Care Home: House Of Light

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What the care home does well What has improved since the last inspection? Medication systems have been made safer and care plans now contain information that consents to care workers administering medication and personal preference for administration. This is good practice and makes sure people get what they need. Environmental risk assessments have been carried out to make sure the environment is safe for people. Hand washing facilities have been provided in the laundry. The laundry has also been re-decorated.The manager has completed the registered managers award. This means she has a management qualification to assist in the management of the home. Staff have been trained in using the tools of person centred planning. This means they can support people to identify their needs and future aspirations and dreams. CARE HOME ADULTS 18-65 House Of Light 13 Allerton Park Leeds West Yorkshire LS7 4ND Lead Inspector Dawn Navesey Key Unannounced Inspection 4th September 2008 2:00pm House Of Light DS0000001469.V370559.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 House Of Light DS0000001469.V370559.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. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service House Of Light Address 13 Allerton Park Leeds West Yorkshire LS7 4ND 0113 268 1480 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) allerton.park@catholic-care.org.uk Catholic Care (Diocese of Leeds) Miss Aileen Donnelly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2006 Brief Description of the Service: The House Of Light provides accommodation for 6 people with learning disabilities. The home does not provide nursing care. The home is based in a large detached private house situated in the residential area of Allerton Park. The house is adjacent to other private dwellings and blends into the suburban area. The accommodation is on four floors with 6 single bedrooms based on the lower ground, 1st and 2nd floors. There are three reception rooms based on the ground floor providing alternative communal seating and activity areas. The home has extensive gardens and lawn, which complement the overall appearance of the home. The local shops and community facilities are a short walk away in the Chapel Allerton area. The home also has its own minibus. The current charges at the home are £654.33 per week. More information is available from the manager of the home. House Of Light DS0000001469.V370559.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 3 star. This means the people who use this service experience excellent 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 One inspector who was at the home from 2:00pm until 7:15pm on 04 September 2008 carried out this unannounced visit. 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, staff and the manager. 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 manager. What the service does well: People who live at the home said they were happy with the service. Comments included: • I am happy at the house. • This is my home, I love it. • They are very good, make sure we get what we need. The home has a low turnover of staff and many staff have worked at the home for a number of years. They showed a good understanding of person centred care. They had excellent knowledge of people’s personal and emotional House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 6 support needs. Staff were thoughtful, discreet and respectful of people’s dignity when attending to any of their needs. People who live at the home looked well dressed and groomed. A staff member said, “I feel the staff work together to meet the needs of the residents and we are continually supporting each other to provide high quality care for our residents.” People who live at the home and staff get on well. We saw good interaction between people who live at the home and staff. People were very relaxed with staff and were pleased to see staff when they arrived. People were chatting, laughing and joking, and enjoying the company of staff. There was a good atmosphere. People lead an active and fulfilling lifestyle. They are encouraged to be independent and to take part in community life. People who live at the home said they enjoyed life there. These are some of the things they said: • • • • • • Staff help me to choose my summer holiday and take me to the holiday shop to get brochures. I like going abroad and staying up late at the disco. I do lots of different things with the staff at the house because I go to the centre on a afternoon. I like to make everyone tea. I do the shopping on Friday. I am happy that we go out and about. I always use the telephone to speak to my family and visit my mum anytime that I can. The manager is supportive of staff and leads by her own example. Staff said: • • It is good to know that you have support from your manager. She’s brilliant, always there when you need her. The manager is highly organised and records in the home are well kept. What has improved since the last inspection? Medication systems have been made safer and care plans now contain information that consents to care workers administering medication and personal preference for administration. This is good practice and makes sure people get what they need. Environmental risk assessments have been carried out to make sure the environment is safe for people. Hand washing facilities have been provided in the laundry. The laundry has also been re-decorated. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 7 The manager has completed the registered managers award. This means she has a management qualification to assist in the management of the home. Staff have been trained in using the tools of person centred planning. This means they can support people to identify their needs and future aspirations and dreams. 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. House Of Light DS0000001469.V370559.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 House Of Light DS0000001469.V370559.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 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 who use the service can be sure that the home will meet their needs following assessment. EVIDENCE: No new people have moved into the home for some time. We looked at the home’s admissions procedure and saw this clearly states the steps to be followed for anyone moving into the home. This included, assessment carried out by the home and a care management or social worker assessment. Introductory visits to the home would then be planned. These would be person centred and include visits for meals and overnight stays. The thoughts and feelings of people currently living at the home would also be considered to make sure people get on well together. People who live at the home were positive about their choice of home. They said: • • • I am happy at the house. My social worker visited the house with me a long time ago. This is my home, I love it. DS0000001469.V370559.R01.S.doc Version 5.2 Page 10 House Of Light The needs of people who live at the home are re-assessed on a regular basis. Staff said they go through peoples’ care plans with them on a monthly basis to see if anything has changed and if people’s needs are being properly met. They said they then make sure this is communicated to all staff via handovers and meetings. Staff gave examples of how they had identified changes for people through doing this. For example, someone who was finding an evening class too tiring. House Of Light DS0000001469.V370559.