Care Home: Allport Road (136a)

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What the care home does well The service is very good at ensuring that those who use the service have their needs summarised in a plan of care, which is detailed and as a result ensure that their needs are met. Those who use the service benefit from being able to make decisions about their daily lives and future aspirations. The service is very good at ensuring that risks faced by individuals in their daily lives are taken into consideration and acted upon so that they may experience a quality of life in a safe manner. Those who use the service are able to have their self-esteem increased by the significant provision of education and occupation as well as leisure pursuits by the service. Individuals are able to maintain contact with family and friends to ensure that they are not socially isolated. Those who use the service have their rights respected by the practices of the agency and are entirely involved in the planning and preparation of meals.Those who use the service are supported in a manner by staff that is in line with their wishes and takes their dignity into account. The health needs of individuals are met through the practices of the agency. The health and safety of individuals is maintained by the safe management of medication systems, which takes the independence of individuals into account. Those who use the service are able to influence the support provided to them with the provision of a clear complaints procedure provided to them by the agency. Individuals are protected from abuse through the training provided to staff, the policies and procedures made available and the thorough recruitment process for staff. Individuals have their self worth enhanced by the provision of a comfortable and hygienic environment. Those who use the service have their needs met through the provision of training for staff. Those who use the service benefit from having the staff team managed by an experienced individual who provides consistency of management. Those who use the service are able to influence the support they are provided with through the quality assurance system adopted by the organisation. What has improved since the last inspection? The service has now ensured that the decorative issues in relation to the seating provided in the home and the exterior terrace area have been addressed to ensure that the self-esteem of individuals is maintained. What the care home could do better: The service must ensure that fire-fighting appliances are serviced within the required timescale so that the health and safety of all is fully promoted. A number of good practice recommendations are also included within this report. CARE HOME ADULTS 18-65 Allport Road (136a) 136a Allport Road Bromborough Wirral CH62 6BB Lead Inspector Mr Paul Kenyon Unannounced Inspection 19th August 2008 14:30 Allport Road (136a) DS0000018966.V370399.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 Allport Road (136a) DS0000018966.V370399.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. Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allport Road (136a) Address 136a Allport Road Bromborough Wirral CH62 6BB 0151 201 6657 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) jane.roberts@wirral.autistic.org Wirral Autistic Society Phillip Hatton (Acting) Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only adults (aged 18 - 64 years) who have a learning disability may be accommodated. 29th August 2006 Date of last inspection Brief Description of the Service: This home is a first floor, two storey flat above a shop in Bromborough. The flat is reached via an external stairway and terrace at the rear of the building. The shop is part of a small shopping parade about a mile from Bromborough Village and a short walk from the New Chester Road. It is close to bus and rail routes to Birkenhead, Eastham and beyond. The home is registered for two people and has three bedrooms - one of which is used as a staff sleep in room and office. The flat also has a kitchen, bathroom and a spacious lounge/diner. There were two residents in occupation at the time of the site visit. The Registered Manager has gone on a period of extended leave and Phillip Hatton currently manages the service in an acting capacity. The Wirral Autistic Society operates the service. Fees charged at present range from £940.15 to £968.62. Allport Road (136a) DS0000018966.V370399.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 the people who use this service experience Good quality outcomes. This visit was a key inspection held during the inspection year (April 2008 to March 2009). Some notice of the visit was given to ensure that those who use the service and staff would be available. A separate visit to examine training and personnel records was made prior to the visit to the service. National Minimum Standards for Younger Adults were used to measure the quality of support provided to the service. The inspection included a tour of the premises, an examination of a number of records relating to the support provided, and interviews with staff, one service user and the Acting Manager. Comments about the experience of these individuals are included within this report. The communication abilities of those who use the service was such that the experience of one individual could be verbally expressed to the Inspector while observations of care practice in relation to the other individual were used to make judgements on the level of support provided. What the service does well: The service is very good at ensuring that those who use the service have their needs summarised in a plan of care, which is detailed and as a result ensure that their needs are met. Those who use the service benefit from being able to make decisions about their daily lives and future aspirations. The service is very good at ensuring that risks faced by individuals in their daily lives are taken into consideration and acted upon so that they may experience a quality of life in a safe manner. Those who use the service are able to have their self-esteem increased by the significant provision of education and occupation as well as leisure pursuits by the service. Individuals are able to maintain contact with family and friends to ensure that they are not socially isolated. Those who use the service have their rights respected by the practices of the agency and are entirely involved in the planning and preparation of meals. Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 6 Those who use the service are supported in a manner by staff that is in line with their wishes and takes their dignity into account. The health needs of individuals are met through the practices of the agency. The health and safety of individuals is maintained by the safe management of medication systems, which takes the independence of individuals into account. Those who use the service are able to influence the support provided to them with the provision of a clear complaints procedure provided to them by the agency. Individuals are protected from abuse through the training provided to staff, the policies and procedures made available and the thorough recruitment process for staff. Individuals have their self worth enhanced by the provision of a comfortable and hygienic environment. Those who use the service have their needs met through the provision of training for staff. Those who use the service benefit from having the staff team managed by an experienced individual who provides consistency of management. Those who use the service are able to influence the support they are provided with through the quality assurance system adopted by the organisation. 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. Allport Road (136a) DS0000018966.V370399.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 Allport Road (136a) DS0000018966.V370399.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who come to live at Allport Road have benefited in the past from having their needs taken into account through the assessment process so that their needs can be met. EVIDENCE: Two individuals live at Allport Road. Both have lived there for a number of years. As a result this standard relating to assessment could not be measured. Previous inspections have noted that the assessment process to identify the needs of individuals has been satisfactory. Allport Road (136a) DS0000018966.V370399.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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Those who use the service have their needs summarised in a care plan, which is very detailed and covered all aspects of their personal lives. This enables individuals to have a good quality of life. Those who use the service are able make significant decisions about their lives which enhances their self esteem yet any risks associated with this are taken into account in order to keep individuals safe from harm. EVIDENCE: Two care plans were examined relating to both individuals using the service. A staff interview was held and this noted that staff were aware of the location and how care plans are used as part of the support provided to individuals. Care plans are detailed and include a range of information relating to each person. This information included a pen picture, general assessment information, reference to the religion and ethnic background of the individual, a communication assessment, nutritional needs, levels of family support, a Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 10 behaviour management plan, health action plan, preferred daily routines and levels of social interaction skills. The profile and routines showed evidence of consultation with those who use the service and an interview with one service user noted that he was able to confirm the contents of the care plan. All care plans are subject to an annual review, which includes the individual, family and social worker acting as advocates. In between this there is a care plan review, which is held every six months. One review was held earlier in August 2008. Care plans are detailed and cover all aspects of the life of individuals. An interview with one individual living at Allport Road concluded that they considered that they were able to make decisions about their life and this was evidenced through his preferred routines as well as his routines in relation to cooking and domestic tasks. The individual is in control of his finances and finances of the other individual are administered in using a system of recording and receipts, which offers a degree of accountability. Individuals can access all monies at all times. Meetings are held with those who use the service and minutes available. A decision making form has been devised, which is reviewed and agreed by the individual and their representatives. This form relates to meals, finances, accessing the wider community, staying at home, reviews and the holding of keys. All decision-making statements are retained within care plans. Risk assessments for both individuals were examined. These related to those activities which are unique to each person, for example, holidays, managing their behaviour, financial support, accessing the community independently, using transport, levels of staff support and environmental risks in the building, for example fire risks. One risk assessment had been reviewed in February 2008 and the other again earlier in the year. Both risk assessments in turn made reference to the behavioural management strategies in place for each person including triggers and interventions needed as well as staff training through the use of the nonviolent crisis intervention training. In cases where risk is identified, there was evidence that actions to minimise risk are in place without limiting the aspirations of the individual to participate in a particular activity. Allport Road (136a) DS0000018966.V370399.