Care Home: New Hope Project

What the care home does well One service user spoken to who has lived at the home for some time stated regarding the home,` ` It has helped me to build my confidence and find my feet and look after myself really`. The home has a thorough admission process to ensure that the needs of service users can be fully met. Service users are well supported with key work sessions being held with them and also weekly clinics are held at the home at which mental health professionals attend as well as staff from the home to regularly monitor and review their needs. Care plans outlining service users` individual needs are comprehensive and reviewed regularly with their involvement. Risks to service users and others are assessed and appropriately managed. Service users take part in a number of educational, occupational and leisure activities both in the home and within the local community. Service users are supported to make their own decisions and routines of the home promote independence for example service users are supported to shop for and cook their own meals. Service users are well protected by thorough recruitment practices, an effective complaints and adult protection procedures. All staff have received training in adult abuse. The home provides accommodation to a very good standard and is well maintained, clean and hygienic. The home has competent and well -qualified staff working at the home and their training needs are comprehensively addressed to ensure the individual and joint needs of service users are effectively met. There are good quality assurance systems in place that involve service users to ensure standards within the home are maintained and areas for improvements can be identified. What has improved since the last inspection? The home met all the previous requirements specified at the last inspection of which there were seven. These included making some improvements in recruitment, medication and in the area of health and safety practices. What the care home could do better: Some minor improvements are required in respect to the home`s medication and quality assurance mechanisms. CARE HOME ADULTS 18-65 New Hope Project 377-381 Queens Road New Cross London SE14 5HD Lead Inspector Ornella Cavuoto Unannounced Inspection 4th January 2008 10:00a DS0000025652.V357818.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 DS0000025652.V357818.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. DS0000025652.V357818.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Hope Project Address 377-381 Queens Road New Cross London SE14 5HD 0207 6356339 0207 635 0066 Newhopepenrose@freeuk.com newhope@penroseha.org.uk Penrose Housing Association 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) Sizwile Tshuma Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places DS0000025652.V357818.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: Male whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 12 25th October 2006 Date of last inspection Brief Description of the Service: New Hope Project is registered for 12 men who are mentally disordered offenders leaving regional medium secure units. The service is offered in partnership with South London and Maudsley Mental Health Trust under the supervision of a Community Forensic Consultant. Service users are expected to work with the psychiatric services throughout their stay at the Project. Penrose Housing manages the project. The property is owned and maintained by Hyde Housing Association. It is located in New Cross Gate, close to local shops, community facilities and public transport. The home has been converted from three houses and provides service users with en-suite bedroom accommodation on the first floor. The house is set back from the main road and there is a garden at the rear of the property. One of the twelve places is kept for overnight trial visits by prospective service users. A planned rehabilitation programme is offered to assist service users to move on to suitable alternative accommodation where less support will be provided. Individual and group work in the home aims at developing service users skills and abilities. Service users are supported to attend day centres, adult education and training, leisure and recreational activities. Potential service users receive information about the service from referring agents (CMHTS, consultants and medium secure units) so that service users can find out about the service before a referral is made. Upon the receipt of referral applications the home sends prospective service users information about the service namely leaflets on the service, Service Users Handbook, service specifications and CSCI inspection reports. CSCI Inspection reports are DS0000025652.V357818.R01.S.doc Version 5.2 Page 5 also kept on the residents’ notice board that both potential and current service users have access to or they can be made available on request. DS0000025652.V357818.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was present for the duration of the inspection and was helpful in facilitating the process. One of the service users were spoken to that was case tracked and two staff members that had started working at the service since the last inspection were also spoken to. Other inspection methods included inspection of records and a partial tour of the building. In addition, prior to the inspection the service was sent an Annual Quality Assurance Assessment (AQAA) for completion, which was returned to CSCI. This will be referred to within the report. This inspection found that the home had sought to make further improvements in the service delivered to service users by addressing previous requirements, as identified at previous inspections resulting in a consistently high standard of service provision. What the service does well: One service user spoken to who has lived at the home for some time stated regarding the home,’ ‘ It has helped me to build my confidence and find my feet and look after myself really’. The home has a thorough admission process to ensure that the needs of service users can be fully met. Service users are well supported with key work sessions being held with them and also weekly clinics are held at the home at which mental health