Care Home: Frank House

What the care home does well The service was run in the best interest of the residents and residents were involved and included in decisions about running the service and their lifestyles. Staff understood individual residents and their needs and how to meet them. The staff team presented as cohesive and supportive. Staff received training relevant to their work. Residents were supported to live as independently as possible, to access age appropriate social and leisure activities of choice and to develop personal life and living skills. Staff worked with relatives to ensure residents had a lifestyle that suited them. Relatives were encouraged to maintain an active role in the resident`s lives and were invited to attend social functions organised in the home. The environment provided a homely atmosphere for the residents but did require some improvements. Residents had the opportunity to develop and practice independent living skills in the `independent training unit`. What has improved since the last inspection? Medicines were safely managed, the medicine policy and procedure had been rewritten and staff had started working with residents to enable them to manage their own medicines. All records seen were signed and dated. CARE HOME ADULTS 18-65 Frank House 8 Twigg Close Erith Kent DA8 3LD Lead Inspector Pauline Lambe Unannounced Inspection 13th May 2008 10:15 Frank House DS0000070959.V363261.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 Frank House DS0000070959.V363261.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. Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frank House Address 8 Twigg Close Erith Kent DA8 3LD 01322 334 318 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) frankhouse@hillpark.co.uk Hill Park Autistic Trust Leela-Jade Williamson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 12/09/07 (Prior to the service change of name). Date of last inspection Brief Description of the Service: Hill Park Autistic Trust is a registered charity and a non-profit making organisation. It has a management committee made up of volunteers and was reregistered as a charity in 2007. Horizon Housing Association owns the property and Hill Park Autistic Trust provides the care. Frank House is situated in a small residential close near Erith. It is close to bus routes and local shops and is a purpose built, detached property. The home has 6 bedrooms, 2 bathrooms with toilets, a shower room with toilet and a further toilet. There is a large kitchen/diner, lounge, utility/laundry room, staff office, garage and enclosed garden. The property has a bed sitting room with a kitchen that is used by residents to develop their independent living skills and to entertain family and friends. All residents are funded by Local Authorities and the current fees were £585.00 per week. Residents paid a weekly contribution of £64.15 towards fees and food. Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The site visit for this unannounced inspection was completed on 13th May 2008. The responsible individual, manager, residents and staff assisted with the inspection. Six residents were in residence and two residents seen during the inspection. The service had a key unannounced inspection on 12th September 2007. The inspection process included a review of information held on the service file, a tour of the premises, inspection of records, talking to residents, staff and the responsible individual and reviewing the information provided in the annual quality assurance assessment. Satisfaction surveys were sent to residents and relatives and positive feedback received about the service and the quality of care provided. The service was well managed, staff had the ability to meet the needs of the residents and residents were supported to live a lifestyle that suited them. Residents and relatives were satisfied with the quality of care provided and feedback received about the management of the service, the staff and the care provided was very positive and complimentary. What the service does well: What has improved since the last inspection? Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 6 Medicines were safely managed, the medicine policy and procedure had been rewritten and staff had started working with residents to enable them to manage their own medicines. All records seen were signed and dated. 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. Frank House DS0000070959.V363261.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 Frank House DS0000070959.V363261.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): Standards 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory admission procedures were in place and information provided for prospective residents in the statement of purpose and service user guide. EVIDENCE: No new residents were admitted since the last inspection. Satisfactory admission procedures were in place and included guidance for prospective residents. Trial visits were offered to prospective residents prior to admission. In feedback surveys from residents and relatives they said they had enough information about the service. Management were aware of the need to comply with regulation 14 when admitting residents. The manager was ware of the need to confirm in writing to residents that based on assessment the home was suited to meeting their needs. Frank House DS0000070959.V363261.