Care Home: Gainsborough Avenue, 1a

What the care home does well The service is good at developing and keeping up to date care plans which reflect residents assessed and changing needs. The service is good at supporting residents to make choices and decisions and take risks as part of an independent lifestyle. The service ensures that residents enjoy a varied and fulfilling lifestyle by providing and supporting activities, hobbies and interests both at home and in the local community. The service provides residents with the appropriate personal and healthcare support, which ensures their physical and emotional well-being. The service has a good set of policies and procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The service is good at ensuring that the staff team have the qualities, qualifications and training that they need to meet the needs of the residents. Residents and staff benefit from a manager who is experienced, approachable and supportive. What has improved since the last inspection? Personal development plans which form part of each persons care plan are better used to set and monitor gaols, which aim to develop independent living skills. Some parts of the home have been improved although there are still a number of improvements required to enhance the comfort, dignity and safety of residents. Staff files are kept at the home and contain all the required information to show that they are fit for the job. Since the last inspection the manager has consulted the local fire authority for advice regarding equipment, which is required to ensure the safety of residents and staff. What the care home could do better: The floor in the shower room must be repaired to reduce the risk of people falling. Imrovements should be made the parts of the home identified in the main body of the report to enhance residents comfort dignity and independence. CARE HOME ADULTS 18-65 Gainsborough Avenue, 1a 1a Gainsborough Avenue Maghull Liverpool Merseyside L31 7AT Lead Inspector Mrs Janet Marshall Key Unannounced Inspection 17th September 2007 10:00 Gainsborough Avenue, 1a DS0000005244.V347721.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 Gainsborough Avenue, 1a DS0000005244.V347721.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. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gainsborough Avenue, 1a Address 1a Gainsborough Avenue Maghull Liverpool Merseyside L31 7AT 0151 520 3176 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) Expect Limited Mrs Shirley Tinsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should employ a suitably qualified and experienced manager who is registered with the CSCI 29th August 2006 Date of last inspection Brief Description of the Service: 1a Gainsborough Avenue is a small residential care home operated by Expect formerly Sefton Support Services. It is registered to accommodate three service users who have learning disabilities. Currently there are three women living at the home. The property is a detached dormer style bungalow situated in a popular residential area of Maghull. Its location is close to local amenities such as shops, pubs and restaurants and is easily accessible to all forms of public transport. The philosophy of care continues to be focused on maximising independence for residents and supporting them to achieve this. The current fees for the service start at £280 up to a maximum of £380 per week. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The Commission considers 22 standards for Care Homes for Adults as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA, which is in two parts, a selfassessment and dataset, has replaced the pre-inspection questionnaire. The document, which was sent out to, the service was completed and returned to the commission before the site visit took place. A number of surveys, which were sent out to people as part of the inspection, were returned, the results have been used as evidence for this report. The inspection also involved an unannounced visit to the home (site visit). Records that were examined, staff comments and observations made during the visit have also been used as evidence for the report. A number of residents were case tracked during the site visit. This involved talking to staff, looking at the environment and a selection of residents records such as assessments, care plans and daily notes to get an idea about peoples experiences and to find out if they are receiving the care and support that they need and which have been agreed by them and/or their representatives. What the service does well: The service is good at developing and keeping up to date care plans which reflect residents assessed and changing needs. The service is good at supporting residents to make choices and decisions and take risks as part of an independent lifestyle. The service ensures that residents enjoy a varied and fulfilling lifestyle by providing and supporting activities, hobbies and interests both at home and in the local community. The service provides residents with the appropriate personal and healthcare support, which ensures their physical and emotional well-being. The service has a good set of policies and procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The service is good at ensuring that the staff team have the qualities, qualifications and training that they need to meet the needs of the residents. Residents and staff benefit from a manager who is experienced, approachable and supportive. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gainsborough Avenue, 1a DS0000005244.V347721.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 Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move into the home so that they can be sure it is the right place for them to live. EVIDENCE: The AQAA and site visit showed that no new residents have been admitted to the home since the last inspection. The last admission took place approx two years ago the other two people have lived there for a number of years. The AQAA showed that the service has available a number of policies and procedures for assessing, introducing and admitting new residents to the home. The documents, which were looked at as part of the inspection, provide people with clear information about the processes, which have to be followed before a person moves into the home. Other documents such as the homes Statement of Purpose and Service user Guide also provide information about these. A needs assessment document, which has been developed by the company, is completed by a manager as part of the process, before a person moves into the home. The information gathered helps everybody decide if persons needs can be met at the home. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 9 A needs assessment, which was completed for the most recently admitted resident, was looked at. It covered many areas of the person’s life and the help that they need with things such as communication, mobility, risk management and health and personal care. Gainsborough Avenue, 1a DS0000005244.V347721.