Care Home: Hough Top

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What the care home does well What has improved since the last inspection? People who live at the home now have a detailed contract showing what it costs for them to live at the home. Care plans now have more information in them on how people like to be supported. This means their needs are well met in a person centred way. Staff have received training on epilepsy. This means they are better equipped to meet people`s needs. There has been a reduction in the number of errors made with people`s medication administration. This means people`s medication is safely managed. The garden area of the home continues to improve and be more attractive for people who use the service. CARE HOME ADULTS 18-65 Hough Top 7 Hough Top Leeds West Yorkshire LS13 4QW Lead Inspector Dawn Navesey Key Unannounced Inspection 8th August 2008 10:30 Hough Top DS0000001468.V369448.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 Hough Top DS0000001468.V369448.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. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hough Top Address 7 Hough Top Leeds West Yorkshire LS13 4QW 0113 204 0155 0113 2040155 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) TACT UK Ltd Mrs Joanne Clare Hargreaves Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hough Top DS0000001468.V369448.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 following gender: Either, whose primary care needs on admission to the home are within the following category: Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 4th January 2007 2. Date of last inspection Brief Description of the Service: The home is located in the residential area of Swinnow in Leeds not far from Pudsey. It is within easy walking distance of a local parade of shops that includes a post office. People who live at the home use these facilities on a regular basis. The home has a car that is well utilised to take people to appointments and trips out. A regular bus service is available to travel into the city centre or further afield. Personal care is provided for up to four people who have learning disabilities. All are currently below the age of 65 years. Nursing care is not provided and the home is supported by local health care services. Accommodation is domestic in style. The home is situated in a quiet street in a residential area. The home is located on two floors and bedrooms are situated on the ground floor. They are all single rooms, comfortable and well decorated in the personal style of the individual. There are large enclosed gardens to the rear of the house with a small patio area. The current scale of charges at the home is £1387.86 per week. Additional charges are made for hairdressing, activities, toiletries, clothes, holidays, transport and petrol. Hough Top DS0000001468.V369448.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 Commission for Social Care Inspection (CSCI) inspects services at a frequency determined by how the service has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk This unannounced visit was carried out by one inspector who was at the home from 10:30am to 3:15pm on 08 August 2008. The purpose of the inspection was to make sure the home was providing a good standard of care for the people who use the service. Before the inspection, evidence about the home was reviewed. This included looking at any reported incidents, accidents or complaints. This information was used to plan the visit. The manager of the home completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information. We looked at a number of documents during the visit and visited areas of the home used by the people who live there. We spent a good proportion of time talking with the people at the home and the staff. Comments made to us during the day appear in the body of the report. Survey forms were sent to people living at the home and staff. Information from those returned is reflected in this report. Feedback at the end of the visit was given to the senior support worker. What the service does well: People who live at the home said they were happy there. Most people nodded, smiled or said yes when we asked if they liked the home. One person said they had made good friends there. The environment is very homely, comfortable and safe for people who live at the home. A thorough assessment of people’s needs is carried out before anyone moves into the home. This means that people can be sure the home will meet their needs properly. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 6 Care plans are clear and have detailed instruction on how the needs of people who use the service are to be met. This makes sure people’s needs are met well, in the way they want them to be. People receive good personal support and look very well cared for. People’s health and personal care needs are well met. Staff had good knowledge of people’s personal support needs. Good records are kept of health appointments and their outcomes. People who live at the home get on well with staff. There was a good atmosphere in the home and staff’s interaction with people was respectful and dignified. One person said, “They look after me thank you” and “They are very good thanks”. Staff spoke highly of the training they receive from the organisation. These are some of the things they said: • • • • • • Training is seen as on-going. I have received much training recently. Updating all mandatory training. Also intensive interaction, breakaway, mental capacity act to name but a few. All new starters receive full relevant induction and training. Initially I shadowed senior staff and then was monitored and then signed off on individual tasks. Induction training was carried out at tact offices and covered all aspects of the job. We get a lot of training, Tact are really good for that. What has improved since the last inspection? What they could do better: Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 7 The contact details of the local authority should be included in the safeguarding adults and whistle blowing policies so that staff are able to report concerns to people outside of the home or organisation. This will make sure that people are properly protected. Staffing levels should be kept under review to make sure people’s needs are being fully met and they are getting out on activities in the community. Consideration should be given to the introduction of satisfaction questionnaires. These should be distributed to people who live at the home, their relatives or friends and any other professionals the home is involved with. This will make sure that people are asked for their views on any improvements that could be made to the service. 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. Hough Top DS0000001468.V369448.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 Hough Top DS0000001468.V369448.