Care Home: Jean Marshall House

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What the care home does well There is a detailed admissions and assessment process to ensure that individual residents care needs can be met in the home. The information from which is used to compile a detailed individual plan of care. The staff team were observed during the inspection to ensure that the privacy and dignity of residents is respected at all times. The standard of the environment is good. The home provides residents with a homely, relaxed and caring environment. Residents are enabled where possible to exercise choice and control over their lives whilst resident. There is a detailed complaints procedure in place for residents/representatives to raise any concerns should they wish to. What has improved since the last inspection? No Requirements were made following the last Inspection. What the care home could do better: CARE HOME ADULTS 18-65 Jean Marshall House 15 Wilbury Avenue Hove East Sussex BN3 6HR Lead Inspector Judy Gossedge Unannounced Inspection 22nd February 2008 10:40 Jean Marshall House DS0000068102.V357923.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 Jean Marshall House DS0000068102.V357923.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. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jean Marshall House Address 15 Wilbury Avenue Hove East Sussex BN3 6HR 01273 772866 01273 773109 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) The Outlook Foundation Mrs Jean Marshall Care Home 9 Category(ies) of Learning disability (0) registration, with number of places Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability (LD). The maximum number of service users to be accommodated is 9. Date of last inspection 28th February 2007 Brief Description of the Service: Jean Marshall House is a registered care home for up to nine people who have a learning disability. The home is owned by a charity the Outlook Foundation who also operates another registered care home and supported accommodation unit within the Brighton area. The homes aims to provide three long-term placements for residents aged over 25 years and six placements for residents aged 18 to 25 years. For residents who are aged 18 to 25 years the home offers a programme of further education and life and vocational skills over a maximum period of seven years. This is with the intention of residents developing sufficient skills and confidence to be able to live an independent life when they leave. For residents over 25 years the intention is for them to be supported to maintain their independence. The home is a converted domestic dwelling within a residential area on the outskirts of Hove. It is located near to train and bus links into Brighton and Hove. The home is presented across three floors with resident’s accommodation consisting of six en-suite bedrooms and three bed sits. Communal space consists of a lounge and conservatory, which is used as the dining room. There is a small courtyard garden to one side of the home. The homes literature says that it aims to help residents learn new skills, provide support to do the things that service users are good and work with service users so they can live more independently. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 5 The fees for residential care are currently £44K to £45K per annum, depending on the services and facilities provided, with additional charges made where one to one support is provided. Extra such as: Hairdressing, chiropody, holiday’s, some leisure activities and toiletries are also additional costs. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 6 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. This unannounced inspection took place over five hours on 22 February 2008. This also included a visit to the organisations headquarters to view staff recruitment and training documentation not held at Jean Marshall House An Annual Quality Assurance Assessment (AQAA) has been requested for this service, and detail from this has been included in this report. A tour of the premises took place to look at communal areas and a selection of resident’s bedrooms and care records were inspected. Three residents were present during the Inspection and all were spoken with individually. The remaining five residents were away for the half term. The care that two of the residents received was reviewed. The opportunity was also taken to observe the interaction between staff and residents in the communal areas. Five residents surveys were sent out and all came back completed. The two care workers on duty, the training manager, the cook, the housekeeper, care manager, administrative staff and the Registered Manager were all spoken with. Three relative surveys were sent out and two came back completed. A social care worker was also spoken with after the Inspection. The Manager stated that age range and number of residents to be accommodated is being reviewed, and changes to the accommodation planned to provide seven bedrooms with en-suite facilities, one bed sit, and further additional communal space. What the service does well: What has improved since the last inspection? Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 7 No Requirements were made following the last Inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Jean Marshall House DS0000068102.V357923.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 Jean Marshall House DS0000068102.V357923.