Care Home: Companion In Care

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What the care home does well At least one bedroom is well over the minimum size standard. It is also expected that if measurements are provided it could be confirmed that other bedrooms and communal areas also exceed the minimum standard. The home has a good record of supporting service users in a way that reduces the incidence of relapse. Although a requirement has been set for 50% of staff to have a NVQ2, The organisation provides this training to all of its staff. This could mean that the home could maintain a higher level of qualified staff more consistently than if it only aimed for the required 50%. The water temperatures are controlled by thermostatic mixer valves and actual temperatures tested daily. The Standards state consideration of this should be based on risk and so this is normally only required where there is a risk of scalding due to the service users condition, e.g. for all under 8s, and people with conditions like dementia or a physical disability that would stop them sensing overly hot water or stop them moving out of its way in time. As there are no service users currently at risk from scalding due to their condition, this practice is seen as good practice. What has improved since the last inspection? There have been a number of improvements to the environment since the last inspection, and these are as follows: The communal lounge has been redecorated. The hallway walls have been redecorated. The communal kitchen diner have been redecorated. The loose floorboard on the upper landing has been repaired. The wall in the front garden has been repaired. The manager has ensured that the service user with a rug in his room can open his door properly. Routine maintenance and repairs are now being attended to more promptly. Service users have confirmed that they were consulted and involved in the decisions about the recent decoration of the home. The home now has more clearly laid out individual care plans on service users` files which show how their needs are being reviewed and met. This helps staff know all a service user`s needs and changing needs and how to meet them. The medication policy has also be revised to cover self-medication and service users who are partially or fully self-medicating now only do so within a risk assessment framework. This reduces the risk of medication being taken inconsistently or inappropriately. The Registered Manager has reviewed with service users the range of entertainment available in the home. As a result digital TV and a new stereo music system has been provided. The manager has explored and recorded the service users` wishes and feelings around both death and the consequences of ageing. This ensures future preferences are known. The home has reviewed its adult protection policy to include guidance for support staff on action to be taken if they have adult protection concerns. Staffing levels are now regularly reviewed to better reflect service users` cultural needs. This has been done by rotating some staff from the organisation`s sister home to ensure that there are some staff from a similar culture to the service users at the home. The home`s recruitment policy has been revisited to clearly state that it will obtain its own enhanced level Criminal Records Bureau check for all new employees. In addition the home`s own CRBs have now been acquired for staff. This protects the service users better by ensuring fuller vetting of staff. The home now records evidence to show that all new staff have completed an induction. This creates a more skilled workforce. What has improved since the last inspection continued.... Staff now receive supervision at least six times per year. This provides a better supervised workforce. The home has developed its quality assurance process to obtain the views of professionals, service users` families and other stakeholders. Potentially hazardous cleaning materials are now kept securely in a lockable metal cupboard in the garden. This better protects service users from dangerous chemicals and fire. The Registered Person has ensured that an up to date Portable Appliance Testing certificate is obtained for the home. This promotes better safety for portable appliances. What the care home could do better: The home should ensure that the now booked adult protection refresher training occurs on time as planned. The stairway carpets need to be cleaned or replaced. The outcome of the quality assurance process should be recorded and made available to stakeholders so that they can monitor mprovents in quality. 50% of staff should have a NVQ2 or above to provide a better trained workforce. CARE HOME ADULTS 18-65 Companion In Care 495 Barking Road Plaistow London E13 8PS Lead Inspector Barry Khabbazi Unannounced Inspection 25th February 2008 10:00 Companion In Care DS0000043729.V358695.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 Companion In Care DS0000043729.V358695.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. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Companion In Care Address 495 Barking Road Plaistow London E13 8PS 0208 586 5712 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) companionincare@hotmail.com Companion In Care Ltd Ms Monica Makoni Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: Companion in Care is a residential home for 3 service users diagnosed as having a mental disorder. The home is 24 hour staffed, with sleeping night cover. In addition to the manager, 2 support workers are in post and a regular bank support worker also covers shifts at the unit. The property comprises three bedrooms, a kitchen diner, a lounge, a bathroom, shower room and a staff office/sleeping area. There is a small yard to the rear of the property. There is unrestricted parking in a residential road to the rear of the property. The home is located on main road on the Plaistow/Canning Town border. There is easy access to local shops and local bus routes. Companion In Care DS0000043729.V358695.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 meand that people who use this service experience good quality outcomes. This inspection was unannounced. During this inspection the Director, Manager, and one support worker were interviewed. Both the current service users were met. Records, policies, care plans and the building were examined. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. An improvement in standards was observed at this inspection. The previous inspection report contained 18 requirements. 