Care Home: Church Lane (12)

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What the care home does well Overall the inspector believes this to be a well run home, and service users expressed satisfaction with the care and support provided. One said "The staff are very nice, and its nice food." One relative commented, "The staff are so kind, compassionate and caring." Service users have access to a variety of social and leisure activities, including holidays away from the home. The home`s environment is well maintained, and service users have been able to personalise bedrooms to their own tastes. Appropriate steps have been taken to help ensure that service users are safeguarded from the risk of abuse. What has improved since the last inspection? There have been improvements since the last inspection, and the inspector was pleased to note that all eight of the outstanding requirements from the previous inspection were found to have been met. In particular, the administration and recording of medications has improved considerably, and were found to be satisfactory on this occasion. Other improvements include service users now having access to their own bank accounts, and the quality and choice of food offered. What the care home could do better: There are still some issues that must be addressed, and a total of four requirements have been made in this report. The home must ensure that comprehensive risk assessments are in place, and that clear records are maintained of medical appointments. In terms of health and safety, fire alarmsmust be tested at least weekly, and staff must undertake health and safety training as appropriate. CARE HOME ADULTS 18-65 Church Lane (12) 12 Church Lane Walthamstow London E17 9RW Lead Inspector Rob Cole Unannounced Inspection 3rd July 2008 09:10 Church Lane (12) DS0000007273.V366203.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 Church Lane (12) DS0000007273.V366203.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. Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Lane (12) Address 12 Church Lane Walthamstow London E17 9RW 020 8520 0138 020 8520 0138 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) Outward Manager post vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2007 Brief Description of the Service: 12 Church Lane is a purpose built house offering accommodation to six service users with learning disabilities. The home is located in a residential area of Walthamstow in the London Borough of Waltham Forest, close to shops and other local amenities, including transport networks. The home consists of six single bedrooms, one ensuite, and service users share a kitchen, a sitting room, a conservatory and a sensory room, as well as a garden. The home is operated and managed by Outward. Church Lane (12) DS0000007273.V366203.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 inspection took place on the 3/7/08 and was unannounced. The inspector had the opportunity of speaking with service users, staff, and the homes manager was present for much of the inspection. The inspector was able to observe staff in their duties, and their interactions with service users. The inspection also included a tour of the premises and an examination of records and other documents. Prior to the inspection the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. This has been used to help form judgments made within this report, and as part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: There are still some issues that must be addressed, and a total of four requirements have been made in this report. The home must ensure that comprehensive risk assessments are in place, and that clear records are maintained of medical appointments. In terms of health and safety, fire alarms Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 6 must be tested at least weekly, and staff must undertake health and safety training as appropriate. 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. Church Lane (12) DS0000007273.V366203.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 Church Lane (12) DS0000007273.V366203.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): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that prospective service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has both a Statement of Purpose and a Service User Guide in place. The Statement says the aim of the home is “Supporting service users to maximise their potential for independence to live a full and active life.” The Statement is subject to regular review, and includes details of the management and staff team, the organisational structure and of the facilities and services provided by the home. The Service User Guide has been revised since the previous inspection, and has now been produced in a combination of plain English and pictorial format, making it more accessible to service users, and helping to meet needs around equality and diversity issues. The Guide includes details of the physical environment and of the home complaints procedure, and is in line with National Minimum Standards (NMS). Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 9 All service users are issued with a contract/statement of terms and conditions. Contracts have been signed by the service user, and a representative of the home. Contracts include the rights and responsibilities of both parties, and details of fees payable. Two new service users have been admitted to the home since the previous inspection. The inspector checked their records, and there was evidence that pre admission assessments were carried out by the homes management staff. Assessments covered needs around personal care, mobility and equality and diversity issues such as religion. Clear transition plans were in place for the two service users, and these indicated that service users and their relatives were able to visit he home before making a decision as to move in or not. The transition period included overnight stays. Both service users initially moved in on a trial basis, after which a placement review meeting was held, in conjunction with the placing authority. The home has an admissions procedure, which makes clear that prospective service users will be able to visit the home prior to moving in. Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors judgement that service users have a large degree of control over their daily lives, and that they have the opportunity of been involved in the day to day running of the home. EVIDENCE: Care plans are in place for all service users, these are drawn up with the involvement of the service user, their keyworker and the homes manager. Care plans are subject to regular review. All service users also have an annual review in conjunction with their placing authority which feeds into the care planning process. Care plans are generally of a good standard, produced in a combination of written and pictorial form, and signed by the service user to indicate their involvement in the process. Plans include detailed information around needs Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 11 such as personal care and accessing the community, and are in a clear and easily accessible format. Plans cover needs around equality and diversity issues, such as religion and disability, although perhaps more detail could be provided around meeting cultural needs, for example the plans for two service users state “I was born in England and consider my culture to be white British.” But there was no information how the person’s needs are to be met with regard to their culture. A risk assessment has been put in place for each service user, and as with the care plans these have been subject to regular review. However, the quality of risk assessments varies from service user to service user. While some are of a satisfactory standard, others are fairly basic. For example, for one service user, the assessment merely identifies risks from choking and around mobility, although this person has profound learning and physical disabilities. To help enable service users to be able to take risks, and live independent lives, it is required that comprehensive risk assessments are in place, which identify any potential risks, and include strategies to help manage and reduce those risks. Guidelines are in place around managing any challenging behaviours that service users present. Through observation and discussion their was evidence that service users have a large measure of control and choice over their daily lives, for example when to get up and go to bed, and what to wear. Service users are involved in the daily routines around the home, such as cooking, keeping bedrooms tidy and shopping. Service users are involved in the day to day running of the home. For instance, the two service users who recently moved into the home were able to choose the décor for their bedrooms, while it is planned that the home will have a new kitchen fitted soon, and service users have been involved in choosing this. The home has made use of speech and language therapists to work with service users to improve ways of communication, such as the use of objects of reference. This has enabled service users to make more choices for themselves around meals and activities, and helped to meet needs around equalities and diversity issues. The home holds regular service user meetings. Minutes seen by the inspector evidenced that service users are consulted over the running of the home, for example around planning and choosing holiday destinations. Service users are also involved in the running of Outward, the organisation responsible for the home, for instance by sitting on staff recruitment panels. Confidential records are stored securely, staff and service users can access their records as appropriate. The home has a confidentiality policy in place, which makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector judgement that service users are supported to live valued and fulfilling lives, and that they have access to the local community. EVIDENCE: No service users are currently involved in any formal educational or employment opportunities at present. However, one service user informed the inspector that they would like to do some voluntary work in an older persons day service. The manager said they were actively looking into this. There was evidence that service users have routine access to the community. One service user attends a luncheon club, while service users visit various places of worship, including Catholic, Church of England and Spiritualist churches, which helps to meet needs around equality and diversity issues. The Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 13 organisation that runs the home provides various day services and activities, and service users are involved in music groups, gardening and drawing. Two service users went to a music group on the day of inspection, and were recently involved in a production of the musical Greece. Service users have access to community facilities, including banks, shops, markets, cafes and post offices. The home has access to an unmarked vehicle, which service users can use to access the community. Service users have access to a variety of social and leisure activities, both in house and in the community. In house service users have access to television, music, foot spa’s, massages and the home has its own sensory room. One service user informed the inspector that they liked painting, and examples of their paintwork were on display around the home. The home holds occasional parties, and recently held a party to celebrate a service users birthday. They said “I liked my party, I was dancing.” The home arranges various community based social and leisure activities, such as swimming, pubs, restaurants and the theatre. Occasional day trips are arranged, such as to Southend and the London Aquarium. One service user went horse riding on the day of inspection and said “I love going horse riding.” Service users are offered a weeks annual holiday as part of their basic contract price, which they are able to help plan and choose. For instance, one service users wanted to go to Butlins the week a church festival was been held there, and this was arranged. Another service user has said they would like to go to Spain. The home has just managed to obtain a copy of their birth certificate, and are planning on applying for a passport in enable to facilitate the trip to Spain. Records are maintained of menus, and the inspector was pleased to note that the quality of food provided has improved since the last inspection. Menus are individual to each service users, who are able to choose their own meals. Menus indicated that meals are healthy, varied and balanced. One service user commented that “I like the food here.” The kitchen was clean and tidy, and food was stored appropriately. At the previous inspection it was recommended that the home install a new kitchen, in line with the expressed wishes of service users. Although this has not been done, the manager informed the inspector that it has been agreed to install a new kitchen in the near future. Service users spoken to informed the inspector that they were involved in choosing the proposed new kitchen. Church Lane (12) DS0000007273.V366203.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 and 21. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home is able to meet the health and personal care needs of service users. Service users are supported to manage their own personal care as much as possible, and the standard of medication within the home is satisfactory. EVIDENCE: Care plans indicated that service users are supported to manage their own personal care as much as possible. There was evidence that staff aim to promote the privacy and dignity of service users, for instance staff were seen to knock and wait for an answer before entering bedrooms. All service users are registered with a GP. Individual health action plans are in place for service users, at the time of the inspection the home was in the process of re-developing these to help make them more accessible to service users. Plans provided information on how the home was able to meet the Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 15 health needs of service users, for example around exercise, diet and the involvement of health care professionals. However, record keeping around medical appointments was not of a very good standard, and must be improved. For example, a service user saw the GP on the 14.2.08, were it was said that a blood test must be arranged, the manager informed the inspector that they believed that this had been done, but their was no record of it. Again, the manager informed the inspector that all service users had received dental care since the previous inspection, but this was often not recorded. In order to appropriately monitor service users health, and ensure that they have access to health care professionals as appropriate, the home must ensure that clear records are maintained of all medical appointments, including the reason for the appointment and details of any follow up action necessary. The home works with the district nurse to draw up programmes around continence, and used continence products are disposed of appropriately. The home has a comprehensive medication policy in place, and all staff undertake training before they are able to administer medication. Medications are stored in individual locked cabinets inside each bedroom. No service users currently self medicate or are on any controlled drugs. The overall standard of recording and administering of medications has improved since the previous inspection, and was found to be of a satisfactory standard. Records are maintained of medications entering the home and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained, these were found to be accurate and up to date, and information on MAR charts was consistent with information of medication labels. Correction fluid is no longer used on MAR charts. The home has sought and recorded the views of service users on their wishes in the event of their death. The manager informed the inspector that service users would be able to remain in the home with a terminal illness, as long as the home could meet their medical needs. The home has recently experienced the death of both staff and service users, and service users were supported to attend funerals. There was evidence that service users have been provided with the opportunity to discuss any issued they may have around these bereavements. Church Lane (12) DS0000007273.V366203.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home has appropriate safeguards and systems in place to help protect service users from the risk of abuse. EVIDENCE: The home has a complaints procedure in place. All service users have been provided with their own copy, and since the previous inspection a copy of the procedure is now on display within the homes communal areas. The procedure makes reference to the CSCI, and includes timescales for responding to any complaints received. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home also maintains a complaints log, which indicated that complaints received are appropriately investigated. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. This was in line with current legislation. Staff have undertaken training around safeguarding adults, and those spoken to during the inspection demonstrated a good understanding of their roles and responsibilities in this area. The home holds money on behalf of service users in a locked safe. Monies are checked and signed for at the beginning of every shift. Records and receipts Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 17 are maintained of financial transactions involving service users monies, those checked by the inspector were satisfactory. Since the previous inspection, service users now have access to their own bank accounts. Church Lane (12) DS0000007273.V366203.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): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users are provided with adequate private and communal space. EVIDENCE: The home is purpose built, and suitable to meet its stated purpose with regard to the physical environment. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, close to shops, transport links and other local amenities. The home was generally well maintained, both internally and externally, and on the day of inspection was clean and tidy. Fixtures and fittings were well maintained and domestic in character. Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 19 The home’s communal areas consisted of an adapted sensory room, sitting room, kitchen, conservatory, and garden, with appropriate garden furniture. Service users were observed to move freely around communal areas. The home has one shower room and toilet, one bathroom and toilet, and a toilet on its own, and all service users have hand basins in their bedrooms. Both the shower and the bath are adapted and suitable for all service users. All bathrooms had locks on them, and on the day of inspection were clean, tidy and free from offensive odours. All service users have their own bedrooms, one of which is ensuite. On the day of inspection rooms were clean and tidy. The inspector was informed that service users are involved in maintaining their rooms, for example helping to keep them tidy. Bedrooms were personalised to service users individual tastes, with family photographs and personal items on display. Furniture was well maintained, and consisted of wardrobes, chest of draws, table and chairs. Bedrooms meet National Minimum Standards on size requirements, and all had adequate natural light and ventilation. Curtains and bedding were domestic in character and well maintained. Two of the bedrooms have been decorated since the previous inspection. Since the previous inspection one service user has moved from an upstairs bedroom to a downstairs room. They informed the inspector ”I asked to move down stairs, I don’t like to climb the stairs anymore.” The home was purpose built to accommodate people who make use of wheelchairs, with widened corridors and door frames, and all areas of the home are fully accessible to service users. The home has a lift operating between the two floors. There are handrails in place around the home, and grab rails in the toilets and bathrooms. Service users have their own hoists and there was evidence that these are regularly serviced. The home has a call point alarm system in place, which all service users have access to in their bedrooms. The home has a policy on infection control, and protective clothing is available such as disposable aprons and latex gloves. The laundry room is domestic in character, and all service users have their own clothes basket. Washing facilities are appropriate to meet service users needs. Hand washing facilities are situated near to the laundry facilities, and throughout the home. The home has a macerator to dispose of soiled incontinence products, and all COSHH products were stored appropriately. Church Lane (12) DS0000007273.V366203.