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): 1,2,and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Detailed information about Jean Marshall House is available to be viewed prior to any admission to the home and there are detailed pre-admission procedures in place to ensure that service users are appropriately placed in the home. Resident’s benefit from the protection of written terms and conditions with the home. EVIDENCE: There is a detailed Statement of Purpose and Service Users Guide available to view. The Manager stated these documents are available to potential new residents or their representatives to read. All five of the resident’s surveys stated they had received enough information about the home before they moved in. There is a lengthy and vigorous assessment process to ensure that prospective residents need’s can be met and that they are suitable to undertake the programme. This involves interviews and visits, which can range from an overnight stay to weeklong assessments. During the weekly assessment, a comprehensive individual assessment programme is developed. This covers Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 10 standard skills and the current range of abilities. The organisation provides new care workers with induction and mandatory training. Records viewed demonstrated there are training opportunities through the organisations. There is a comprehensive staff handbook for staff to reference. The care workers spoken with demonstrated knowledge of the service users care needs for those whose care needs were reviewed. There are written terms and conditions between the home and the resident and the three residents documentation viewed had a completed copy in place. Jean Marshall House DS0000068102.V357923.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 and 9. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents individual care plans and supporting risk assessments provide staff with the information they need to ensure that service users individual care needs are met. Residents are enabled to make decisions in all areas of their daily living during their stay. EVIDENCE: Three residents individual plans were viewed, which were detailed, and drawn up with the resident and based on each individual assessment of need. All the care plans contained detailed information about the individual support to be provided for each resident to enable them to achieve maximum independence and develop their skills, and had been subject to a review to ensure that the agreed goals are being worked towards. Staff spoken with demonstrated that they are aware how they should provide support to assist each resident. Supporting risk assessments were also seen to be in place. The five residents surveys were varied when asked if they can make decisions about what they Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 12 do each day and stated usually or sometimes. The two relatives surveys stated that the home always or usually meets the needs of the residents and both stated that service users are always supported to live the life they choose. Comments received were, ‘yes, I believe they work very hard to meet the needs of their service users,’ ‘as far as I am aware Jean Marshall House make every effort to meet my relative’s needs. Where circumstances make this difficult, and it is inevitable in the real world, that this sometimes be the case, they do their very best. Whenever difficulties have (rarely) arisen, I have found Marshall House open minded and flexible.’ Evidence gathered from documentation, feedback and observation of staff supporting residents highlighted that the home provides a service where residents are encouraged and supported towards independence. The daily routines of the home are largely determined by the resident’s individual programmes, and the three resident’s spoken with confirmed flexibility in their daily routines and respect for their personal freedom and lifestyles. During the Inspection residents were observed to move around the communal space freely, choosing which rooms to be in and what level of company they wanted to enjoy. Residents were able to choose when to spend time on their own, and can do so in their own bedrooms. Jean Marshall House DS0000068102.V357923.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, 15, 16 and 17. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to pursue their educational, vocational and social interests. The meals on the home are good offering both choice and variety and residents have the opportunity to plan and prepare their own meals. EVIDENCE: Each resident has their own life skills programme, which is designed to meet their individual need and support them to reach their full potential for independent living. Care plans and weekly timetables viewed, discussions with residents, and staff evidenced that service users are being supported to access a range of educational, vocational and social activities. Residents spoke of are being supported to access activities in their local community and make use of available facilities. One relative stated when asked what does the home does well that, ‘tailors an individual specific life plan which allows them to develop Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 14 independence at a pace best suited to them and their needs. Jean Marshall House staff are very supportive of the residents emotional needs as well as sourcing work/study and leisure pursuits.’ Residents undertake various college courses at further education centres, where possible chosen by themselves. They also attend life skills lessons held at the organisations, headquarters development centre, which is an approved as a satellite centre by Sussex Downs College. These courses are tailored towards the individual needs of residents and include numeracy, literacy, information technology and home economics. Some courses lead to formal qualifications. One resident over twenty-five years also undertakes a work placement. Residents are provided have a weekly allowance and are supported to budget, as part of life skills training. On the day of the Inspection two of the residents went to the local library and gym, all three were then going to a local farm centre for cider tasting and in the evening were planning to go bowling. The home has its own transport enabling residents to access a wide range of leisure