15 of these previous requirements have now either been met or no longer apply. Two others were part met and only one remains unmet. The two part met requirements contained multiple requirements within them. These have been re-written to reflect the remaining elements needed. One new requirement for 50 of staff to have a NVQ2 was set at this inspection. Service users have commented that they are happy living in the home and that the food is good and they were consulted and involved in the recent decoration of the home. What the service does well: At least one bedroom is well over the minimum size standard. It is also expected that if measurements are provided it could be confirmed that other bedrooms and communal areas also exceed the minimum standard. The home has a good record of supporting service users in a way that reduces the incidence of relapse. Although a requirement has been set for 50 of staff to have a NVQ2, The organisation provides this training to all of its staff. This could mean that the home could maintain a higher level of qualified staff more consistently than if it only aimed for the required 50 . The water temperatures are controlled by thermostatic mixer valves and actual temperatures tested daily. The Standards state consideration of this should be based on risk and so this is normally only required where there is a risk of scalding due to the service users condition, e.g. for all under 8s, and people with conditions like dementia or a physical disability that would stop them sensing overly hot water or stop them moving out of its way in time. As there are no service users currently at risk from scalding due to their condition, this practice is seen as good practice. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? There have been a number of improvements to the environment since the last inspection, and these are as follows: The communal lounge has been redecorated. The hallway walls have been redecorated. The communal kitchen diner have been redecorated. The loose floorboard on the upper landing has been repaired. The wall in the front garden has been repaired. The manager has ensured that the service user with a rug in his room can open his door properly. Routine maintenance and repairs are now being attended to more promptly. Service users have confirmed that they were consulted and involved in the decisions about the recent decoration of the home. The home now has more clearly laid out individual care plans on service users’ files which show how their needs are being reviewed and met. This helps staff know all a service user’s needs and changing needs and how to meet them. The medication policy has also be revised to cover self-medication and service users who are partially or fully self-medicating now only do so within a risk assessment framework. This reduces the risk of medication being taken inconsistently or inappropriately. The Registered Manager has reviewed with service users the range of entertainment available in the home. As a result digital TV and a new stereo music system has been provided. The manager has explored and recorded the service users’ wishes and feelings around both death and the consequences of ageing. This ensures future preferences are known. The home has reviewed its adult protection policy to include guidance for support staff on action to be taken if they have adult protection concerns. Staffing levels are now regularly reviewed to better reflect service users’ cultural needs. This has been done by rotating some staff from the organisation’s sister home to ensure that there are some staff from a similar culture to the service users at the home. The home’s recruitment policy has been revisited to clearly state that it will obtain its own enhanced level Criminal Records Bureau check for all new employees. In addition the home’s own CRBs have now been acquired for staff. This protects the service users better by ensuring fuller vetting of staff. The home now records evidence to show that all new staff have completed an induction. This creates a more skilled workforce. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection continued…. Staff now receive supervision at least six times per year. This provides a better supervised workforce. The home has developed its quality assurance process to obtain the views of professionals, service users’ families and other stakeholders. Potentially hazardous cleaning materials are now kept securely in a lockable metal cupboard in the garden. This better protects service users from dangerous chemicals and fire. The Registered Person has ensured that an up to date Portable Appliance Testing certificate is obtained for the home. This promotes better safety for portable appliances. 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. Companion In Care DS0000043729.V358695.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 Companion In Care DS0000043729.V358695.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; Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: There had been no new admissions since the last inspection. It was therefore not possible to assess Standard 2 at this inspection. However it was assessed as met at the last inspection and the overall rating for the group was Good. This rating will remain until this area can be reassessed following the admission of a new service user. The previous inspection report contained the following requirement under Standard 3: The manager and provider must demonstrate by clearly laid out individual care plans on service users’ files, how their needs are being reviewed and met. The last inspection report recorded that ‘Each of the service users personal files sampled evidenced that there is a clearly laid out individual plan that addresses how service users needs are to be met and dates for review.’ This was also the case at this inspection. As this has been consistently the case over two inspections this requirement is met. Companion In Care DS0000043729.V358695.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): Standards 6, 7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ assessed needs, changing needs and how the home meets these needs are recorded. This supports the home’s ability to meet and show how it has met all a resident’s known needs. Service users make decisions about their lives with support where needed. The service users are generally well and safely supported to take risks as a part of independent living. EVIDENCE: Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 11 All service users have an individual plan of care that is signed by service user, and reviewed at least every six months. See also Standard 3 for further information. Service users are supported to manage their own finances, and details of the support required are detailed in their individual plan. The previous inspection report stated that at that time, ‘one service user told the Inspector that with support, they had been able to save several hundred pounds that they hoped to use in move on accommodation in the future.’ The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of services through, regular house meetings, individual discussions with their key workers, and involvement in the quality assurance system for the home. See also standard 39 for Quality assurance. This involvement was confirmed by service users who said they were fully consulted and involved in the decisions about the recent decoration of the home. All service users’ files contained risk assessments that had been regularly reviewed. The last inspection report contained the following requirement under Standard 9: Service users who are partially or fully self-medicating must do so within a risk assessment framework. Risk assessments have now been produced for this and are supported by a now updated connected policy. {see also Standard 20}. This requirement is now met. Companion In Care DS0000043729.V358695.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): Standards 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity for self-development, are part of the local community and are able to take part in appropriate activities. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised. The food provided is sufficient in quantity, and it is sufficiently nutritious. This is important to ensure good health. EVIDENCE: Discussions with service users confirmed that there were a suitable range of activities provided at this home. The community is well used and service users were observed accessing the community freely during this inspection. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 13 Service users are currently involved in a range of activities including attendance at a gym and keep fit group, playing pool in a local club, attending support groups, contact with family, a meal and drink out with staff and other service users. Key working sessions are held approximately once per month. At these sessions a range of issues are discussed including activities inside and outside of the home such as outings, day centres and employment. Service users meetings are also used for discussions with service users regarding activities they may be interested in individually or as joint days out. The last inspection report contained the following requirement: The Registered Manager should review with service users the range of entertainment available in the home, including the provision of digital TV and the repair of the home’s CD player. The home has consulted service users and now provided digital TV and a new stereo CD player. This requirement is now met. Service users are supported to develop and maintain independent living skills, for example maintaining their own bedrooms and joining staff on shopping trips. The daily routines and house rules do generally promote independence and choice. Meals, for example, can be taken where and when service users want, and they go to bed and get up when they want. This is done within the context of supporting service users to attend appointments and other commitments. Service users can receive visitors and are supported to visit relatives and friends where they wish. Service users choose their own meals and prepare a shopping list, and prepare their own food. Where required service users receive support from staff with this process. Records of meals offered were seen and these demonstrated that a variety of food was offered and that service users can choose the meal they would like to prepare. Service users are also able to choose where and when to eat, and whether to eat alone or in company. Companion In Care DS0000043729.V358695.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): Standards 18, 19, 20 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal support needs and emotional health needs are met by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users’ medication is also well managed to ensure maximised good health. Service users’ wishes regarding aging and death are now recorded to ensure they are known and acted upon. EVIDENCE: The service users accommodated in the home are able to attend to their personal care needs with staff offering verbal prompting as and when required. Timings for support with care are flexible. Consistency and continuity is achieved through designated key workers. Residents are supported to attend regular health checks, outpatient appointments and other medical appointments as required. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 15 The last inspection report contained the following requirement under Standard 18: Appropriate professionals (Occupational Therapist) must assess the service user who has brain injury and physical disability, for aids and adaptations. This service user has now left this home and no other service users in this situation are currently accommodated. This requirement is therefore no longer applicable and is withdrawn. The home is reminded however, that should a similar placement be made in the future, an Occupational Therapist assessment for aids and adaptations will be expected to be in place. Medication records were examined and were in order. Residents administer their own medication subject to risk assessment. {see also Standard 9} Medication is stored securely in a lockable cabinet fixed to the wall Medication profiles were present with a list of possible side effects and medication administration records were complete. The last inspection report contained the following requirement under Standard 20: {see also the now met connected previous requirement under Standard 9}. The current medication policy must be revised to adequately cover selfmedication. This policy was examined and had indeed been updated to include a procedure for self medication. This requirement is now met. The last inspection report contained the following requirement under Standard 21: The manager must develop a procedure to explore service users’ wishes and feelings around both death and the consequences of ageing. A procedure has been developed and this information has been sought and recorded. This requirement is therefore also now met. Companion In Care DS0000043729.V358695.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): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel their views are listened to and acted upon. The home’s policies and procedures relevant to this Standard generally facilitate protecting service users from abuse. EVIDENCE: The home has a complaints procedure that meets all the elements of this Standard including a minimum response time of less than 28 days {20 in this case} and details of how to contact the Commission, and holds a record of outcomes of complaints. There had been no complaints since the last inspection. This meets the elements of the complaints standard. It is suggested only, that widening the complaints procedure to include concerns, complaints and compliments may improve the system further by allowing service users to raise minor concerns that they do not want to record as an official complaint. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 17 The last report recorded the following under the protection standard: ‘The adult protection policy includes definitions of the different types of abuse service users may experience and possible indicators staff should watch for. The policy includes guidance for the manager and includes reporting to the placing authority, the local adult protection officer and the Commission for Social Care Inspection. The policy also makes reference to the homes whistle blowing policy. The Inspector noted however that the policy does not include a procedure for staff to follow if they have adult protection concerns, or advise what staff should do if an allegation is made against the manager.’ The following double requirement was set at that time: ‘The home must review its adult protection policy to include guidance for support staff on action to be taken if they have adult protection concerns. All staff must receive adult protection training at the time of their induction, and refresher training at regular intervals.’ The adult protection policy had been updated to include guidance for support staff on action to be taken if they have adult protection concerns and this section of the requirement is therefore met. Although adult protection training and refresher training had been booked for this June it obviously had not occurred yet. To reflect the parts of the requirement that have been met the requirement will be currently seen as met and the following new recommendation will be set: The home should ensure that the now booked adult protection refresher training occurs on time as planned. Companion In Care DS0000043729.V358695.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. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. The home is generally hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: At least one bedroom is well over the minimum size standard. It is also expected that if measurements are provided it could be confirmed that other bedrooms and communal areas also exceed the minimum standard. The communal lounge would benefit from redecoration. This is a restated requirement. The previous target of the 01/06/06 was not met. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 19 There was a 7 part multiple requirement in the last report. 6 of the areas identified have now been addressed. See below for details. 1, The hallway walls should be redecorated. This had occurred and the service users said they had been consulted. This section has been met. 2, The communal kitchen diner should be redecorated. This had occurred and the service users said they had been consulted. This section has been met. 3, The loose floorboard on the upper landing must be repaired. This had been repaired. This section has been met. 4, The manager must ensure that the service user with a rug in his room can open his door properly. This had been addressed. This section has been met. 5, The wall in the front garden must be repaired to an appropriate standard. This had been repaired This section has been met. 6, Routine maintenance and repairs should be attended to promptly. This had been actioned, shown by maintenance records and the completed work recorded above. This section has been met. 7, The stairway carpets should be cleaned or replaced. This is the only minor area left from the previous multiple requirement. The director made arrangements during the inspection to address this last remaining area. To reflect the progress made and clarify the remaining work the original requirement will be replaced with the following new requirement: The stairway carpets must be cleaned or replaced. The last report also contained the following requirement: Shared spaces should reflect the personality of service users. Evidence of the service users being consulted about the recent re-decoration of the communal areas was provided and the service users confirmed they had been consulted about this and that the knew they could reflect their personalities in these areas if they wished, but did not want to beyond the colour selection. This requirement is therefore met. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 20 The last report also contained the following requirement: The registered person must ensure the provision of environmental adaptations and disability equipment necessary to meet the individually assessed needs of service users. As stated under Standard 18, the service user that had needs for adaptations to improve access as a result of his disability has now left, and the remaining service users do not have these needs. This requirement is therefore no longer applicable and is withdrawn. The home is reminded however, that should a similar placement be made in the future, an Occupational Therapist assessment for aids and adaptations and the required aids and adaptations will be expected to be in place. The building clean and tidy. The home gave the impression of a generally clean and hygienic home. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 21 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, and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. None of the current staff are qualified to NVQ level 2. 50 of staff need this qualification to provide a suitably qualified staff team. The home’s recruitment procedures protect the residents through vigorous staff vetting. Staff receive induction training to ensure that they are appropriately inducted. Staff are appropriately supervised to ensure they are working within the home’s aims and values. EVIDENCE: None of the current staff are qualified to NVQ level 2. 50 of staff need this qualification to provide a suitably qualified staff team. The following requirement is therefore now set: 50 of staff must be qualified to NVQ level 2 in care or equivalent. However, the following good practice was acknowledged regarding NVQ training at this home: Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 22 The organisation provides this training to all of its staff. This could mean that the home could maintain a higher level of qualified staff more consistently than if it only aimed for the required 50 . The last inspection report contained the following requirement: The Registered Person must consider how to meet the cultural needs of service users whose culture and ethnicity are not reflected in the staff group. Staffing levels must be regularly reviewed to reflect service users’ changing needs. Staffing levels are now regularly reviewed to better reflect service users’ cultural needs. This has been done by rotating some staff from the organisation’s sister home to ensure that some staff from a similar culture to the service users at the home. This requirement is therefore currently met. The last inspection report contained the following requirement: The home’s recruitment policy requires minor revision to clearly state that it will obtain its own enhanced level Criminal Records Bureau check for all new employees. The home’s recruitment policy has been revised to clearly state that it will obtain its own enhanced level Criminal Records Bureau check for all new employees. In addition the home’s own CRB’s have now been acquired for staff. This requirement is therefore currently met. This home has an equal opportunities recruitment policy. Criminal Record Bureau checks were available in staff files examined and these were of the required level and specific to the post. The staff files sampled contained identification checks, e.g. copies of a passport and birth certificate, two written references and staff photographs. The last inspection report contained the following requirement: The home must evidence that all new staff have completed an induction. The home now records evidence to show that all new staff have completed an induction. This requirement is therefore currently met. The last inspection report contained the following requirement: Staff must receive supervision at least six times per year. Supervision records were examined and were occurring at a rate of once every two months {six times a year.