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): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is staffed in sufficient numbers to meet the needs of service users, and that staff generally have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staff rota on display, this accurately reflected the staffing situation on the day of inspection, and indicated who was in charge of the home at any given time. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and that they have built up good relations with individual service users. Staff were observed to interact with service users in a respectful and friendly manner. Throughout the inspection the inspector noticed examples of positive staff interactions with service users, for example planning days out and supporting a service user who became distressed over the recent death of someone. Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 21 The AQAA supplied by the home indicates that the home has all necessary employment related policies and procedures in place. Staff records are held centrally by the organisation, with the agreement of the CSCI. The home does however keep information on what records are held by the organisation, and these indicated that appropriate employment checks are carried out, including CRB checks and proof of ID. Staff receive regular supervision, either from the homes manager or deputy manager. Written records are maintained of supervision, which staff have access to. Records evidenced discussions around performance and service user issues. All staff undertake a structured induction on commencing working at the home, which includes health and safety and service user issues. The manager informed the inspector that over 50 of care staff employed at the home have achieved a relevant care qualification. Records are maintained of staff training, these evidenced recent training in medication, epilepsy, adult protection and person centred planning. It is planned that staff will undertake training around dementia in the near future. However, records also suggested that not all staff are up to date with health and safety training. For instance one staff has not had food hygiene training for six years, even though they are expected to prepare meals as part of their duties, other staff have not had fire safety training of first aid training in over four years, while some staff have not received any training at all around infection control. In order to help promote the health, safety and welfare of service users and others it is required that all staff undertake all necessary health and safety training as appropriate. Church Lane (12) DS0000007273.V366203.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): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors judgement that this is a generally well run home, with appropriate quality assurance systems in place. EVIDENCE: The home has recently appointed a new manager, who also manages another home run by the same organisation. They have fourteen years experience of working in social care, including nine years in a managerial capacity. They informed the inspector that they have a diploma in management and social care, and that they intend to commence working towards the Registered Managers Award later this year. They also informed the inspector that it was planned that they would apply for registration with the CSCI within the year of Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 23 2008. Staff and service users spoken to said they found the manager to be approachable and accessible, and staff were seen to interact with the manager in a relaxed manner. Record keeping in the home was generally of a good standard. Confidential records are stored securely, and staff and service users can access their records as appropriate. The AQAA supplied by the home indicates that they have all necessary policies and procedures in place. Those checked by the inspector, including medication, adult protection and admissions were all satisfactory and in line with NMS. Service user meetings, staff meetings and care plans reviews all contribute to the quality assurance in the home. The organisation that runs the home issues questionnaires to service users to gain their feedback on the running of the home, and copies of previous inspection reports are available to view in the home. The inspector was pleased to note that since the last inspection monthly Regulation 26 visits are now taking place. Fire extinguishers are situated around the home and were last serviced in July 2007. Fire exits were clearly signed and free from obstruction. Fire alarms were last serviced on the 14/3/08. However, records indicated that the home had not tested its fire alarms since the 31/5/08, more then a month before the date of this inspection. To help ensure the safety of service users and others it is required that fire alarms are tested at least once a week. The home had in date safety certificates for PAT testing, gas safety and electrical installation, and in date employer’s liability insurance cover. Fridge/freezer and hot water temperatures are tested. COSHH products were stored securely. Church Lane (12) DS0000007273.V366203.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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 3 3 3 2 3 Church Lane (12) DS0000007273.V366203.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 YA9 Regulation 13 Requirement The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. The registered person must ensure that clear and comprehensive records are maintained of all medical appointments, including details of whom the appointment was with, the reason for the appointment, and details of any follow up action necessary. The registered person must ensure that staff receive all necessary health and safety training as appropriate. The registered person must ensure that fire alarms in the home are tested at least once a week. Timescale for action 30/09/08 2. YA19 13 31/07/08 3. YA35 18 30/11/08 4. YA42 13 and 23 31/07/08 Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 26 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 Church Lane (12) DS0000007273.V366203.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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