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 judgment 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, ‘Our aim, ethos and vision for the home is to instill a sense of self-empowerment in people. We ensure that our residents are fully aware of their own decision-making power, that to take appropriate risks can be healthy in life and that their personal goals and dreams are very important, so much so that we incorporate them in each persons care file/care plans.’ We looked at care plan records for some people who live at the home. We found them to be person centred and very individual to each person. They House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 12 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. People who use the service had been involved in drawing the plans up and developing their person centred plan. Pictures, photographs and artwork represented the plans. This variety of creative methods has helped people to contribute well to the development of their plans. People who live at the home were very pleased with and proud of their plans. One person told us how planning had helped contribute to them reaching their goals in life. They said they had been on holidays and started a re-cycling project in the home. Staff were familiar with what was written in people’s care plans and could talk confidently about the support they give. As mentioned in the Choice of Home section of this report, 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. We also looked at people’s risk assessment records too. Most of these had been completed in full and where there were risks to people, a risk management plan had been put in place. These were based on people’s strengths and aimed at furthering people’s independence. Some people have been supported so they can go out in the local area independent of staff. A staff member said, “ We all have to take risks in life to get our independence”. One person’s records showed some minor shortfalls in that there were some risks for them that had not been fully assessed. We discussed this with the manager and she said she would make sure this was now completed with the person. Staff said they felt they met people’s needs well. This is a selection of their comments: • • • • • Care plans are done twice a day and we do handover at each shift. Individuals have a choice of what they’d like and we always try to accommodate their needs to the best of our ability by having one-ones and always asking them what they would like to do. We help promote independence, choice, rights individually and try to give our residents a fulfilled and happy life. I really feel that the service works well with all the residents. Treating them with respect dignity and treating them as individuals with individual needs. Reviews ensure we are continually looking at the residents changing needs and choices and adapting their care required to meet these needs. People who live in the home said they had regular meetings in the home to discuss activities, the menus, staff/volunteer recruitment and anything that was bothering them. We saw minutes of these meetings that showed people had been able to voice their opinions. People who live at the home chair the House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 13 meetings. It was clear that people could choose how to spend their time and make decisions about their lives. One person said, “I enjoy chairing the residents’ meetings because people listen to me.” House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14,15,16 and 17 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. People who use the service are able to make choices about their lifestyle. Social, educational, cultural and recreational activities meet people’s expectations. They also benefit from a good, healthy and varied diet. EVIDENCE: In the AQAA, the manager said, ‘We encourage our residents to participate in age-related activities in various social settings, both at the skills centres and outside the home at evening classes and clubs of their individual choice. We encourage family contact as well as contact with friends outside the home, as this is so important for overall wellbeing and a sense of worth and value. We have assisted this last year in providing some excellent personal holidays. By way of example, we have had three group holidays - one to Kos, another to Rhodes and the third to Egypt, all staying in 5 star hotels, all inclusive House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 15 real dream holidays, enjoyed by all. Another group have just returned from a weeks pilgrimage to Lourdes in France. People who live at the home said they enjoyed life there. These are some of the things they said: • • • • • • Staff help me to choose my summer holiday and take me to the holiday shop to get brochures. I like going abroad and staying up late at the disco. I do lots of different things with the staff at the house because I go to the centre on a afternoon. I like to make everyone tea. I do the shopping on Friday. I am happy that we go out and about. I always use the telephone to speak to my family and visit my mum anytime that I can. Staff’s comments included: • • • • We do a lot of one to ones which is great for the residents. We always take into account a persons beliefs and values religion, cultural values, age and choices, gender, family, also risk taking. They all have a summer and winter holiday. One person recently had an interview for a volunteer’s job at the day centre. We did lots of practice with them. People who live at the home are involved in their local community. Staff said they have an open day every year where they invite neighbours and families for a party. People who live at the home said how much they enjoyed this. People are regular users of the many local cafes and shops. One person said they liked to go out for coffee and try out all the different coffees on offer. Another person told us how they had recently been to a local arts and music festival. Another said they had been to a recent West Indian carnival and sampled West Indian food. Staff said they had good links with a number of church parishes in the area. Some people choose to attend Catholic church, others go to a Methodist church. People are given good support to keep in touch with family and friends. Staff said they support people by reminding them to contact their family or take flowers when they visit. Staff said they also encourage families and friends to visit the home and get involved with life there. We saw lots of photographs of parties and events at the home where families had been involved. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 16 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, such as signing, 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. In the AQAA, the manager said, ‘Our menus have become more adventurous, with meals from Thailand, India, China and Mexico and others appearing on the weekly menu sheets.’ 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 choose the menus from recipe books and cards. This is good practice and makes sure everyone who lives at the home can get involved in menu planning. 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. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 17 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 excellent 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: In the AQAA, the manager said, ‘As a team we carefully monitor the health needs of all our residents, not just physical needs, but mental, emotional and also spiritual needs. We work closely within a multi-disciplinary model of support, liaising with GPs, nurses, psychiatrists and other specialists to ensure that the care of the whole person is being met in an holistic manner.’ 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 encouraged to manage their own health care appointments and collect their prescriptions. People are referred to health professionals when needed. Staff have identified and monitored health needs well. Where House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 18 they have found additional needs for people, new care plans have been put in place to make sure people’s needs are fully met. Care plans regarding people’s health and personal care needs are detailed and specific. Staff have received training on meeting the specific health needs of people who live at the home. For example, training from local health professionals on meeting people’s emotional needs. Also, in the AQAA, the manager said, ‘The staff team are at present involved with a Nutrition in Health Care course. This will highlight the importance of healthy eating within our home.’ Staff had excellent knowledge of people’s personal and emotional support needs. Staff were thoughtful, discreet and respectful of people’s dignity when attending to any of their needs. People who live at the home looked well dressed and groomed. A person that lives at the home said, “They are very good, make sure we get what we need”. A staff member said, “I feel the staff work together to meet the needs of the residents and we are continually supporting each other to provide high quality care for our residents.” We looked at the medication in the home. As previously mentioned, people are encouraged to collect their prescriptions and the medication is brought in to the home. Staff complete a medication administration record (MAR) sheet with details of people’s prescribed medication. We checked the MAR sheets and found them to be in order. However, the manager had not been recording the amounts of medication received in to the home. This means that any errors in medication administration could not be investigated properly. She agreed to rectify this and introduce a system for it. All staff are trained in medication administration and handling. Staff confirmed that no one would administer medication unless they had been trained to do so. Care plans now contain information that consents to care workers administering medication and personal preference for administration. This is good practice and makes sure people get what they need. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 19 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: In the AQAA, the manager said, ‘We pride ourselves on active listening skills and giving our residents the time they need to express themselves and their views and opinions fully. We ensure that all of our residents are protected from abuse, neglect, etc, by using the appropriate policies and guidelines provided by Catholic Care and the Adult Protection Agency.’ The home has an easy read complaints procedure. This is kept on display in the home. In surveys returned to us, everyone said they would speak to staff if they were not happy about something. 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. Staff were aware of the procedures to follow if someone made a complaint. We looked at the complaints book. The home has not received any complaints for quite some time. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 20 In the AQAA, the manager also said ‘We will soon be attending a course on the Deprivation of liberty/Mental Capacity Act. This will ensure that staff have a greater understanding of the rights of people in our care, their liberty and the decision making process.’ Staff said they were looking forward to this training. One said, “All staff at the house of light are undergoing training in the Mental Capacity Act. This is about supporting people we care for to make their own decisions and if the decision taken for someone who lacks capacity must be taken in the persons best interest.” 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. Staff showed they had a good understanding of need to report concerns through management system or outside the home if needed. The home has a detailed safeguarding adults policy and a whistle blowing policy. They also have a copy of the Leeds Multi-Agency Adult Protection Policy and Procedure. This gives staff information on who to contact in the event of any allegations or suspicions of abuse. It is recommended that the contact details from here are also recorded in the home’s own policies to make sure this information is easily accessible. 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, to make sure people are protected from financial abuse. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 21 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 good 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: In the AQAA, the manager said, ‘Every effort is taken to provide a very comfortable home for people to live in. This includes residents bedrooms, where personal choice is of the utmost importance to us. The residents are fully involved in the cleaning and upkeep of their own rooms and the home in general. We try to instill in people a sense of personal pride in their environment, whilst ensuring that health and safety measures are adhered to whilst carrying out any cleaning tasks and that the residents are aware of these and fully understand them.’ House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 22 A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was very clean, tidy and homely. People who live at the home were proud of their bedrooms and were pleased to show us round. One person said, “I like the house and the garden and trees.” Another said “I love it here”. 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 items. In the AQAA, the manager also said, ‘We have also become a much greener home, with many ideas implemented by staff and residents alike, eg, low energy bulbs, glass, cardboard and paper recycling, and a greater awareness of waste within the home.’ People who live at the home were eager to talk about this project and what they had done to recycle. The gardens are very attractive and kept to a high standard. People who live at the home said they use the garden a lot in the better weather. The manager said the home has a gardener for its upkeep. 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. 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 not available in all areas of the home. Liquid soap and paper towels should be available in all hand washing areas. This ensures good hygiene practice. The manager agreed to do this. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 23 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. Overall, there are 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: We saw good interaction between people who live at the home and staff. People were very relaxed with staff and were pleased to see staff when they arrived. People were chatting, laughing and joking, and enjoying the company of staff. There was a good atmosphere. People who live at the home said they liked the staff. One said, “If I need anything the staff always get it.” Others smiled, nodded and signed with a thumbs up when asked if staff treated them well. The home has a low turnover of staff and many staff have worked at the home for a number of years. Staff had good knowledge of the people who live at the home and were able to provide information about individual likes and dislikes. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 24 There are usually two staff on each shift through the day and one staff member who sleeps in at the home to provide any support if needed through the night. There is also a senior member of staff on call for any emergencies. The manager said that for ten months of the year they have overseas volunteers who work at the home. This then means that they have more staff on shift and more staff around for activities. We looked at some staff and volunteer recruitment records. These were in order and include references and CRB (criminal records bureau) checks. However, some staff’s records are not kept in the home at the moment. The manager said these are people who have worked at the home for a long time and their records are at the head office. She said she would make sure she got them to keep at the home so they could be inspected. Staff confirmed proper recruitment procedures took place. One said, “I had to give names of employers I had worked for. They also did a CRB before I could start my employment, once it was fine I could start work.” 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: • • • The induction was really good and I also felt it really helped me and gave me a good insight to my job. I have just done my NVQ 3 and feel that I gained lots of knowledge. We always have the chance to go on courses which is relevant to our role. All of the permanent staff have completed an NVQ (National Vocational Qualification) in care at level 2 or above. Some staff are also trained in 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. Staff also said they received regular supervision and had opportunities for personal development. Their comments included: • • • • I have supervision every month and this gives me chance to voice any concerns I have. We have regular supervisions where I can discuss all aspects of my job and if I am happy with how it is going and I have the opportunity to discuss any training I would like to do. I would just like to say that I really enjoy working at the house of light. We have a good team that all strive for the same thing. I really enjoy my job and get great job satisfaction. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 25 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 very 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 the home is run well ‘By working as a team and having monthly staff meetings and shift hand-overs ensures information is shared. Residents also have monthly meetings to raise issues and share their views. We work with person centred planning to ensure residents maintain their individuality and diversity and hold six-monthly reviews.’ House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 26 A staff member thought the home is well run and said, “I think as a service we cater really well for residents we always put their needs first and try to give them a full and happy life.” The home has an experienced, well-organised manager who has now achieved the registered managers award. We recommend that she now go on to complete the NVQ level 4 in health and social care so that she has a qualification in care as well as management. Some of the time she works alongside staff to make sure of good practice. She also has some management time to attend to her management role. All staff said she was supportive and had good leadership qualities. One said, “It is good to know that you have support from your manager.” Another said, “She’s brilliant, always there when you need her”. A representative from the organisation, 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 organisation does not send out its own quality assurance feedback questionnaires to gain the views of people who use the service. 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. Records are kept in excellent order. They are clear, accessible, reviewed and up to date. House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 27 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 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 4 3 X X 4 X House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 28 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. 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 YA20 Good Practice Recommendations The amounts of medication received in to the home should be recorded on the MAR sheets. This will make sure that any errors in medication administration can be properly investigated. Liquid soap and paper towels should be available at all sinks where hands are washed. This is to prevent the spread of infection. 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. YA30 3. YA39 House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 29 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 House Of Light DS0000001469.V370559.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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