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available so that staff can enable residents to live independent and safe lives. EVIDENCE: The AQQA showed that a care plan is in place for each of the residents. Care plans and daily notes for two residents were looked at in detail as part of the case tracking process. Case tracking showed that each persons care plan has been put together using information from assessments made. The plans included detailed information about peoples care need requirements and how they will be met. The plans also included information about restrictions and choice of freedom which following assessments have been put in place for people for example use of keys and accessing the community. Written protocols and support guidelines were also part of each persons care plan. These are procedures that staff need to following when supporting residents who are likely to become aggressive or display inappropriate Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 11 behaviours. The procedures, which were looked at, were clear and focused on positive outcomes for the residents. Daily notes, which are kept for each person, were looked at as part of the case tracking process they showed that staff are following the guidelines which are set out in each persons care plan. Care plans were signed and dated to show that they have recently been review and updated with the involvement of the resident and/or their relative/representative. The service operates a key worker system to enable residents to develop to a closer relationship with a specific staff member. The key worker is responsible for reviewing the resident’s monthly plan and to arrange healthcare appointments etc. for residents. During discussion a member of staff described clearly their role and responsibilities as a key worker. A selection of records, which were looked at during the visit, discussion with residents, observation, and results of surveys showed that residents make decisions about their lives. One resident made the following comments “I always choose what clothes I wear each day”, “I decide when I go to bed”, “and I choose the food I eat”. Surveys completed by residents showed they always make decisions about what they do each day. During the visit staff were seen offering residents choices and encouraging them to make decisions about things such as activities and food. There are some choices and decisions, which have to be made by others this is because assessments show that it is not safe for the person to make them on their own. Records looked at showed how individual choices have been made and of instances when others have made decisions and why. Each of the residents need some help with managing their personal money. The level of help each person needs varies and is recorded in their individual plan of care. Discussion with one resident showed that they have their own bank account and always have enough money to spend. The AQAA showed that risk is assessed before a person moves into the home and that risk assessments are in place for each person. A selection of these, which were looked at during the visit, provided staff with information so that they can enable residents to take responsible risks. They described the action that staff need to take to minimise identified risks and hazards. Gainsborough Avenue, 1a DS0000005244.V347721.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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available so that staff can enable residents to live independent and safe lives. EVIDENCE: A personal development plan was part of each persons care plan. There aim is to encourage independence by identifying areas for development in the person’s life such as daily living, leisure and communication. The personal development plans that were seen at the last inspection identified goals and provided information about timescales and the people involved in supporting the person to achieve that goal. It was recommended as part of the last inspection report to provide more information about how and when the goal is monitored and the outcome. Personal development plans, which were looked at during this visit, showed that this has been done. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 13 The AQAA showed that residents lead very individual lifestyles and each take part in different community and home based activities. Available in each persons care plan was a structured weekly programme of activities which showed the things that residents are involved in as part of their weekly routines. Activities include day care, college, and shopping trips. Other activities, which were detailed in the AQAA, include trips to the cinemas, hairdressers and pubs. Daily notes which were looked at as part of case tracking showed that residents are appropriately supported to lead the kind of lifestyles that they choose and which are detailed in their individual plans of care. One resident said “I go to the Centre on some days in the week and do things at home or go out on the other days”. One resident confirmed that they have had a holiday this year as well as a number of short breaks the resident said that they were fully involved in choosing and planning their holidays. Case tracking and details provided in the AQAA showed that residents religious beliefs are respected and appropriately supported by staff as are important relationships with family and friends. One resident said they receive visitors whenever they choose and they are all made welcome at the home. A visitor’s book, which was kept in the hallway, showed that people regularly visit the home. Residents mostly eat at the main dining table, however they often eat their meals from their laps whilst watching TV in the lounge. During the visit one resident was observed eating her lunch in the sitting room whilst watching a video. Food stores, which were looked at as part of the inspection visit, showed there was a good stock of fresh, frozen and tinned food items. The kitchen was equipped with domestic style appliances such as a microwave and cooker. There was plenty of crockery, cutlery, pots and pans, which were of a good standard and in good condition. Available at the home was a record of all food provided to the residents. Staff explained that even though there is a planned menu alternatives are always available. This was confirmed during discussion with a resident. Examination of a selection of records showed that residents special dietary needs are catered for and identified in their individual plan of care. Residents spoken with during the visit confirmed that they are involved in the menu planning and shopping for food. One resident said, “I enjoy shopping for food, staff help us shop at the local supermarkets”. Gainsborough Avenue, 1a DS0000005244.V347721.