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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from having both educational and occupational opportunities and leisure in the wider community either independently or with staff support and this enables their self-esteem and self worth to be sustained and enhanced. All individuals benefit from having continued contact with their families and have their rights respected. Individuals who use the service are able to fully plan and prepare meals. EVIDENCE: Examination of records noted that during the weekday, both individuals attend local day services. One individual confirmed that he enjoyed this. Timetables relating to this are in place and suggested that the day service content was varied and reflected the wishes of individuals. Activities included work placements and education and for another individual, work placements, access to local college and day services. One person is able to access these services himself while the other is reliant on staff to assist with transport. Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 12 Preferred leisure activities for both individuals are in place and are noted in care plans. One person has identified his preferred leisure activities identified and is reliant on staff supervision to be able to achieve this. There was evidence that this occurs and that decision making in preferred activities is provided to the individual. The other individual is more independent in leisure activities and will pursue these weekly as a matter of routine. The same individual has been able to be involved in an activity which has seen him have significant community contact with a great deal of success in this activity. The risks faced by this person in these activities are taken into account by use of his own mobile telephone and regular staff contact. Included within the care plan is a decision making document which outlines a number of issues including the desired level of contact from family members as well as the method of contact. Both service users do not originate from the local area with the result that families cannot always easily visit them. All individuals have contact with family and this is outlined in care plans. Contact is made by occasional visit, telephone or through the post. One individual to have support in maintaining contact with their family and this is recorded within their behaviour management plan. The level of contact with others was confirmed through interview with one individual. In addition to this, this person received a call from a family member during the visit. The person had the option while using the service’s cordless telephone to speak in private but choose not to. Staff respect the privacy of individuals in relation to their bedroom and this was evidenced through the inspector’s request to view bedrooms. A key is offered for bedrooms and other areas but decisions made by those who use the service to hold a key or not is included within the decision making form and both individuals have declined to have keys. The preferred form of address is included within each care plan. One person has had their Christian name shortened and the individual agrees with this. Staff interaction with those who use the service was noted to be respectful and significant during the visit yet relaxed and informal. One person was noted to have his own routine and preferred his own company for a while and this was accepted and respected by staff. All individuals have unrestricted access to all parts of the home with no one requires any assistance aids at present. Food provided is determined entirely by the two individuals. Care plans suggested that no one had special nutritional needs yet information was present on healthy eating and this was also available in the kitchen for reference by all. One the day of the visit, one individual cooked an evening meal by himself with no support. An interview with this person noted that they had their own routines for cooking and their own methods for cooking. The Inspector was invited to have tea and the individual prepared all aspects of the meal with minimal assistance needed by staff. A staff member did state that occasionally an advice was needed with the preparation of meals. The other Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 13 individual has the chance to prepare meals yet staff support is needed. Local shops are used for the purchase of foodstuffs. A dining room is available and both staff and individuals had the meal together. No one has any cultural requirements in relation to food yet the individual who cooked did have a set routine for preparation and discussed this with the Inspector at length. The meal was unhurried and relaxed and no one requires assistance with eating at present. Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service have their self-esteem maintained through the support they receive and have their health maintained through the practices of staff. The management of medication is safe which in turn promotes the well being of those who use the service EVIDENCE: An interview with one individual concluded that they were happy with the manner in which they were supported by staff. One person needs more support than the other in terms of supervision. This is included within the person’s care plan. Support in general tends to be emotional as opposed to direct intimate personal care and again this is reflected in both care plans. No one has mobility problems and rules are in place for smoking and the consumption of alcohol. Those who use the service able to express their sexuality and they maintain their appearance is in line with their preferences. Staff interactions with service users are positive, significant and respectful with an emphasis on a relaxed and informal style and this was observed during the inspection. Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 15 An interview with one service user concluded that they were ‘glad’ they had access to his General Practitioner and receives checkups from a number of health care professionals. This was reflected in his health care action plan and the same was noted for other person. The health action plan outlines the level of support required by each person in respect of health appointments. Records are maintained to suggest that visits are recorded and outcomes noted. Appointments of late have included: Doctor visits, Opticians, chiropody, attendance at a well man clinic and dentist. One person needs support with dentistry and this was included in both his care plan and health action plan. Medication reviews also take place. Medication is stored in a purpose built cabinet and is dispensed by the pharmacy in blister packs with prescribed controlled medication stored and appropriate stock level checks are maintained with these. Homely medications are provided and this is reinforced by a homely remedy policy and recording procedure. Medication training is provided and a member of staff as well as training records confirmed this. All medication administration records are appropriately completed and these include receipt as well as disposal records. One person self medicates. They confirmed that they have a lockable cabinet in which to store this. A risk assessment is in place but a disclaimer from service user confirming the arrangements is dated from 2003. It is recommended that this be updated. This person is happy with the arrangements with self-medication. Lists of prescribed medication are available in care plans and there is evidence of regular Doctor medication reviews. Allport Road (136a) DS0000018966.V370399.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 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from having the information they need to make a complaint and as a result have their views taken into account. Those who use the service are protected from abuse through the policies and procedures of the service as well as training provided to staff. EVIDENCE: An interview with one service user noted that he was clear who he would talk to if he had a complaint but has none at present. A complaints procedure is in place but contains reference to previous regulator and its address details. It is recommended that this be changed. No complaints have been received by the service or the Commission for Social Care Inspection. Complaints records as a result are not completed. A Local Authority protection of vulnerable adults procedure is in place as well as the agency’s own instructing staff on action to take in the event of an allegation being made. An interview with a member of staff confirmed that they have received protection of vulnerable adult training and is aware of the whistle blowing procedure. Financial guidelines are in place placing restrictions on staff in relation to the financial interests of the service users. No allegations of abuse have been received by with the service or the Commission For Social Care Inspection since the last key inspection. Training is provided to staff on non-violent crisis intervention and this places an emphasis on the prevention of aggressive behaviours and was confirmed by training records and in interviews Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 17 with staff. Policies are in place relating to the use of physical intervention as well as the dealing with incidents of aggression either physical or verbal. Behaviour management plans are in place including the triggers to certain behaviours and the means for staff to intervene. An interview with person stated that he felt safe living at Allport road. When incidents do occur, they are documented. Allport Road (136a) DS0000018966.V370399.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 good. This judgement has been made using available evidence including a visit to this service. Those who live at Allport Road benefit from living in a comfortable and hygienic environment. This in turn enhances their self-esteem. EVIDENCE: A tour of the premises internally and externally was undertaken. Access to the building is via a gate, which then has stairs leading to a terrace and front door. A doorbell is available for use by visitors. The terrace area contains seats and potted plants. A requirement raised at the last key inspection relating to the structural soundness of the terrace had been met. It was noted that there was an accumulation of surface water on the terrace following recent rainfall. It is recommended that action be taken to minimise this. The exterior of the building is well maintained and it is not identifiable as a care home given that it is in keeping with the local community. The interior of the building contains lounge/diner, kitchen, two bedrooms and an office as well as bathroom/toilet. Some decorative issues to the interior of the building were noted but at Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 19 present they are cosmetic in nature and do not adversely impact on the quality of life of individuals. One individual interview stated that they were happy with the decoration and facilities in the building. Furniture is of good quality and no issues raised in this inspection. Bedrooms were viewed with permission. These were noted to be personalised and reflected the interests of individuals. Maintenance staff are available and the Acting Manager reported that the response time to repair requests was good. Maintenance requisition slips are available and noted that repairs are responded to. Staff are responsible for maintaining the hygiene of the home through domestic tasks and a rota evidenced this. In addition to this there is an expectation that those who live there are expected to participate and this was confirmed. No offensive odours were noted and infection control training had been given to staff. It was noted that a washing machine is included within the kitchen where food is prepared. It is recommended that guidelines be given to staff when laundering clothes to ensure the maintaining of hygiene standards in the home. Allport Road (136a) DS0000018966.V370399.