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): Standards 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. Care plans were prepared with residents and showed how staff were to meet assessed needs. Residents had written some of the care plans seen. Staff worked together to support and encourage residents to develop independence. Risk assessments were completed with residents where needed. EVIDENCE: Care records for two residents were viewed and these included assessment of needs, risk assessments, care plans and individual development programmes. Care plans seen provided clear guidance for staff as how to meet resident’s assessed needs. The residents had written some of the care plans seen and all care plans seen showed that the resident was involved in preparing these. Residents had a six monthly individual programme review, which was completed with the resident, relatives where possible, the key worker and other interested parties. Weekly and monthly progress reports and one to one meetings with key workers were completed. Records seen included a history of the resident and these provided staff with a brief but detailed assessment of Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 10 the resident in relation to social, physical and emotional needs, skills and abilities. Feedback surveys received from residents and relatives showed satisfaction with the care provided. Comment made included “staff show great dedication to the residents”, “our relative has improved enormously since being in the home” and “the key worker sometimes advises me on things” Residents had the ability to voice their views, opinions and preferences about their lives. Records seen showed that residents were very involved with making decisions about their lives for example in relation to personal care, daily activities and social and leisure time. Staff spoke confidently about residents and displayed a commitment to ensuring residents were involved in all aspects of their lives. Residents spoken with confirmed that this happened and that staff supported them to meet personal goals. The interaction between staff and residents was friendly yet professional. Records seen showed that residents were supported to take risks and encouraged to maintain and develop an independent lifestyle. Risk assessments were completed with residents in relation to going out alone, holidays, activities they took part in and managing their own medicines. Residents had various commitments outside, which they accessed independently. To enable this to happen all residents had travel passes. Some residents attended College, visited friends or did volunteer or paid work. Comments made in feedback from residents and relatives showed they were very satisfied with the support residents received to maintain and develop independence. Frank House DS0000070959.V363261.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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff supported residents to have a lifestyle that suited them and supported them to use local amenities, attend social events of choice, maintain contact with family and friends and to do voluntary or paid work. Residents were satisfied with meals provided and the way staff respected their privacy. EVIDENCE: Residents were supported to access age appropriate social and leisure activities. All the residents could access the local community independently and were staff supported them to attend social activities and maintain friendships outside the home. Residents were encouraged to attend a social group in the community every two weeks, took part in group and individual activities such as bowling, visits to the pub, theatre, cinema, going out for meals, swimming and other activities based on individual choice and interest. B.B.Qs, parties and games evenings were organised in the home and residents were welcome to invite family and friends to attend these events. When Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 12 residents had a day off staff supported them to take part in activities on a oneto-one basis. Most of the residents had an annual holiday and they decided where this should be spent. Plans were in place for a holiday in Clacton later in the summer. Feedback from relatives and residents showed independence was encouraged and comments made included “I make choices of what to do in my leisure time”, “I usually make decisions for myself” and “my relative has always been encouraged to pursue their interests and make best use of their talents”. Residents were supported to or were able to independently use local facilities. For example residents could develop their interest in areas such as college studies, music, art, volunteer work, use of local leisure facilities, practice their religion and where possible do volunteer or have paid employment. Bexley Two-fold supported residents with employment opportunities. Residents seen indicated they lived their lives the way they wished and could come and go as they pleased provided they informed staff of their movements. Residents had a key to the home and to their bedrooms. Comments made by residents were “I feel safe her and would talk to staff if I had any concerns”, “I enjoy going out and I choose the leisure activities I want to use” and “I make my own choices about my life and enjoy cooking”. Residents presented as relaxed and comfortable in their environment and in their interaction with staff. Staff said that where possible they worked with and involved relatives in decisions and plans that benefited resident’s lives. Relatives were encouraged to be involved with the six-monthly individual programme planning, visiting the home, having residents home for visits, attending appointments and activities outside the home with residents and joining in social activities. A number of residents had built friendships with people outside the home and were supported to maintain these friendships. Friends were welcome to visit but the home did not accommodate overnight visits. Records seen showed that residents were consulted about their lives and involved in decision-making. A house rule was that staff did not enter a resident’s bedroom without permission. Residents were responsible for keeping their bedrooms clean and tidy with staff help if needed. As part of the monthly one to one key worker