Care Home: Horse Leaze (7)

What the care home does well People who live in the home told us that they were "happy" and "liked living here". They also commented that staffs were "helpful" and "very good" and that they "got on well with them". The home was assessed as being able to meet the needs of an older group of men and women with mental health issues from diverse backgrounds and cultures. Staffs are also from diverse cultures and backgrounds, and this reflects the resident group and the local community. The home develops individual plans with people who use the service that are regularly reviewed. Residents are encouraged to manage their own finances and appropriate support provided where required. The home holds regular meetings to involve residents in the running of the home. Potential risks to people who use the service are assessed and subject to a management plan. Residents are involved in meaningful daytime activities of their choice both inside and outside of the home - according to their own interests and capabilities. Residents are also supported to maintain important personal and family relationships. People who use the service are involved in deciding what meals are provided and are generally happy with the food provided. Where able, residents are encouraged to be independent for their personal care, and where support is provided this is done in a sensitive and dignified manner that respects the resident`s preferences. Residents are aware of the complaints procedure and know how to use it. Where they have made a complaint they have been happy with how it was dealt with. The home provides safeguarding training to staff. Discussion with one staff member demonstrated a sound understanding of safeguarding issues and their responsibilities. People who use the service told us they feel safe and comfortable there. The home is well maintained and offers a range of shared and private space. Each resident has his or her own bedroom that they can personalise. The home was found to be clean and free from offensive odours. Staffs are employed in sufficient numbers and are encouraged to undertake external National Vocation Qualifications. A suitably qualified and experienced Manager has been appointed and a quality assurance exercise to obtain the views of people who use the service has been completed. Many of the health and safety records required by legislation are maintained. What has improved since the last inspection? As a result of a previous inspection in November 2007 the home was issued with four Statutory Requirement Notices. This inspection evidenced that the home has complied with each. The home has completely refurbished its shower and bathroom facilities in line with Occupational Therapy assessments of residents needs. It has carried out a quality assurance exercise that includes the views of residents and other stakeholders, and published the outcomes. The home has also appropriately addressed the potential for residents to make false allegations. Food safety has been promoted by ensuring that fridge temperatures are maintained within acceptable limits. New service users are admitted on the basis of a full assessment carried out by the home. In addition, the home was assessed as having complied with a number of other requirements made at earlier inspections. These include ensuring that the healthcare needs of people who use the service are assessed and recognised, and that procedures are in place to address them. The home currently has no self-medicating residents. Accurate records of the actual medicines being administered were evidenced as being maintained. The home also evidenced that medicines were being administered in accordance with their prescription. Personnel information was available for inspection on site, and a current insurance certificate evidencing appropriate cover was also displayed. A permanent full time Manager has been appointed and they have commenced the Commissions registration process. Personnel records indicate that new staff completes an induction to the home. What the care home could do better: Three requirements made at a previous inspection in November 2007 were restated. The home must ensure that individual plans comprehensively address areas of identified need. The home must evidence that all staffs receive regular supervision - a minimum of six per year. The home must also evidence that all staff receive a minimum of five days training each year. Two requirements were made as a result of this inspection. The home are required to evidence that freezer temperatures are recorded on a daily basis and maintained within acceptable limits. The home must also carry out and record weekly fire alarm call tests and evidence that two references are obtained for staff as part of their pre employment checks. We also recommend that the home record more detailed information where residents decline meals. The home should develop a policy on the timescales within which Criminal Records Bureau checks will be renewed. CARE HOME ADULTS 18-65 Horse Leaze (7) 7 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Unannounced Inspection 12 & 13th May 2008 12.55 th Horse Leaze (7) DS0000063910.V362616.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 Horse Leaze (7) DS0000063910.V362616.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. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Horse Leaze (7) Address 7 Horse Leaze Beckton London E6 6WJ 020 7473 1945 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) ann.bissett@heritagecare.co.uk www.heritagecare.co.uk Heritage Care Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2007 Brief Description of the Service: 7 Horse Leaze is a care home for adults with mental health support needs. The home is operated by the Heritage Care organisation, which provides residential care services to a variety of service user groups across the region. The home is a single storey building located within a residential area of Beckton. There are bus routes and the Docklands Light Railway is accessible nearby. The home aims to provide a supportive environment within which service users can develop confidence, dignity and personal responsibility. Each service user has their own bedroom and access to communal lounge, dining area, kitchen and bathroom facilities. The home has three male and three female service users in residence. The home is culturally reflective of the local community with service users from African Caribbean, Asian and White British backgrounds. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of two visits. The Inspector had visited the home on numerous previous occasions, most recently in November 2007. During the course of the inspection we spoke privately with the Manager, a care worker and three people who live in the home. We also examined a range of records and documentation including personal files, care plans, health and safety records and personnel records. During the course of the inspection key National Minimum Standards were assessed, along with the homes compliance with requirements made at earlier inspections. The quality rating for this service is two stars. This means the people who use the service experience good quality outcomes. What the service does well: People who live in the home told us that they were “happy” and “liked living here”. They also commented that staffs were “helpful” and “very good” and that they “got on well with them”. The home was assessed as being able to meet the needs of an older group of men and women with mental health issues from diverse backgrounds and cultures. Staffs are also from diverse cultures and backgrounds, and this reflects the resident group and the local community. The home develops individual plans with people who use the service that are regularly reviewed. Residents are encouraged to manage their own finances and appropriate support provided where required. The home holds regular meetings to involve residents in the running of the home. Potential risks to people who use the service are assessed and subject to a management plan. Residents are involved in meaningful daytime activities of their choice both inside and outside of the home - according to their own interests and capabilities. Residents are also supported to maintain important personal and family relationships. People who use the service are involved in deciding what meals are provided and are generally happy with the food provided. Where able, residents are encouraged to be independent for their personal care, and where support is provided this is done in a sensitive and dignified manner that respects the resident’s preferences. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 6 Residents are aware of the complaints procedure and know how to use it. Where they have made a complaint they have been happy with how it was dealt with. The home provides safeguarding training to staff. Discussion with one staff member demonstrated a sound understanding of safeguarding issues and their responsibilities. People who use the service told us they feel safe and comfortable there. The home is well maintained and offers a range of shared and private space. Each resident has his or her own bedroom that they can personalise. The home was found to be clean and free from offensive odours. Staffs are employed in sufficient numbers and are encouraged to undertake external National Vocation Qualifications. A suitably qualified and experienced Manager has been appointed and a quality assurance exercise to obtain the views of people who use the service has been completed. Many of the health and safety records required by legislation are maintained. What has improved since the last inspection? What they could do better: Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 7 Three requirements made at a previous inspection in November 2007 were restated. The home must ensure that individual plans comprehensively address areas of identified need. The home must evidence that all staffs receive regular supervision - a minimum of six per year. The home must also evidence that all staff receive a minimum of five days training each year. Two requirements were made as a result of this inspection. The home are required to evidence that freezer temperatures are recorded on a daily basis and maintained within acceptable limits. The home must also carry out and record weekly fire alarm call tests and evidence that two references are obtained for staff as part of their pre employment checks. We also recommend that the home record more detailed information where residents decline meals. The home should develop a policy on the timescales within which Criminal Records Bureau checks will be renewed. 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. Horse Leaze (7) DS0000063910.V362616.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 Horse Leaze (7) DS0000063910.V362616.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been carried out. EVIDENCE: We looked at the personal files for two people who use the service. This evidenced that each had been assessed by the home prior to their moving in. Previous inspections have evidenced that the home has developed a statement of purpose that accurately reflects the service provided. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle, and these plans are regularly reviewed. EVIDENCE: The home has developed care plans with each resident that address a range of health personal and social care needs. However, discussion with residents, the Manager and care staff evidenced that important area’s of care such as diabetes management for one resident and the arrangements for administering depot medication for another, were not adequately addressed in the current plans. Plans were reviewed every six months or as residents needs change. There was also some evidence of person centred planning and life story work within Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 11 the current plans, and the sampled plans were also found to reflect resident’s abilities to make decisions about their lives. We were told by the Manager that people who use the service have their own bank account and that some people receive support in managing their finances. We sampled the personal file for one person who uses the service and this evidenced that with their agreement the home holds monies on their behalf that they can withdraw whenever they like. We looked at the record book for monies held on this residents behalf, and it contained an entry for each deposit and withdrawal that detailed the date and amount. The resident and care worker signed each entry. We looked at the records of residents meetings. Two had been held in 2008, and the minutes evidenced that activities and the menu were discussed at both. Sampling of the personal records for two residents evidenced that potential risks identified in their plans were subject to a risk assessment and management plan. The home had also developed an assessment to address the potential for false allegations of abuse, as required by an earlier inspection. Horse Leaze (7) DS0000063910.V362616.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): 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. Residents are involved in meaningful daytime activities of their own choice and according to their own interests and capabilities. Residents are also supported to maintain important personal and family relationships. EVIDENCE: The homes residents are predominantly older, and some experience symptoms of mental illness or deteriorating physical health that impacts upon their ability to engage in activities. Discussion with people who use the service, the Manager and care staff and sampling of records evidenced that people who use the service are engaged in a range of activities according to their interests and wishes. Some residents help care for the homes cat and are supported to engage in daily chores around the home. One resident has expressed an interest in knitting and flower arranging and the home are supporting them to Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 13 pursue these interests within the home. Another resident is interested in gardening and the home is supporting them to develop their own plot within the garden. One resident told us that they had been supported to attend weight watchers meetings. Another resident told us how they liked to listen to music and watch the TV in their own room, and that they had been supported to obtain their own TV set and stereo to facilitate this. Some residents are able to visit local shops independently, or visit the local shopping centre at East Ham with staff on a weekly basis. Two residents have expressed an interest in visiting the Isle of Wight this summer and a day trip is in the process of being arranged. The Manager told us that people who use the service have recently been registered with a local resource centre and that this may lead to additional activities for some residents. We spoke to three residents who all each said that they were happy with their current activities and routine and did not wish to change this. The home has identified two residents as having specific religious needs and the Manager told us that both had declined support in attending places of worship. The Manager also told us that one resident from an Asian background is supported to visit Asian shops and restaurants in the Green Street area. Discussion with people who use the service, with the Manager and sampling of records evidenced that people who use the service are supported to maintain contact with their family and friends. Some residents visit their families on a weekly basis and others are supported to maintain telephone contact and receive occasional visits. People who use the service told us that they choose when to be alone or in company, and whether to join in an activity. During the course of the inspection we observed staff interacting regularly with residents, and engaging them in discussion. Discussion with people who use the service, the Manager and with staff evidenced that residents meet each week to decide what meals will appear on the menu for that week. Residents told us that they generally enjoyed the meals provided. We sampled the homes meal log and this evidenced that a range of varied and nutritious meals is provided. We did notice that on some days no meal was recorded as having being provided for some residents and on other days “declined” was written by the residents name. Horse Leaze (7) DS0000063910.V362616.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. The home encourages residents to access healthcare services. More able residents are encouraged to be independent with their personal care and where support is required this is provided in sensitive and dignified manner. EVIDENCE: Two of the homes residents currently receive practical assistance in managing their personal care. The Inspector spoke to one of these, and sampled their personal file. These evidenced that the nature of the assistance was clearly identified, and that assistance was provided in a respectful and dignified fashion. Discussion with the Manager and the resident evidenced that residents are given a choice about the gender of the care worker who assists them with personal care. Discussion with people who use the service evidenced that each chooses their own clothes and hairstyle, and that their appearance reflected their personality. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 15 Sampling of personal records for two residents, discussion with people who use the service, care staff and the Manager evidenced that residents are supported to attend regular healthcare appointments. One of the residents sampled was reluctant to attend these appointments, and had recently declined to attend a dentist appointment. A care plan to address this issue had been developed and implemented. A second resident was evidenced as having recently attended GP appointments, diabetic clinic, hospital outpatient appointments and the smoking clinic. We were told that none of the homes residents are currently self-medicating or using controlled drugs. The medication records and available medication were sampled for two residents. This evidenced that the Medication Administration Records (MAR) corresponded with the available medication available. The MAR sheets were found to be in good order. Horse Leaze (7) DS0000063910.V362616.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. The home has an open culture that allows residents to express their views and concerns. Residents know how to make a complaint and have been satisfied with how the matters they have raised have been dealt with. There are clear policies and procedures regarding safeguarding available, and staff is aware of their responsibilities. EVIDENCE: The home operates a corporate Heritage Care complaints policy and procedure. Previous inspections have evidenced that this complies with National Minimum Standards. We examined the complaints log and found that one complaint had been received since the last inspection. The details of the complaint along with the investigation, outcome and action taken were recorded. Discussion with three people who use the service evidenced that each was aware of the homes complaints procedure and the steps they could take if they wanted to make a complaint. Two people who use the service told us that they had made a complaint in the past and were happy with how the home had dealt with these. During the course of the inspection one resident complained to the Inspector that a personal item in their room had been broken. They told us that they Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 17 had forgotten to mention this to staff previously. With their agreement this complaint was passed to the Manager for investigation. There have been no adult protection issues since the previous inspection. Discussions with the Manager and with one care worker evidenced that both had recently completed safeguarding training. Each was aware of the organisations safeguarding policy and procedure and their responsibilities. The care worker spoke to by us was able to identify a range of potential abuses that vulnerable people may experience. The three residents we spoke to told us that they felt safe within the home and felt happy talking to either staff or the Manager if their was something they felt uncomfortable with. Horse Leaze (7) DS0000063910.V362616.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 good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, well-maintained environment that meets the needs of residents. A range of shared and private space is available, and each resident has their own room that they are able to personalise. EVIDENCE: The home is located within a semi-detached bungalow in a residential area. Access is via a large entrance hall that has a payphone and comfortable seating. The staff office, utility room, bathroom and a large “L” shaped lounge diner are situated off of this hallway. The lounge is comfortably furnished with a sofa and armchairs and there is a TV and stereo. A door at one end of the lounge leads to another hallway off which is situated a WC with hand basin, three residents bedrooms and a storeroom. Another door from the lounge leads to a large conservatory area that is also comfortably furnished and houses a second TV and stereo. From the conservatory a large lawned garden Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 19 can be accessed. The kitchen is located off of the dining area and has a range of fitted units and the necessary appliances including a fridge and freezer. A door from the dining area leads to third hallway off of which is located the shower room and a further three bedrooms. Each resident has his or her own bedroom. Some residents showed us their rooms and told us that they were able to personalise them by displaying mementos. A major refurbishment programme has recently been completed within the home. As a result each residents bedroom and the communal areas have been redecorated. Some residents have also had their carpets replaced with laminate flooring. Since the last inspection the homes shower and bathrooms have been refurbished. Each has been converted to a “wet room” with walk in shower facilities, low level shower controls and storage shelves and shower seats. A hand basin and WC is also available in each. The shower room has been fitted with a urinal and the larger bathroom retains a tub with mixer tap and safety rails. People who use the service told the Inspector that they were happy with the new facilities and that they met their needs. During the course of the inspection we found the home to be clean, hygienic and free from offensive odours. Horse Leaze (7) DS0000063910.V362616.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 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs are employed in sufficient numbers and undertake National Vocational Qualifications. However, although the organisation offers a rolling annual programme of refresher and core training, take up by staff at the home is poor. There are also some gaps in the available documentation to evidence what pre employment checks have been undertaken by the organisation, and some staff are not evidenced as receiving regular supervision. EVIDENCE: The Manager told us that the home employs six full time care staff, and of these five have completed National Vocational Qualifications (NVQ) at level 2 or 3. We viewed the homes current staffing rota and found it reflected the situation in the home on the day of the inspection. The Manager is on site during office hours on weekdays, and two care staff is also on duty. The day is split into an early and late shift. One waking night staff is also employed. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 21 Heritage Care operates a centralised personnel department. Photocopies and records of some pre-employment checks were available on site, and we looked at these. Only one reference was available for each of the care staff sampled. An enhanced level Criminal Records Bureau check had been obtained for each in 2003 and 2004 respectively. Discussion with the Manager and sampling of personnel files for two staff members evidenced that new recruits receive a corporate induction to the organisation and a separate induction to the home. Residents within the home come from a diverse range of cultural backgrounds, and this is reflected within the staff group. Sampling of supervision records, discussion with the Manager and with care staff evidenced that training needs had been discussed in supervision sessions and access to online learning materials was available. However, only one staff member was evidenced as having undertaken training in the previous year. Sampling of supervision records and discussion with staff also evidenced that one care worker who had transferred to the home earlier in the year was on target to receive a minimum of six supervisions. This care worker told the Inspector that their supervision sessions were regular, and that they found them helpful and supportive in carrying out their work. However, a second care worker based at the home for some years had received two supervisions last year and one in the current year. Horse Leaze (7) DS0000063910.V362616.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 & 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is suitably qualified and experienced, and the home appropriately maintains many of the health and safety records required by legislation. The home has completed an annual quality assurance exercise to obtain the views of people who use the service. EVIDENCE: Since the last inspection the acting Manager has been permanently appointed on a full time basis. They have commenced the registration process with the Commission for Social Care Inspection. The Manager told us they had successfully completed their NVQ level 4 and Registered Managers Award studies. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 23 Since the last inspection the home has completed a quality assurance exercise. The Responsible Individual has published an executive summary. In addition to the homes six residents, eight other stakeholders were also canvassed for their views. The homes residents indicated in their questionnaires that they liked living at the home and rated the different services provided to residents as either good or very good. We examined a number of health and safety records that the home maintains. The fire records evidenced that the fire alarm call points are maintained in good working order, however these should be tested on a weekly basis and the homes record indicate that on two occasions in January and April 2008 a two week period elapsed between tests. The home carries out regular evacuation drills. The home maintains accident and incident reports and we sampled these and found them to be in good order. We looked at the homes log of water temperatures and found that these are tested and recorded on a weekly basis. The recorded temperatures were within acceptable limits. We also looked at the homes record of fridge and freezer temperatures. The temperature for the fridge was recorded on a daily basis, and when the temperature fell outside an acceptable range appropriate action was recorded as having taken place. There were several dates in February 2008 were freezer temperatures were not recorded. There were also some dates in April 2008 were the freezer temperature was too low and no action was recorded as having taken place to ensure food safety. The home displayed a current insurance certificate with adequate cover. Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 X 3 X 3 X X 2 3 Horse Leaze (7) DS0000063910.V362616.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 YA6 Regulation 15 Requirement Individual plans must address all aspects of personal, social and healthcare support. This is a restated requirement. The previous target of the 30/04/08 was not met. 2. YA34 19 & Sch 2 The home must evidence that two references are obtained for staff as part of their pre employment checks. The home must evidence that all staff receive a minimum of five days training each year. This is a restated requirement. The previous target of the 30/04/08 was not met. 4. YA36 12 & 18 Staff must receive regular, recorded supervision at least six times per year. This is a restated requirement. Previous targets of the 30/09/06 and Horse Leaze (7) DS0000063910.V362616.R01.S.doc Version 5.2 Page 26 Timescale for action 30/09/08 30/09/08 3. YA35 18 31/03/09 31/03/09 30/04/08 were not met. 5. YA42 16 & 23 The home must ensure that freezer temperatures are recorded on a daily basis and maintained within acceptable limits. The home must carry out and record weekly fire alarm call tests. 30/09/08 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 YA17 YA34 Good Practice Recommendations The home could record more detailed information when residents decline meals. The home should develop a policy on the timescales within which Criminal Records Bureau checks will be renewed. Horse Leaze (7) DS0000063910.V362616.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 Horse Leaze (7) DS0000063910.V362616.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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