professionals attend as well as staff from the home to regularly monitor and review their needs. Care plans outlining service users’ individual needs are comprehensive and reviewed regularly with their involvement. Risks to service users and others are assessed and appropriately managed. Service users take part in a number of educational, occupational and leisure activities both in the home and within the local community. Service users are supported to make their own decisions and routines of the home promote independence for example service users are supported to shop for and cook their own meals. Service users are well protected by thorough recruitment practices, an effective complaints and adult protection procedures. All staff have received training in adult abuse. The home provides accommodation to a very good standard and is well maintained, clean and hygienic. The home has competent and well -qualified staff working at the home and their training needs are comprehensively addressed to ensure the individual and joint needs of service users are effectively met. There are good quality assurance systems in place that involve service users to ensure standards within the home are maintained and areas for improvements can be identified. DS0000025652.V357818.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000025652.V357818.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 DS0000025652.V357818.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): 1,2,4 &5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Current and prospective service users have the information they need to make a decision about the home. The needs of service users are fully assessed before they are offered a place at the home. Service users move in for a trial stay before their stay is confirmed. All service users are issued with a licence agreement that outlines terms and conditions of their stay with the home. EVIDENCE: The home has recently improved the service user handbook. This is very comprehensive and includes all the information current and prospective service users need to make a decision about the home including information about fees as required. The personal files of four service users were inspected. Two of the service users had moved into the home recently within the last two months. There was evidence on all the files that detailed assessments and risk assessments had been obtained prior to service users being offered a place and commencing a trial stay at the home. In addition, there was evidence that the home had carried out their own detailed assessment and risk assessment with service users. DS0000025652.V357818.R01.S.doc Version 5.2 Page 10 Prospective service users move into the home for a trial stay of three weeks before their stay at the home is confirmed. One of the rooms within the home is specifically used for prospective service users staying at the home for this trial period. All the service users whose personal files were examined had been issued with a licence agreement that had been signed by them. At the last inspection it was identified that the agreement did not specify the fees charged, what they cover and when they must be paid and by whom and any additional charges not covered by the fees for services or facilities used by service users. At this inspection this had been addressed with a new licence agreement in place. DS0000025652.V357818.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&9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in the drawing up and reviewing of their care plans so they know their assessed and changing needs and personal goals are reflected in their individual plans. Support is provided to encourage service users as much as possible to make their own decisions. Effective risk assessment and management supports service users to take risks as part of an independent lifestyle. EVIDENCE: Of the four personal files looked at three had evidence that a care plan had been drawn up. The other file belonged to a service user that had moved into the home a month prior to the inspection being held and therefore had only recently completed their trial stay at the home. During this period the service user is allocated a key worker who works with them to identify their needs and areas with which they require support in preparation for drawing up a care plan once their stay is confirmed. There was evidence within the file that the service user had received key work sessions and areas of needs were being looked at DS0000025652.V357818.R01.S.doc Version 5.2 Page 12 with them. A report outlining progress during their stay at the home had been completed for a review that was to take place shortly. The other care plans in place were comprehensive. A new format for care plans had been put in place since the last inspection following consultation with service users to ensure more service user involvement and ownership. These addressed personal, health and areas of social support including daily structure. Restrictions imposed on service users under the Mental Health Act or due to other legal issues were specified within individual care plans and it was clearly evident service users had been involved in the care planning process with their views noted and also their responsibilities as well as their key worker’s responsibilities to achieve identified goals being outlined. Reviews of care plans had taken place six monthly. This is completed in line with Care Programme Approach (CPA) reviews. In addition to this, there was evidence that service users had generally received regular key work sessions and weekly psychiatric clinics had been held at the home where the individual care and support needs of service users had been addressed. All the care plans apart from one had been signed by service users. There was evidence within key work sessions that service users are supported to make their own decisions within restrictions imposed as a result of the Mental Health Act or other legal issues in certain cases. The service user spoken to confirmed this. Monthly resident meetings are also held in which service users are given an opportunity to have an input on decisions about aspects of living in the home. All service users manage their own finances. Information about