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare needs are well monitored and supported to ensure that stay well. EVIDENCE: Each person had a care plan, which covered in detail their healthcare, needs and the support that they need to stay well. Records within this section showed that residents are offered minimum annual checks and that there health is regularly reviewed, monitored and dealt with appropriately. As well as visits to primary healthcare services such as dentist, opticians and doctors residents are also supported to attend specialist services. Records detailing the visits were available in good detail as was information about specialist health care needs and requirements. Where appropriate visits to the home by healthcare professionals are arranged. The key worker system enables residents to develop to a closer relationship with a specific staff member particularly in the areas of health and personal care. The key worker is responsible for reviewing the resident’s monthly health care plan and for arranging healthcare appointments etc. for residents. A resident said, “I can ask to see my doctor any time and the staff will help me with this”. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 15 During this inspection visit all medication and medication administration records were examined. Medication and records were stored in a locked cabinet in the office. Discussion with staff and examination of records showed that staff have completed medication awareness training. A policy for the safe handling and administration of medication was availble at the home. A member of staff showed a good awareness of the homes medication polices and procedures. Gainsborough Avenue, 1a DS0000005244.V347721.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to make a complaint and know that they will be listened to. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. Information provided in the AQAA and examination of the homes complaints book evidenced that there have been no complaints made at the home in the last 12 months. The home had available a complaints procedure in written and picture format. Both included clear information about the stages and timescales involved in the process so that people are clear about how to make a complaint if they wish to. Results of surveys and discussion with a resident showed that they are aware of the home complaints procedures and are confident about telling somebody if they were uphappy. A resident said, “I know who to talk to if I was unhappy about something and yes I would tell them” A copy of the local authorities protection of vulnerable adults procedure was avaialbe at the home. A member of staff was able to describe what action they would take if they suspected or evidenced abuse. They confirmed that they had recently undertaken protection of vulnerable adults training. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 17 Detailed in the AQAA were a number of other polices, procedures and codes of practice which are available the home and aim to protect residents from harm abuse or neglect, they include gifts to staff, Recruitment of staff and Whistle blowing. A member of staff spoken with during the visit showed a good awareness of these documents. Gainsborough Avenue, 1a DS0000005244.V347721.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s comfort, dignity and independence are compromised by the poor condition of some parts of the home. EVIDENCE: The home is a spacious three-bedroom detached bungalow located in a popular residential area of Maghull, Merseyside. There is a good sized patio area at the back of the house, gardens and a driveway with off road parking for a minimum of two cars at the front. The home is in keeping with others in the area and is indistinguishable as a care home. The premises are fully accessible and fitted with some aids and adaptations including wheelchair ramps to all entrances. Public transport links are close by. The AQAA showed that some improvements have be made to the home since the last inspection, including new dining table and chairs, new carpet in the main lounge and redecoration of one residents bedroom. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 19 A requirement was given as part of the last inspection report for all parts of the home to be kept in a good state of repair. This was because some parts of the home including the kitchen and bathrooms were in poor condition. Details provided in the AQAA and a tour of the home, which took place as part of this site visit, showed that no repairs have been carried out to the areas mentioned. However there was evidence to show that the manager has made a number of requests to the housing association for the repairs. The upstairs bathroom suite, which was old, fashioned is in need of updating. Some fittings, which were broken, should be repaired or replaced. The décor, which was showing signs of wear and tear, should be improved. The furniture in the downstairs toilet/shower room was also out dated and should be replaced. The tiles on the wall in the step-in shower were damaged and stained in parts so should be replaced. There was evidence that tiles have been replaced in the past with others that don’t match, matching tiles should be used where this is not possible the whole area should be retiled with new. The flooring in the shower was damaged close to the water waste (plug). This is a trip hazard and must be repaired to ensure residents safety. The kitchen worktops and units, which were in poor condition, should be replaced. The décor, which is also in poor condition, should be improved. The manager explained that residents find it difficult when helping with washing and drying dishes because of where the sink is positioned in the kitchen. The sink should be repositioned so that resident’s independence is fully promoted. All doors inside the house, which were showing signs of wear and tear, should be repaired or replaced. There is a small conservatory at the back of the house, which is used by residents as a quiet area. The outside window frames were badly damaged with wood rot and should be replaced. The old bed base and mattress, which was dumped down the side of the house, should be removed. The hall carpet, which was heavily stained in parts, should be cleaned or replaced. Other parts of the home were clean and tidy on the day of the visit. Resident’s surveys showed that the home is always clean and fresh. Cleaning routines were in place. Detailed in the AQAA were a number of policies and procedures for ensuring a clean and hygienic environment for all. Related policies and procedures, which were also seen at the home included, Infection control, the use of protective clothing and disposal of waste. Gainsborough Avenue, 1a DS0000005244.V347721.