amenities. Residents spoken with spoke of a range of hobbies such as swimming, following of their favourite football club, watching films and spoke of a range of music tastes. Residents have the option of a seven-day annual holiday within the contract price, and the Manager stated that discussions were taking place at the time of the Inspection as to when and where to go. Last year the residents went as a group to Camber Sands for their holiday. Feedback received evidenced enabling residents to maintain contact and relationships with families and friends. Resident’s reviews include the opportunity for resident’s relatives/representatives to attend if the resident wishes. The two relatives surveys stated that residents are always or sometimes supported to keep in touch. One commented, ‘there has never been any problems with regard to this. I’m made welcome when ever I call in and my relative rings home often.’ Resident’s reviews include the opportunity for resident’s relatives/representatives to attend if the resident wishes, and records viewed confirmed relatives attendance. Residents spoken with confirmed flexibility in the routines in the home and have unrestricted access to the home and grounds. The cook was present during the Inspection and stated she holds a basic food hygiene certificate and works in the home Monday to Friday to cook the evening meal. The cook also prepares Saturday and Sunday’s meals ready for the care workers to cook and serve. There is a rotating menu in place, and the cook stated that current meals are being provided in consultation with residents to reflect the meals they wish to have. The evening meal on the night of the Inspection was fish and chips or a salad and rice pudding. Fresh fruit is also available in the home. One night a week residents take it in turns to choose the evening meal and one resident spoken with confirmed it had been their turn to choose and they had chosen pizza. Diets can be catered for. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 15 Feedback from the residents spoken with was that the food was good. Records were viewed of meals provided to individual residents. In addition to the main kitchen there is a smaller kitchenette area where residents can make snacks and prepare their own pack lunches. One resident spoken with confirmed they had made their packed lunch to take out on the farm centre trip. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 16 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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from the provision of flexible and respectful personal and healthcare support and are protected by the systems in place to manage medication. EVIDENCE: Residents at Jean Marshall House largely manage their own personal care, with the offering of verbal prompts where required. Risk assessments are in place to ensure the safety of residents. Staff supports residents to ensure their health needs are met. Feedback and records referred to specialist advice and guidance, which had been sought. Relationships between staff and residents and the care given were observed to be very good, and residents were treated with respect at all times. The AQAA details there are policies and procedures in relation to medication in place. The storage and administration of medication were found to be satisfactory. Records were accurate and current. Some residents were seen Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 17 to be supported to manage their own medicines following a documented risk assessment and signed consent forms. There was a record of a recent pharmacists visit, following which the care manager stated they were in the process of addressing the recommendation by providing more secure facilities for when medication needs to be stored in a refrigerator. The AQQA details that care workers are enrolled on a twelve week medication course and the care workers spoken with confirmed they had received medication guidance since they had commenced working in the home and one could confirm they were booked to attend training provided by the local authority. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 18 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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable residents or their representatives to raise any concerns about the care being provided and systems have been reviewed to ensure that residents are protected from abuse. EVIDENCE: There is a complaints policy and procedure in place. No complaints in relation to the service had been received since the last Inspection. The CSCI have not been informed of any concerns. All five of the resident’s surveys stated that they were aware of the complaints procedure and knew who to speak to if they were not happy. During the Inspection residents were confident to approach the Inspector and were articulate in their feedback regarding their positive experiences at the home. The AQAA details there are written policies covering adult protection and whistle blowing. A copy of the East Sussex, Brighton and Hove Multi-Agency Adult Protection Guidelines is available for reference in the home. The two care workers spoken with confirmed they had attended this training and demonstrated an awareness of the policies and procedures. The training manager also confirmed that to provide this training within the organisation a member of staff is waiting to undertake a train the trainer course. The CSCI has been informed of concerns that there have incidents in the home, which have been investigated, but should have been reported and investigated, Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 19 under safe guarding adult’s procedures. This was discussed with the Manager and care manager who both stated that they had undertaken training and felt they had an awareness of the procedures, that they had discussed this with representatives from Brighton and Hove Adult Services to try to resolve this. That they had reviewed their practices and that they are aware they could seek advice if they required further clarity on if an incident should be reported. The CSCI were also not being informed of instances in the home to meet the reporting requirements of Regulation 37. The Manager who has confirmed that a new format has been drawn up to report incidents in the home Staff supports residents to manage their own personal finances as part of their life skills development. Individual arrangements are in place for the collection and banking of personal monies, depending upon the individual needs of service users. A sample of two of the resident’s records was viewed and was adequate. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 20 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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good and provides residents with an attractive, comfortable and homely place to live. EVIDENCE: The home is a converted late Victorian domestic dwelling, which has been refurbished and is located in a residential area close to Hove station. Décor in the home is to a good standard, and furnishings are of a good quality and domestic in style. A tour of the building was made. There were some cracks and damage to decor in the hallway area, which staff confirmed were in the process of being rectified. The AQAA detailed that over the next twelve months it is planned to create a large patio area to three sides of the property with the provision of car parking for visitors and company vehicles, provide several areas for service users to sit out and a barbeque area for residents to sit out and enjoy and an outside laundry area. Some of this work was Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 21 completed and viewed during the Inspection. The three residents spoken with were happy with the environment. Resident’s accommodation consists of six en-suite bedrooms and three bed sits situated on all floors in the home. There are sufficient numbers of toilets located around the building, with all bedrooms providing en-suite facilities of a bath/shower, toilet and wash-hand-basin. The three residents showed the Inspector their bedroom all of which displayed resident’s individual styles and interests. Bedroom doors are fitted with a lock and the care manager said that residents are provided with keys. Communal space consists of a lounge and a conservatory used as the dining room. There is a small, enclosed garden, which surrounds half of the property. The home is not designed to offer a service to people with physical disabilities and the stairs and other access arrangements would make it unsuitable for service users with significantly restricted mobility. Residents currently do not need any specialist equipment. The AQAA details that there is a policy in place for managing infection control and that Department of Health Guidance has been used to assess current infection control management. The home was clean and free from offensive odours at the time of the Inspection. Feedback received from the one residents survey who completed the question confirmed the home was kept fresh and clean. Residents spoken with on the day also confirmed the home was kept clean. Residents are supported to take responsibility to keep their own bedroom clean and tidy and one service user spoken with during the Inspection was in the process of cleaning their bedroom. There is a separate laundry room for residents to use. The residents spoken with confirmed there is adequate heating and hot water provided in the home. Routine fire checks of the building, which had been completed were viewed and were adequate. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 22 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 and 35. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are robust recruitment procedures and training is provided to staff to enable them to perform their roles effectively. EVIDENCE: The home was calm and relaxed on the day of the Inspection, and the staffing in place on the day provided support for the three residents to access a range of activities. The care manager stated staffing levels vary in accordance with residents individual programmes and college term times. A ‘waking night’ and a ‘sleeping in’ member of staff were due to be on duty that night. Ancillary staff is also employed to work in the home. A cook works five days a week to cook the evening meal and prepares the weekend meals, which are cooked and served by the care workers. A domestic member of staff works in the home three half days a week to clean the communal, toilet and en-suite areas. Residents are expected to keep their own bedrooms clean. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 23 Staff spoken with felt that staffing levels were currently sufficient to undertake their role effectively and spend individual time with service users. They also spoke of a team that are very supportive of each other and of good communication. The two relatives surveys stated that staff always or usually have the right skills and experience to look after the residents, and stated they had received guidance on infection control and control of hazardous substances (COSHH). Recruitment is undertaken jointly with the organisations other home. Staff spoken with and two staff files viewed evidenced a robust recruitment process followed for staff, which included the completion of an application form, at least two written references, the completion of a Criminal Records Bureau (CRB) and a Protection of Vulnerable Adults check. New staff also complete a probationary period. Staff spoken with confirmed they have received a job description and a copy of the General Social Care Council Code of Conduct. A sample of records was also viewed to evidenced the existing staff working in the home have also undertaken a CRB check. The Manager stated that of