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): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service are supported by staff who have been recruited appropriately which in turn enables individuals to be protected from abuse. Those who use the service have their needs met through the training programme provided to the staff that support them. EVIDENCE: Three personnel files were examined as part of the inspection. All included appropriate checks and complied with regulations and National Minimum Standards. Records showed evidence of checks, references, application forms, identity of staff and training. All records are securely locked and are stored in the main office of the Wirral Autistic Society who runs the service at Allport Road. An induction process is in place for staff. A future training plan was made available and this included training for 2008 such as, Non violent crisis intervention, Deafness Awareness, Health and Safety, Manual Handling, First Aid, Communication, Autism Awareness, Adult Protection, Food Hygiene, Drug Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 21 Administration, Epilepsy and general induction. The service has access to training areas within the organisation’s premises. Inductions have bee undertaken by all staff at Allport Road and this includes a period where general orientation to the service is made but also training in mandatory topics as well as issues relating to Non Violent Interventions, Autism, Protection of Vulnerable Adults, Fire Awareness, Medication Administration and Epilepsy. Training received by staff includes all of the above as well as Equal Opportunities and training in Behaviour Management. Allport Road (136a) DS0000018966.V370399.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. Those who use the service benefit from having an experienced individual managing the support they receive. Their views are taken into account and this enables them to influence the support provided. Health and safety systems promote their well-being. EVIDENCE: The Registered Manager is on special leave and this is for a twelve-month period. The Commission for Social Care Inspection have been informed of this development. A meeting with the proposed Registered Manager was held during the site visit. He has remained with the company for nine years and during the past two years has held managerial positions. He is applying to the Commission for Social Care Inspection to become the registered manager. The Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 23 intended previous manager’s absence was made known to the Commission for Social Care Inspection and a smooth transition in managerial arrangements appears to have occurred. Quality assurance is done annually by the wider organisation and surveys are sent to service users and their families. These are then returned to the organisation and general points are fed back to the staff team. An interview with one person who uses the service confirmed this. The staff team cooperated fully with the inspector during the visit enabling records to be examined and the general environment to be viewed. The Inspector was also able to speak to those who use the service in private. All previous requirements from the last key inspection have been addressed. Health and safety training is provided to staff and this was confirmed through the staff interview and the examination of training records. A fire system is in place with fire drills held on a weekly basis as well as tests to fire alarms and emergency lighting. A fire risk assessment is in place and fire procedures are also available. One fire extinguisher has not been serviced in over twelve months. This is raised as a requirement. A process is in place for the reporting of incidents under health and safety legislation and accident books are maintained and correctly completed. In relation to substances hazardous to health, no significant substances are kept in the building, any that are locked up and a reminder is available to staff in relation to the safe use of such products through risk assessments. The central heating boiler regulates water temperatures. Window restrictors are in place in bedrooms and these are checked weekly as evidenced through records. General risk assessments are in place for all tasks carried out within the service and these were reviewed in April 2008. There is only one member of staff on duty and a lone worker policy is in place to reflect this as well as confirmation that the Acting Manager is available if needed at all times. All utility certificates such as electrical wiring and gas are up to date. Portable appliances have been recently tested. There are no hoists or specialist equipment in the building. Allport Road (136a) DS0000018966.V370399.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Allport Road (136a) DS0000018966.V370399.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 YA42 Regulation 23 Requirement The Registered Person must ensure that fire-fighting equipment is serviced within a twelve-month period to ensure the health and safety of those who use the service and staff. Timescale for action 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The individual who self-administers medication should have their risk assessment relating to this updated to ensure that this practice is still safe in order to promote the individual’s health and safety. The contact details of the Commission for Social Care Inspection should be updated to ensure that all stakeholder are able to have any complaints they have investigated appropriately Action should be taken to prevent the accumulation of surface water on the exterior terrace area so that the DS0000018966.V370399.R01.S.doc Version 5.2 Page 26 2. YA22 3. YA24 Allport Road (136a) 4. YA30 health and safety of all is promoted. Written guidance should be provided to staff to ensure that infection control is maintained given the location of laundry appliances within the kitchen in order to promote the health and safety of all. Allport Road (136a) DS0000018966.V370399.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection NW Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Allport Road (136a) DS0000018966.V370399.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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