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): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent and qualified staff group. EVIDENCE: The AQAA showed that there are five care staff and the manager working at the home. Discussion with a staff member showed that they have worked at the home for a number of years, during which time they have developed good relationships with residents. Observation of staff with residents indicated that they had a good rapport with them. Residents surveys showed that staff always treat them well and that they always listen and act on what residents say. One resident spoken with during the visit said, “ I like all the staff they are very good to us” Examination of a selection of staffing rotas and discussion with a staff member showed that the staffing levels at the home are good to enable residents to take part in activities of their choice and to support their individual activity programmes. Staff surveys showed that there are always enough staff to meet the individual needs of the residents and that they always feel they have Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 21 the right support, experience and knowledge to meet the needs of the residents. There was an equal opportunities policy and procedure available at the home. The AQAA showed that the service employs people of various age, gender and ethnicity. The manager confirmed that one new staff member has started work at the home since the last inspection. The AQAA showed that the service carry out strict checks before allowing people to start work at the home. Staff Surveys showed that references and CRB checks were carried out before they started work at the home. The AQAA showed that all but one member of staff have achieved an NVQ in care Level 2 or above and the member of staff who does not yet have the qualification is working towards it. It also showed that training records are kept for all staff. The AQAA shows that the manager intends to produce a better document to show clearer information about staff training needs. A requirement was given as part of the last inspection to ensure that staff files are kept at the home. This is so that the manager has all the information they need to show that the person is fit to work at the home. The AQAA stated that all staff files are kept at the home and contain references, an enhanced CRB check, statement of terms and conditions supervision and training records. Discussion with staff on duty showed that staff were inducted into their role and within six months of starting their employment and they have completed mandatory training in moving and handling, food hygiene, first aid and fire awareness. Staff spoken with commented that the training provided by the company is very good. Staff surveys showed that induction training covered everything that they needed to know about the job when they started and that they are given training which is relevant to their roles, helps them understand individual needs of residents including needs which are related to disability, gender, age, race and ethnicity, faith and sexual orientation. Information provided in the AQAA and discussion with staff showed that they receive regular “one to one” supervision from the manager and a record is kept of things discussed and regular staff meetings are held and minutes of the meetings are kept. Staff surveys showed that they are kept up to date with new ways of working and there are always ways of passing information on to other staff and manager about residents. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed to the benefit of the residents and staff. EVIDENCE: Shirley Tinsley has been the registered manager of the home for several years. The AQAA showed that the manager has NVQ level 4 Registered Managers award and is working toward an NVQ Level 4 in Care. It also shows that she is attending weekly workshops to update her knowledge and understanding of her role. During the visit both staff and residents were complimentary of the manager. They made comments such as, “The manager is great, I can talk to her about anything”, “she knows what she is doing”, “Shirley is approachable and understanding”. Staff surveys showed the manager often meets with staff to give support and discuss how they work. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 23 On display at the home was a current Public Liability Insurance certificate. Records that were looked at were well maintained in the home and residents/representatives are able to access their records in accordance with the home’s policy on access of information. Resident’s records were kept in a secure place ensuring their confidentiality. The health safety and welfare of residents are well protected this was supported by a comprehensive and well presented set of policies and procedures. The homes policies and procedures are developed centrally and forwarded to the home. The AQAA showed that the home has available all the policies, procedures and codes of practice which are required by the law and have recently been reviewed and updated. Reports, which were seen at the home, show that a representative for the service is carrying out regular visits to the home to check the quality of the service. The reports show that residents and staff are happy with all aspects of the home. Information provided in the AQAA and examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electricity checks and environmental risk assessments. A member of staff confirmed that the fire alarm system and water temperatures are tested weekly. Details provided in the AQAA and discussion with staff showed that they have completed training in areas of health and safety such as fire safety and first aid. During a tour of the home at the last inspection visit it was noted that none of the doors inside the house were fire doors nor were they fitted with self-door closures which had the potential to put people at risk in the event of a fire. The manager confirmed that she has contacted the local fire authority for advice regarding this and is waiting for advice from them. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Gainsborough Avenue, 1a DS0000005244.V347721.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 YA24 Regulation 13(4)(a) Requirement The floor in the shower room must be repaired to reduce the risk of people falling. Timescale for action 17/10/07 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 YA24 Good Practice Recommendations Parts of the home, which are in a poor state of repair, should be improved so that residents live in an environment that is completely comfortable. Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Gainsborough Avenue, 1a DS0000005244.V347721.R01.S.doc Version 5.2 Page 27 - 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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