the eight members of staff four members of staff hold NVQ Level 2 in care and a further three are working towards this qualification. Induction procedures are in place which new staff recruited to the home will be taken through. The training manager stated that this is in the process of being updated and met the requirements of Skills for Care. Staff spoken with and records viewed confirmed they had received an induction. Staff spoke of completing or were due to complete a range of training and all spoke of good training opportunities for personal development. All staff feedback confirmed that supervision is provided to meet requirements. All staff consulted said that they felt well supported by the manager and senior staff to undertake their roles and felt able to approach them for advice and guidance. The organisation has an annual appraisal system, which the Manager stated would be put in place as required. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 24 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 and 42. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good with effective systems to protect service users being put in place. EVIDENCE: The Registered Manager who is the organisation’s managing director and founder, visits the home most days, but delegates most of the day to day running of the home to the care manager. The Registered Manager has many years managerial experience and currently overseas the organisations other home. The care manager who started working in the home in January stated she is in the process of making an application to the CSCI to become the Registered Manager and is about to commence the Registered Managers Award. Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 25 The organisation has a quality assurance system, which is being implemented in the home. It was evidenced that feedback about the service provided has been sought from residents through the residents weekly meetings. Further feedback is due to be sought through surveys to be sent to residents, relatives/representatives and other professionals who attend the home. The Manager stated that a forum is also being set up for the resident’s relatives and representatives to meet and give feedback. The AQAA detailed that policies and procedures are in place but that these had not been reviewed since 2005/6. These should be regularly reviewed to ensure they remain upto-date. The care manager confirmed that a new post has been created within the organisation, with the post holder being tasked to update all the paperwork within the organisation. The AQAA details that the Outlook Foundation has commissioned an independent Inspector to carry out monthly unannounced monitoring visits, following which a detailed report is made. The records of these visits were not viewed on this occasion. Training lists have been compiled and were viewed. Staff spoken with confirmed they had received training in infection control, one had had basic food hygiene training and the Manager stated the second would also be sent on this training. One also confirmed they were due to attend first aid training. The Manager stated that moving and handling guidance is provided to care workers at induction and that advice has been sought to ensure this meets current requirements. Systems are in place to monitor the completion of training and ensure staff training needs are highlighted. A fire risk assessment is in place, which the Manager has previously confirmed had been drawn up by a consultant fire safety officer in 2006, which records significant findings and the actions taken to ensure adequate fire safety precaution in the home. The Manager agreed to seek advice as to the frequency these should be reviewed, so a Requirement has not been made on this occassion. A system is in place to ensure a regular detailed check of the environment and fire precautions is carried out and is recorded. There is a health and safety committee for the organisation which service users are invited to join to discuss and monitor health and safety practices. Both care workers spoken with confirmed they had received guidance on fire safety as part of their induction and one had attended a fire drill. The Manager stated that fire training to be provided by an external agency is booked which staff will be expected to attend. The AQAA detailed that the maintenance of equipment and services has been carried out and the Manager was also able to update this information of further checks that have been undertaken since the AQAA was completed. The Manager stated the hot water is controlled centrally at the correct temperature, but that there are no checks of the hot water supply at the outlets accessed by service users to ensure these are maintained close to the recommended safe temperature of 43°C. A Requirement has been made that Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 26 advice should be sought from to clarify the type and frequency of checks that should be undertaken. Accident records were viewed and were detailed. Details were viewed of current insurance in place for the home. Jean Marshall House DS0000068102.V357923.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 3 2 4 3 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 28 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 13 (4) (a) (c) Requirement That guidance is sought and complied with about the requirements of testing the hot water temperature at outlets accessed by residents. To ensure the health safety and welfare of staff and residents. Timescale for action 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Jean Marshall House DS0000068102.V357923.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Jean Marshall House DS0000068102.V357923.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. Re-publishing this information is in breach of the terms of use of that website. 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