and resident meetings staff inspected the bedroom to ensure it was kept in a satisfactory condition and check that no maintenance or safety issues needed to be addressed. Weekly menus were seen and showed that a balanced and varied diet was provided. Residents planned the weekly menu and were encouraged to take part with food shopping and cooking. Each resident had a ‘recipe’ book and were encouraged to prepare and cook meals on a rota basis. Staff were available to help with cooking the evening meal if needed. Residents could eat breakfast and lunch at times to suit them but were encouraged to have their evening meal and Sunday lunch together. Foods were properly stored with records kept for fridge, freezer and food temperatures. Adequate supplies of Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 13 fresh, frozen and dried foods were seen. Residents had free access to the kitchen unless this had been risk assessed as inappropriate. Staff monitored resident’s weight monthly and action was taken to address any concerns with this aspect of their health. No domestic staff were employed and residents helped with cleaning the kitchen. A roster was prepared to show which area they were responsible for on a weekly basis. Residents seen said they took part in cooking, shopping and cleaning and said they enjoyed some but not all of the tasks. Residents spoken with and feedback received showed satisfaction with the meals provided and their involvement with preparing and cooking meals. Frank House DS0000070959.V363261.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were provided with personal care in private and in the way they liked. Systems were in place to meet the health and emotional needs of the residents. Medicines were safely managed and some residents were supported to manage their own medicines. EVIDENCE: The residents in the home currently had a high level of independence and the ability to voice their preferences. Residents required very little personal care but some required prompting with their personal care. When personal care was needed this was provided in private, planned in agreement with the resident and recorded in individual care plans. Residents spoken with and feedback received from relatives indicated they were satisfied with how care was provided. The home had a separate ‘independent living training unit’. This comprised of a lounge and small kitchen. As part of personal development residents assessed as able spent time alone in this unit. The amount of staff assistance residents required was agreed with them and recorded in their care records. Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 15 However staff were available to assist residents on request if necessary. One resident was spending time in the unit at the time of the inspection and staff said the person was enjoying the experience and gaining independent living skills. Records seen showed attention was given to meeting resident’s health and emotional needs. Residents were registered with a GP and supported to access routine health checks with a dentist, optician and chiropodist. Staff supported residents to attend hospital and other healthcare appointments. Monthly supplies of medicines were provided in the monitored dose system together with pre-printed administration charts. Satisfactory systems and records were in place in relation to storage, administration and disposal of medicines. The temperature of the medicine storage room was not monitored and the manager said the room did not get very hot, however it was recommended that the temperature of the room be monitored. Risk assessments were in place in relation to safety, storage and compliance for residents who wished to manage their own medicines and since the last inspection staff were working with two residents to do this. The medicine policy and procedure was re-written in September 2007 and provided adequate guidance for staff. Medicines checked for two residents were found to be correct. Internal and external medicines were stored separately. The manager had not introduced a medicine profile for residents, a record of individual medicine reviews, evidence that staff were assessed annually as being competent to manage medicines or a protocol for the administration of ‘as required’ medicines. This issue was discussed with the manager who agreed to address this recommendation. No homely remedy or controlled drugs were in stock. Almost all of the staff team had completed a 20-week training course on the safe management of medicines. Recommendation 1. Frank House DS0000070959.V363261.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. Systems were in place to manage complaints but not all documentation to do with complaints received was available to view. Systems were in place to safeguard adults but the policy and procedure provided limited guidance for staff. EVIDENCE: A satisfactory complaints policy and procedure was provided and a system in place to record complaints made about the service. Residents said that if they had any concerns they would speak to the manager or one of the staff team. Two complaints were made about the service to management since the last inspection. Not all the correspondence about the complaints was available to inspect. Therefore it was not possible to assess how the complaints had been managed. From information included in the AQAA neither complaints were upheld following investigation. No complaints had been made about the service to the Commission since the last inspection. Feedback from residents and relatives showed they knew how to make a complaint. Requirement 1. Procedures were in place in relation to safeguarding adults and it provided adequate but limited information and guidance for staff. As part of an in depth look at safeguarding systems during this inspection three staff were asked about their recruitment