service. People are offered choices of daily activities and individuals can live their lives as they wish. People have a varied and healthy diet and mealtimes are enjoyable. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The Annual Quality Assurance Assessment informed us, people were involved with external groups and classes, such as bowling, table tennis, gym, college courses, special Olympics and Gateway Club. There were also opportunities for people to go to leisure centres and drop-in centres, to assist in development and occupation of the individual. Staff told us, the home found out about people’s interests, and staff tried to find appropriate day 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 14 placements and activities for each individual. On the first day of the ‘site’ visits, to the home, staff were supporting individuals at their day placements and other people went shopping with staff, there was no one at the home. On the next visit, seven residents were at their day placements and one person was going to an afternoon cooking class. The food was to be brought home for tea. One person did not go to day placements but s/he enjoyed various activities, in and outside of the home. In a survey a person told us, ‘I have been going to classes to help me communicate better’ and another person informed us, ‘I like to go to college, it is good’. The Annual Quality Assurance Assessment stated that people were supported with having an independent lifestyle’ and the home offered people choices about how their care was carried out and individuals had choices with their daily life and activities. In surveys, comments from relatives were: • “S/he enjoys a full and active life” • “My relative always seems to have things to do, whether it is social events or going to college to learn new skills” • “The home is taking steps towards our relative becoming independent which we originally did not think possible” • “I know s/he is happy and well looked after”. One person told us, s/he had a part-time job that s/he enjoyed. The manager told us, there was another person who had a job and the home was supporting someone else with finding part-time employment. The manager and staff told us, people enjoy using local facilities, such as going to the shops, pubs, churches and cafes. Individuals were also supported with going to places out of the town, by means of local public transport (bus or train), taxis and the home’s car. In a survey, a relative wrote, “The home has helped with widening his/her life experiences” and, “S/he appears to be very content”. Staff told us, people were supported with keeping links with families and friends. In surveys, relatives wrote, “There is lots of contact with the home and families” and, “Staff always keep relatives informed”. The manager told us, visitors were encouraged to come to the home and people were supported with visiting their families and friends. A relative told us, ‘We get a warm welcome when we visit’. People chose how to spend their days but they were encouraged with helping to do every day jobs around the home. The home had certain routines and there were rotas, for laundry and cooking. People were supported with carrying out those tasks as well as making sure their bedrooms were clean and tidy. A relative complimented the home for “having good routines” and another relative told us, the routines helped “People to live independently” and, “Residents were able to develop every day living skills”. One person told us, “I get the bus to go to work and I have a front door key and a key for my room”. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 15 The Annual Quality Assurance Assessment informed us, people’s dietary needs and choices were well catered for. People were supported to be involved with menu planning and cooking meals. One person told us, “I am good at cooking and I like doing it”. Staff told us that people enjoyed shopping for their own food. People who went out for the day were usually provided with a packed lunch and those who stayed at home had a light lunch, as the main cooked meal was early evening. Staff encouraged everyone to have a healthy eating plan and the home had asked a Dietician for advice about menus. The menus, that were examined, confirmed people had a varied diet. The home had a good stock of fresh, frozen, tinned and dried foods. Kitchen records included: fridge and freezer temperatures and a cleaning rota. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 16 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): Standards: 18, 19 & 20 There is satisfactory support for health and personal care and there is suitable recording of medicines. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The sample of files that we looked at showed people were appropriately supported with personal and healthcare needs. All care needs were recorded and there was information how those needs would be met. Staff told us, “The home always put resident’s health and well-being before anything else”. In the main, people could manage their own personal care but sometimes staff needed to give prompts. Staff told us, they made sure people’s privacy and dignity was respected at all times. People chose their own clothes and their appearance reflected their personality. A relative of a person informed us, “Residents are supported with independence and control of their lives, so they can move on”. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 17 The manager told us, people were supported with their healthcare arrangements. The Annual Quality Assurance Assessment informed us, all people had Health Action Plans that detailed each person’s healthcare needs. There was documentation for all healthcare appointments and details of the reason and outcome and if any further appointments were needed. Care Plans were updated when necessary. There were records of each person’s dental, optical and other healthcare related checks. The manager told us, when people needed specialist healthcare services the home made sure appropriate referrals were made and followed through. At the time of the inspection there was no one who needed specialist equipment. In a survey a relative wrote, “Some health related problems have improved due to staff giving regular prompts” and a Care Manager told us, “Healthcare needs are closely monitored and there is good liaison with healthcare professionals”. A healthcare professional commented, “The home always asks for advice when it is needed”. We looked at records of medicines. Medication Administration Records had signatures of the staff who had administered the medicine. Staff records confirmed staff had completed training for safe handling of medicines. There was a satisfactory lockable facility for storing medicines. The home carried out a Risk Assessment, to determine if people would be able to take control of their own medication. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 18 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): Standards: 22 & 23 People are confident their views are listened to and they are protected from abuse, neglect and self-harm. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The home had a Complaints Procedure that was shared with people who used the service and their families. A relative confirmed s/he had been given information about how to make a complaint. The home also had the Complaints Procedure as a picture version, so that people could more easily understand the procedure. The procedure informed people the expected timescale for when a complainant would expect to receive a response. Staff told us that people were regularly asked, during meetings, if they had any complaints. During the past 12 months there had been one complaint. The complaint’s record had all details of; the complaint, how it was investigated, the outcome and if the complainant was satisfied with the outcome. The home had received two written compliments that included comments of: “we appreciate the care and efforts you took” and, “the hard work and care put in by you and your staff”. Another person wrote, “I have really enjoyed being here and sad to go. Thank you”. The home had policies, procedures and practice guidance, ‘No Secrets’, for safeguarding adults. Staff had completed training for the protection of vulnerable adults. The home had planned for staff to update their safeguarding 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 19 training. We spoke with a member of staff who told us, s/he was aware of the guidelines and s/he had completed training, for the protection of adults. Staff also said, “We respond quickly when concerns are raised”. The home had a satisfactory record of finances that were held on people’s behalf. There was a suitable lockable storage facility for all monies. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 20 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): Standards: 24 & 30 The home environment is homely, comfortable and safe. Repairs and maintenance work is carried out. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: People lived in a very homely environment. There had been many improvements since the last inspection. A large double room had been divided into two single bedrooms, allowing for all people to have a bedroom of their own. The outside woodwork had been painted. There were new carpets in a lounge and three bedrooms. The home had bought new furniture for both lounges and there was a larger television that had ‘freeview’. A shower had been renovated and an old heating boiler had been replaced. Four bedrooms had been redecorated to the person’s choice. We saw that each bedroom had the personal belongings and each room was differently furnished and decorated. People were offered a key for their bedroom door. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 21 The back garden had been improved but was not quite finished. There was an attractive ‘decked’ area that had accessible seating and new lighting had been installed. Further improvements had been made after the first ‘site’ visit. The second floor kitchen that had peeling wallpaper and the lounge, on that floor, had dampness on the ceiling/wall in the corner of the room. The lounge had been redecorated and the kitchen was in the process of being decorated. The kitchen had new units and there was new dining furniture, in the ground floor dining room. The laundry wall had peeling paintwork and that had also been decorated, as had the chipped paintwork of some doorframes. The home had an annual maintenance programme and a log of all maintenance that had taken place. There was plenty of space for people to move around inside the home. People were seen freely moving around all communal areas. The premise was clean, tidy and free from offensive odours. In surveys, eight people who used the service informed us, the home was always clean and tidy. People were supported to carry out some cleaning jobs but most cleaning tasks were carried out by domestic and care staff. There was a daily cleaning rota, to make sure the home was kept clean. In surveys, relatives comments about the home were: • “The home is clean, hygienic, homely, comfortable and safe” • “The home has good standards of hygiene and clothes are washed and ironed” • “They provide a homely atmosphere” • “There is a warm and caring environment”. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 22 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): Standards: 32, 34 & 35 People are protected and supported by the home’s recruitment procedures and staff are appropriately trained to care for the people at the home. Staff benefit from one to one supervision, at least six times yearly. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: Staff files had records confirming that staff had completed the required basic training. Each member of staff had their own ‘training and development plan’ that was regularly reviewed. The manager informed us, she had arranged for some staff training in the coming months. Seven care staff had successfully achieved National Vocational Qualifications Level 2, in care, two staff had gained Level 3 and one person had achieved Level 4. There was also one staff working towards gaining Level 2 and two staff working towards gaining Level 3 of the qualification. Most staff had completed training for Equality & Diversity and awareness of the Mental Capacity Act. Staff had completed extra training so they had greater awareness and knowledge of people’s specific needs. Staff 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 23 told us, “We are involved when there are new training courses”. In a survey, a relative’s comment about the staff was, ‘Staff have a positive attitude’. People who used the service were supported and protected by the home’s recruitment policy. A sample of staff files were examined, they confirmed new staff had the appropriate Criminal Bureau checks and references before they started work. The sample of staff’s records showed that staff had regular one to one supervision with the manager. One staff told us, ‘We have regular one to one catch-ups’. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 24 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): Standards: 37, 39 & 42 People benefit from a well run home and they are included with developments and changes that take place. The health, safety and welfare of people who use the service, and staff, are promoted and protected. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The home did not have a registered manager but the acting manager had experience of running a care home. She had completed training for the Registered Manager’s Award and the National Vocational Qualification Level 4, as well as gaining other relevant qualifications. Two staff we spoke with said, they were always well supported by the home’s manager. A relative told us, ‘The home is well managed in all respects’. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 25 The home had developed a quality assurance system. People who use the service, their relatives and others are to be asked to give their views about the home. The acting manager told us, external agencies, including the Commission for Social Care Inspection, had recently carried out surveys therefore the she intends to carry out the home’s survey later this year. The survey information will be gathered together into a report and will be used in the home’s annual development plan. The home had regular meetings with the people who used the service and staff. The meetings were an opportunity for people to comment on the running of the home. The home had carried out monitoring checks and audits of the service. A number of health and safety records were examined for: fire, portable appliance tests, water temperatures and accidents. Documentation confirmed there were regular monitoring checks and health and safety maintenance work was carried out. 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 26 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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 27 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 YA37 Regulation 8 Requirement The home must have a registered manager, so that the home meets the registration requirements. The planned quality assurance and quality monitoring system should be put into practice, so that people are involved with the developments of the service. Timescale for action 30/06/08 2. YA39 24 31/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 6 Albion Terrace DS0000000124.V356903.R01.S.doc Version 5.2 Page 29 - 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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