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 and 5 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home will meet their needs following assessment. EVIDENCE: People who live at the home said they were happy there. Most people nodded, smiled or said yes when we asked if they liked the home. One person said they had made good friends there. A thorough assessment of people’s needs is carried out before anyone moves into the home. This means that people can be sure the home will meet their needs properly. A recent assessment included the manager and staff going to assess the person in hospital. They were accompanied by members of staff who all could assist with the assessment. The person also visited the home on a number of occasions to see if it was right for them. Records showed that staff made detailed notes on these visits and that this information formed part of the assessment process. The manager also made sure that information was gained from the person’s previous placement and that a care management and nursing assessment was in place. Assessment for any aids and adaptations Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 10 was also done before the person moved in to make sure they had everything in place to meet the person’s needs. Staff said they had been trained to carry out assessments. The manager had drawn up an initial plan of care based on all the assessment information that they had gathered. Staff said they felt well equipped to meet the person’s needs from all the information they had. It was clear that the person had been involved in the process and had opportunity to say what they wanted. Every effort had also been made to consider the needs of the other people who live in the home when the assessment was carried out. In the AQAA, the manager said that each person is currently undergoing person centred assessments and meetings to establish whether they are happy in their home. This will make sure that any changes in people’s needs are reassessed. We also looked at contracts that had been drawn up between the home and the people living there. These have been produced in an easy read format and now show all costs to people. This includes contributions to petrol for the house vehicle. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 11 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 and 9 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are encouraged to make decisions about their lives and are involved in planning their care and support. EVIDENCE: In the AQAA, the manager said, ‘Each Person has comprehensive person centred care plans and risk assessments to ensure their support meet their needs and choices. The Service supports each Person to participate and review their care plans every three months, and the Person’s key workers review their risk assessments every month.’ We looked at care plan and risk assessment records for some people who live at the home. We found them to be person centred and very individual to each person. They had clear and detailed instruction on how the needs of people who use the service are to be met. They had good information about how people should be supported with personal care, social and health needs. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 12 One member of staff said, “Each supported person has risk assessments, care plans, detailed personal files, giving all the relevant information.” People’s cultural needs were identified well. A person who doesn’t wish to attend a church is however supported to follow Christian beliefs. Care plans on communication include pictures, of a person who uses their own sign language, using the signs. Staff said they found this really useful when getting to know the signs. Staff were familiar with what was written in people’s care plans and could talk confidently about the support they give. There are good systems in place to make sure that staff are aware of any changes in people’s needs. Any new care plans or risk assessments are brought to the attention of staff through handover meetings and a communication file. This makes sure people’s needs are not missed or overlooked. In the AQAA, the manager said, ‘The Service employs three members of staff that are trained and practising Person Centred Planning facilitators.’ Staff said they felt well equipped and trained in care planning and risk assessment. One said, “The training was part of the NVQ (National Vocational Qualification) 3”. Some people have been supported to develop a person centred plan. One we saw had been written in the person’s own words and included lots of pictures to make it more easily understood by the person. This is good practice and shows how the person has been involved in planning their own care, support and future. Care plans are also reviewed regularly. Key workers do this on a monthly basis with people who live at the home, to make sure they are still meeting people’s needs properly. Staff said they also go through each person’s care plans at team meetings so that all staff can contribute to any changes that may need to be made. Staff said this was also a good way for suggestions to be made that may enhance a person’s lifestyle or further their independence. Care plans linked well to risk management plans. There is a clear emphasis on furthering people’s independence and involving them in the daily life of the home. People are given support to be as involved as they can be. Regular meetings take place in the home for people who live there. They are encouraged to discuss activities, events, holidays, menus, staff recruitment and household activity. We saw staff were very respectful in their interactions with people. People who live at the home were encouraged to make choices throughout the day. These included choices of food and activities and also the choice to spend time alone if they wished. Staff respected people’s wishes and gave good explanations if a choice wasn’t available. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are able to make some choices about their lifestyle. Overall, social, educational, cultural and recreational activities meet most people’s expectations. They also benefit from a good, healthy and varied diet. EVIDENCE: In the AQAA, the manager said, ‘The Supported People continue to receive support to participate in a person centred Programme of Activities. Staff ensure that the Supported People are given the opportunity to fulfil their spiritual needs. One individual is supported to visit his church every week and is a volunteer for handing out the hymn books before each Service.’ Activity on offer to people includes, listening to music, watching television, board games, following hobbies such as gardening or collecting things and cooking or baking sessions. Key workers are encouraged to make sure people Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 14 have a plentiful supply of any materials needed to follow hobbies and interests. There are good support plans in place regarding people’s leisure needs. People also attend activities in the community. Some people go to an opportunities service where activity includes, plane spotting, walking and artwork. People who live at the home are well known in their local community. They use local shops, pubs, cafes and parks. Community presence is seen as important for people’s self esteem and well being. On the day of the visit, most people who live at the home went out on some activity. Staff said they try to make sure that everyone gets the opportunity to go out somewhere every day if they want to. Staff said that in the main they had enough staff to support people with their activities. They said that on occasions when there are only two staff on duty it is more difficult to get people out. In a returned survey, one staff said, “The house is staffed accordingly. However on a few occasions staff absences mean there is not always enough staff to get the lads out.” This should be monitored to see how activity levels are being affected by staff shortages. Several holidays have been arranged this year. They include trips to Ireland and a cottage holiday in Darwin Forest. People are given good support to keep in touch with family and friends. Some people regularly write letters to family. Others are supported to make telephone calls or invite their friends and family to the home. People who live at the home get on well with staff. There was a good atmosphere in the home and staff’s interaction with people was respectful and dignified. Staff show a good understanding of peoples different communication needs and make sure people are given good support to maintain their independence. Staff gave good examples of how people are involved in the daily life of the home and encouraged to do what they can for themselves. Menus appear to be well balanced and nutritious. Staff said they try to make sure people have a good variety of foods while still having their favourites and choices. People nodded and said yes when asked if they liked the food. Staff said they would always provide an alternative if people didn’t like what was on the menu. Menus are based on the likes and dislikes of people who live at the home. People who live at the home also help with the weekly shopping and make choices of what they would like when they are out at the shops. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 15 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 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s general healthcare needs are well met and based upon their individual needs. EVIDENCE: Staff had good knowledge of people’s personal support needs. Staff were thoughtful, discreet and respectful of people’s dignity when attending to any personal care needs. People who live at the home looked well dressed and groomed. Good records are kept of health appointments and their outcomes. Staff make sure that people are given support to attend appointments to meet their health needs. People are referred to health professionals when needed. Staff have identified and monitored health needs well. Where they have found additional needs for people, new care plans have been put in place to make sure people’s needs are fully met. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 16 Care plans regarding people’s health needs are detailed and specific. In the AQAA, the manager said, ‘All care plans and risk assessments regarding individual’s personal and healthcare needs are produced with the individual at the centre of the plan. This equips each worker with the knowledge and skill about how to support each person in a way appropriate to them.’ Staff have received training on meeting the specific health needs of people who live at the home. Courses have included, epilepsy and the use of hoists and wheelchairs. Staff spoke highly of the training and said it gave them what they needed to carry out their jobs. In the AQAA, the manager said, improvements to the service had been made. She said, ‘The Service has reduced the number of medication errors by tightening the in-house procedures and practices’, ensuring all medication is given by two trained staff. I have also implemented that the homes medications are audited once a week.’ There had been a number of errors in the administration of medication since our last inspection of the home. Since this new system has been introduced, the number of errors has reduced. Staff confirmed that two staff give medication and that senior staff check the medication and record sheets on a weekly basis. The home uses a monitored dosage pre-packed system for medication. There are good ordering and checking systems in place. We checked some medication administration records (MAR) sheets. These were found to be in good order. Staff said they did not administer medication unless they had been trained to do so. The manager of the home has also been trained to deliver safe handling of medicines training to the staff. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Overall people are protected. People are confident that they will be listened to and that action will be taken when necessary. EVIDENCE: The home has an easy read complaints procedure. This is kept on display in the home. Staff said they are also aware of the signs people may show when they are unhappy about something. One person pointed to a member of staff when asked who they would tell if they were unhappy with anything. It was clear from staff’s interactions with people that the people who live at the home seemed confident to raise their wishes or concerns. In surveys returned to us from staff, staff said they knew what to do if someone living at the home or their relative had any concerns. One said “ Tact has a complaints policy and this would be adhered to”. Most staff have received training in safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. The home has a detailed safeguarding adults policy and a whistle blowing policy. It is recommended that the contact details of the local authority are included in these policies so that staff are able to report concerns to people outside of the home or organisation. This will make sure that people are properly protected. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 18 Good records are kept of the finances of people who live at the home and their monies are kept safe. Proper handovers of the monies takes place at each shift change and the manager regularly checks the finance records and receipts. This makes sure that people are protected from financial abuse. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The environment is very homely, comfortable and safe for people who live at the home. EVIDENCE: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was clean, tidy and homely. People who live at the home were proud of their bedrooms and were pleased to show us round. In the AQAA, the manager said, ‘Staff are responsible for following a daily cleaning programme; this is also the practise of the night staff. By fulfilling this objective, staff are able to promote good health and safety practises, whilst ensuring the home is safe, clean and comfortable.’ Bedrooms were very personal, and consideration had been given to the décor and furnishings to make sure it reflects the hobbies and individuality of the people who live there. Each bedroom had photographs, pictures and personal Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 20 items. In the AQAA, the manager said, ‘All décor is done by collaborating with the People who use the Service, and their needs and choices are the forefront of the workers practises.’ The gardens are very attractive and kept to a high standard. Staff said they assist with the gardens as part of special projects and team building events. Staff said that some people at the home also do some of the gardening. One person had recently done the hanging baskets. The kitchen was clean and proper procedures were being followed to promote safe food hygiene practices. People who live at the home can access the kitchen with staff’s supervision. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who live at the home. Staff have received training in infection control as part of their induction and were able to say what infection control measures are in place. Hand washing and hand drying facilities were available in all areas of the home. Liquid soap or paper towels were available. This ensures good hygiene practice. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are, in the main, enough staff. They are trained and competent to meet the needs of the people who use the service. People are protected by the home’s recruitment procedures. EVIDENCE: People who live at the home said they liked the staff. One person said, “They look after me thank you” and “They are very good thanks”. Staff said that ideally they have three staff on the morning and afternoon shifts at the home. We looked at the rota for the last few months and saw that on most occasions there are only two staff on each shift. Staff said that this happens when there is any sickness or vacancies. In the AQAA, the manager had identified recent problems with staff sickness. She said, ‘The Service must reduce staff absences. This would entail intensive supervisions and supportive back to work interviews after a worker has had a number of periods of absences from work.’ Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 22 As mentioned in the Lifestyle section of this report staff said that staff shortages affect their ability to get people out on community activities. However, staff also said that on the occasions when there are two staff on duty they are able to meet people’s needs. One said, “There is always enough staff to ensure the supported people are not in any danger”. Another said, “Rotas are designed to meet service users needs”. Staffing levels should be kept under review to make sure people’s needs are being fully met. The manager and the deputy manager are the only people in the home who have access to staff’s recruitment records. The manager however, has developed a recruitment chart that she signs to say recruitment is carried out properly and includes application forms, interview notes, references and CRB (criminal records bureau) checks. This was available for our inspection. Records showed that staff’s training was up to date. The manager has good records on staff’s training and can easily see when updates are due. Staff spoke highly of the training they receive from the organisation. These are some of the things they said: • • • • • • Training is seen as on-going. I have received much training recently. Updating all mandatory training. Also intensive interaction, breakaway, mental capacity act to name but a few. All new starters receive full relevant induction and training. Initially I shadowed senior staff and then was monitored and then signed off on individual tasks. Induction training was carried out at tact offices and covered all aspects of the job. We get a lot of training, Tact are really good for that. The majority of staff have completed an NVQ (National Vocational Qualification) in care at level 2 or above. Other staff are also working towards this. Some staff are also trained to be facilitators of person centred planning. This has given them the skills to work with people to identify their future hopes, dreams and aspirations. Staff meetings are held every month and additional meetings are held to talk about care issues. Staff also said they received regular supervision and had opportunities for personal development. One said, “We receive regular supervisions, the door is always open for a ‘chat’ or any advice”. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed. The interests of people who use the service are seen as important to the manager and staff and are safeguarded and respected. EVIDENCE: In the AQAA, the manager said she thought the service does well by saying, ‘The service continues to deliver a person centred service to meet the diverse needs of the People we Support.’ The home has an experienced manager who continues to work on gaining the registered managers award. Some of the time she works alongside staff to make sure of good practice. She also has some management time to attend Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 24 to her management role. All staff said she was supportive and had good leadership qualities. Staff said they felt trusted and the manager was able to delegate to them. One said, “The Service manager has an open door and always willing to listen or give advice at anytime on any subject”. The organisation’s area manager, visits on a on a monthly basis to carry out monitoring visits. This involves talking to people who live at the home and to staff. A report of these visits is made showing details of any action to be taken to improve the service. The senior support worker, in charge on the day of the visit, was not aware of any quality assurance feedback questionnaires being sent out by the organisation. It is recommended that consideration is given to the introduction of these to people who live at the home, their relatives or friends and any other professionals the home is involved with, asking for their views on any improvements that could be made. Arrangements are in place to make sure of safe working practices. The home has a comprehensive range of health and safety policies and procedures in place. Staff are given opportunity to read and become familiar with these. Health and safety checks are carried out around the home and fire records are maintained. In the AQAA, the manager confirmed that all health and safety checks are up to date. Accident or incident reports are completed. The manager analyses these to identify any patterns or trends and to look at ways of avoiding future accidents. Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 25 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 4 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 3 2 X X 3 X Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 YA23 Good Practice Recommendations The contact details of the local authority should be included in the safeguarding adults and whistle blowing policies so that staff are able to report concerns to people outside of the home or organisation. This will make sure that people are properly protected. Staffing levels should be kept under review to make sure people’s needs are being fully met. Consideration should be given to the introduction of satisfaction questionnaires. These should be distributed to people who live at the home, their relatives or friends and any other professionals the home is involved with. This will make sure that people are asked for their views on any improvements that could be made to the service. 2. 3. YA33 YA39 Hough Top DS0000001468.V369448.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Hough Top DS0000001468.V369448.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. 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