checks, their training and understanding of safeguarding. All of the staff spoken with provided satisfactory information on these areas, displayed a good understanding of safeguarding, knew about the whistle blowing policy and what it meant to them and records seen showed Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 17 they had received training on this topic in the last 12 months. Two residents were asked if they felt safe in the home and if not did they know who to talk to. Both residents said they felt safe in the home, knew the manager by name and said they would talk to her or their key worker if they had a concern or worry. The manager was asked questions in relation to safeguarding including the recruitment process, staff training, implementation of and content of the safeguarding policy and how to manage an allegation or suspicion of abuse. The manager was aware of the role she, the organisation and external organisations played in safeguarding adults. The manager and responsible person knew that Bexley Council’s had safeguarding adult’s policies and procedures. Recommendation 2. Frank House DS0000070959.V363261.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): Standards 24, 25, 27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the environment required repairs, improvements and upgrading. Residents did not have any concerns about their private space. EVIDENCE: The areas of the home seen were generally clean, tidy and adequately furnished. Staff recorded repairs and health & safety issues requiring attention and these were reported to the Housing Association for attention. Although the environment did not pose a risk to residents many areas of the property required repairs and upgrading. The units in the main and the independent living unit kitchens were worn and damaged and must be replaced as these were no longer hygienic. Units were chipped, had parts missing, hinges damaged and they could no longer be cleaned properly. These problems applied to the utility/laundry room where the units were also badly damaged and must be replaced. Requirements 2 and 3. Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 19 Bedrooms were not seen as a rule of the house was that the rooms were entered only with the resident’s permission. Two residents asked did not wish their rooms to be inspected. The manager said that bedrooms were generally well maintained but that some residents required assistance and prompting to keep their bedrooms clean and tidy. As part of the key worker monthly one to one meetings with residents staff viewed their bedrooms and arranged for any repairs or hygiene issues to be addressed. Residents spoken with said they were satisfied with their bedrooms. Two bathrooms and one shower room were provided. The bathroom on the ground floor was used mainly by staff when they did ‘sleep over’ shifts. The bathroom on the first floor was out of order. The manager said a new bath had been fitted but not properly sealed so it could not be used. This situation had gone on for some months. Residents spoken with said they found that not having use of this bathroom was very inconvenient. Currently the residents were using the ground floor bathroom but this was not available to them once the night support worker went to bed. The shower room was poorly ventilated, the tile grout and seal in the shower cubicle and round the shower tray was worn, stained and looked very unpleasant and the room overall was not very clean. This was discussed with the manager as the issues were raised at the last inspection but had not been addressed. At the request of the residents and supported by individual risk assessments the hot water temperatures in this home were not fitted with thermostats to control the temperature. Requirements 4 and 5. Staff and residents worked together to keep the environment clean and tidy as designated domestic staff were not employed. Although cleaning schedules were in place the standard of hygiene generally in the areas seen should be improved. This applied particularly to the kitchens, the utility area and the shower room. Hand washing facilities were provided for staff. Requirement 6. Frank House DS0000070959.V363261.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): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were maintained and staff received training relevant to their work. Accurate staff rosters were kept to show staff on duty at all times. Some improvements were needed staff recruitment records. EVIDENCE: The staff team comprised of a full time manager and support care staff. No waking night staff were employed but one member of staff ‘slept in’ with access to ‘on-call’ back up. Staff rosters seen showed adequate staffing levels maintained and staff seen said that staffing levels were adequate to meet the needs of the residents. From observation and comments received from residents and relatives staff maintained a friendly yet professional relationship with the residents. Comments made by relatives included “staff are very approachable, caring and do an excellent job”, “staff encourage people to be as independent as possible” and “we feel our relative is in very capable hands and staff have a great deal of common sense”. Resident feedback also showed satisfaction with the staff team. Eight support care staff were employed, seven had achieved NVQ level 2 or above and one person was working towards this qualification. Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 21 Three staff files were inspected. None of the files had evidence of proof of the person’s identity. The responsible individual said she did not know she had to keep this but had seen and checked this for everybody when doing the CRB checks. She agreed to ensure copies of proof of identity would be placed on every file. Staff spoken with confirmed they had to show proof of identity when applying for their CRB check. All other information including CRB checks were obtained prior to staff starting work. Requirement 7. Staff spoken with said they had access to training relevant to the work they did and attended training and workshops on Autism and Aspergers’ syndrome. Records seen for three employees showed that since the last inspection all three people had 3 days training. Topics included were safeguarding adults, nutrition & health, managing aggression, fire safety and safe handling of medicines. Staff spoken with said they received supervision every two months. Two completed staff surveys were sent to the Commission and both people said they felt the service did not need to improve as it was already very good and staff worked well together to meet the needs of the residents. Frank House DS0000070959.V363261.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): Standards 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. The manager had the skills and experience needed to manage the service. A quality assurance system was in place and a safe environment provided for residents and others. EVIDENCE: The manager was registered with the Commission and assessed as having the skills and experience needed to manage the service. The responsible person who was the previous service manager, supported her in her role. Staff meetings were held and minutes kept. Staff and residents seen said they felt involved in the running of the service and could put forward ideas and suggestions at meetings. The service had the benefit of a stable staff team. Feedback received from relatives indicated they were satisfied with the way the service was managed and a comment made was “I find it very difficult to think of anything that could improve Frank House”. Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 23 Staff were supported to be involved with decisions made about the service and their lifestyle through regular resident meetings and one to one meetings. Residents were invited to add topics to the house meeting agenda. Minutes seen showed that residents were involved in making decisions. The National Autistic Society undertook a full quality assurance audit of the service annually. This audit included getting feedback on the service from residents, relatives and others and included information provided in the manager’s self-audit of the service. Any issues that required improvement or change were brought to the attention of management. Trustees made regulation 26 visits and reports were kept in the home. In view of the size of the service it was easy to maintain regular communication between management, staff, residents and relatives. A health & safety policy and procedure and safety notice was provided. Annual health & safety assessments were completed by the Trust and the Housing Association. This provided management with the opportunity to discuss environmental issues such as repairs and improvements. A selection of safety records viewed included fire safety, electricity supply testing, records of fridge, freezer and food temperatures and the gas safety certificate, all of these were up to date. The fire alarm was tested weekly and fire drills held quarterly and included staff and residents. The last fire drill was held on 7/3/08 and records showed that staff and residents responded appropriately. Risk assessments were in place for residents in relation to the decision not to restrict windows above the ground floor. Other risk assessments were in place in relation residents’ self-administration of medicines, use of the kitchen, laundry area, garden, going out alone and use of the independent training unit. The assessments were reviewed six monthly or sooner if needed. Frank House DS0000070959.V363261.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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 3 X Frank House DS0000070959.V363261.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA22 Regulation 17 Requirement Complaint records must include all the correspondence relating to the complaint available for inspection. The kitchen cupboards must be kept clean and hygienic. (Timescale of 02/11/07 was not met). The units in the main kitchen, the kitchen in the independent unit and the utility/laundry room must be replaced as these were worn and damaged. The ventilation in the shower room must be improved and the tile grout and shower seal replaced. (Timescale of 2/11/07 was not met). The bath on the first floor must be repaired. The standard of hygiene in the home must be improved particularly in the main kitchen and shower room. All information required by regulation must be obtained for staff prior to commencing work and this made available for inspection. (Timescale of 26/10/07 was not met.) DS0000070959.V363261.R01.S.doc Timescale for action 04/07/08 2 YA24 23 04/07/08 3 YA24 23 04/08/08 4 YA27 23 04/08/08 5 6 YA27 YA30 23 23 04/07/08 04/07/08 7 YA34 18 04/07/08 Frank House 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. 1 Refer to Standard YA20 Good Practice Recommendations A medicine profile should be in place for all residents, a record of individual medicine reviews should be maintained, staff should be assessed annually as being competent to manage medicines and a protocol for the administration of ‘as required’ medicines should be in place. The temperature of the medicine storage area should be monitored. The safeguarding adults procedures should be reviewed and provide more details about types of abuse and the action staff must take if abuse is alleged or suspected. 2 YA23 Frank House DS0000070959.V363261.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. Extracts may not be used or reproduced without the express permission of CSCI Frank House DS0000070959.V363261.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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