} This requirement is also currently met. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 23 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. Service users benefit from a well run home. There is a quality assurance system which involves the service users and provides a way for them to measure improvements in quality for themselves. This does however need to be better recorded so that service users can measure improvements for themselves. The health and safety, and welfare of the residents is generally promoted and protected. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager has a professional background as a qualified nurse. They have yet to start NVQ level 4 studies. This meets the care element of the required qualifications. The last inspection report therefore contained the following requirement: The registered manager must commence an NVQ level 4 courses or equivalent in management. There have been significant improvements since the last inspection {see summary}. These represent a major investment and commitment from the manager and senior management of the home, and have improved outcomes for the service users under all of the groups of standards inspected. Although there is currently a requirement for the manager to commence an NVQ level 4 courses or equivalent in management, the manager does have the care element required. This in conjunction with the support of senior management and staff has had a positive outcome for the home and service users in facilitating long standing unmet requirements to be met, thus raising standards. This is why and how the service users now benefit from a well run home, despite the technicality of not currently having a fully qualified manager. To be proportional and reflect the achievement of the desired positive outcomes, and bearing in mind that a manager is partly qualified, the outcome for this section will be currently assessed as good on this occasion. However, if the manager does not now start the NVQ4 or equivalent in management in a timely fashion this may effect the outcomes of the management group of standards and they may be lowered at that time. The last inspection report contained the following 2 part requirement under Standard 39: [a]The home should develop its quality assurance process to obtain the views of professionals, service users’ families and other stakeholders. [a]The outcome of the quality assurance process should be published and made available. The home has now sent questionnaires to professionals, service users families and other stakeholders. This requirement is therefore met. All that remains is for an annual development plan to be created to record the outcomes of the quality assurance process. This then needs to be fed back to the service users to allow them to be involved in monitoring progress in quality for themselves. The following new recommendation is now set to clarify the remaining element needed: An annual development plan should be produced and made available to the service users and other stakeholders so that they can be involved in monitoring progress in quality for themselves. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 25 The last inspection report contained the following requirement: Policies and procedures must comply with current legislation and recognized professional standards. This requirement referred to the policies and procedures specifically identified in the last report that needed amending. These have all now been amended and this requirement is therefore currently met. See Standards 9, 20, 21, 23, 33, 34, and 39, for details about how identified shortfalls in specific policies and procedures have now been addressed. The last inspection report contained the following requirement: Potentially hazardous cleaning materials must be appropriately stored. Potentially hazardous cleaning materials are now kept securely in a lockable metal cupboard in the garden. This better protects service users from dangerous chemicals and fire. The last inspection report contained the following recommendation: The Registered Person must ensure that an up to date Portable Appliance Testing certificate is obtained. The Registered Person has ensured that an up to date Portable Appliance Testing certificate was obtained for the home. This was inspected at this inspection. All of the health and safety policies and procedures relevant to Standard 42 were seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling are all also included in staff induction. Control Of Substances Hazardous to Health policies were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 42 were also present including fire alarm tests, gas safety, and portable appliance testing. Companion In Care DS0000043729.V358695.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 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 2 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 27 yes 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. 2. 3. Standard YA24 YA32 YA37 Regulation 13, 18(1) 9(2)(b) Requirement The stairway carpets must be cleaned or replaced. 50 of staff must be qualified to NVQ level 2 in care or equivalent. The registered manager must commence an NVQ level 4 courses or equivalent in management. {This is a restated requirement. The previous target of the 01/06/06 was not met.} Timescale for action 30/06/08 01/06/08 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA23 YA39 Good Practice Recommendations The home should ensure that the now booked adult protection refresher training occurs on time as planned. An annual development plan should be produced and made available to the service users and other stakeholders so that they can be involved in monitoring progress in quality for themselves. Companion In Care DS0000043729.V358695.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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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