advocacy services is made available to service users within the service user handbook and there was also evidence seen of a newsletter for service users in which information about advocacy services had been provided. Clear and comprehensive risk assessments and management plans to reduce risks had been completed in respect to service users’ mental health that had been regularly reviewed. Service users complete part of the assessment themselves and if their views differ from the worker’s they can make write down their comments. Furthermore, all service users had a rehabilitation checklist completed with them. This looks at all aspects of daily living with service users such as shopping, cooking, transport, personal safety, social skills amongst others. This acts as a risk assessment to identify areas that service users need support and/or where presenting risks need to be managed. It is aimed that these are also reviewed six monthly. DS0000025652.V357818.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 &17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate educational and occupational activities and also make use of the local community. Service users are supported to maintain appropriate relationships. Routines at the home promote independence and respect service users’ rights. Service users are encouraged and supported to cook their own meals. EVIDENCE: The aim of the home is to prepare service users for more independent living. As a result encouraging and supporting service users to get involved in educational and occupational activities is an important part of service users’ stay at the home, for example the home had organised a literacy group for service users in which a tutor from the local college attends the home on a weekly basis. This was previously provided at the home but had stopped for a period. It was set up again following service users’ suggestions. Also, as mentioned in relation to Standard 7 the home had compiled a newsletter DS0000025652.V357818.R01.S.doc Version 5.2 Page 14 specifically for service users at New Hope in which individual service users had contributed articles they had written. The home has a computer and it was reported that the aim was to get service users to take even more responsibility in the drawing up of the newsletter. There was evidence from service users’ personal files that they had been supported to undertake college courses in areas that they have an interest and also to become involved with the Community Opportunities Service (COS) scheme within the borough that provides a range of different educational and leisure activities. Furthermore, there is an Employment Training and Education (ETE) Manager for all Penrose homes who aims to look at ways to involve service users in different ways within the homes, for example at New Hope there is an in-house employment scheme where service users can apply for posts working as housekeepers and also as a gardener for which they are paid. At the last inspection it was reported that service users doing the house keeping jobs were to receive training in manual handling. It was also recommended they receive training in health and safety. The home’s AQAA specified that this training was still to be addressed (See Recommendations). Service users are supported to make use of the local community. All are taken out to the local area when they move in to assess their support needs in respect to be able to shop, use public transport and manage their personal safety as part of completing the rehabilitation checklist. Service users were seen going out on the day of the inspection to use the local shops and there was evidence within personal files that they use facilities including the gym and pub. All have access to free travel. There was evidence within service users’ personal files that they are supported to maintain appropriate personal and family relationships and service users regularly visit family and friends. Routines at the home do promote independence and respect service users’ rights. The service user spoken to stated how the home supports individuals ‘to have your own life’. All service users are given a key to their rooms and the front door. Staff do not enter service users’ rooms without their permission. Individual rooms have an intercom telephone. On the day of the inspection this method was used to ask one of the service users if their room could be inspected as part of the inspection. Service users complete a selfassessment form regarding daily living skills and they are required to undertake housekeeping tasks such as tidying and cleaning their own rooms. Responsibilities regarding these tasks and restrictions on smoking and the use of alcohol and drugs were specified within the service user handbook, a copy of which is issued to service users when they move in. Interaction observed during the inspection between service users and staff was warm and respectful. DS0000025652.V357818.R01.S.doc Version 5.2 Page 15 Service users are encouraged to shop for their own food and to cook their own meals. When service users enter the home they are observed preparing a meal and cooking it as part of completing the rehabilitation checklist to identify if service users require any ongoing support and monitoring in this area and/or if there are any risks that need to be managed. These are then addressed as part of their individual care plan. Cookery groups are provided in -house at intervals to support service users. Whether or not service users are coping with cooking their own food and are eating a nutritious diet is checked in key work sessions. Weekly health and safety checks are carried out on the kitchens including cupboards and fridges and service users will be observed cooking on occasions. This also assists staff to identify any concerns /problems being experienced by service users to maintain a balanced diet and to prepare meals. DS0000025652.V357818.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&20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users are supported in a flexible and responsive way. The physical and emotional health needs of service users are well met. The home has robust systems in place to support service users to take responsibility for their own medication. EVIDENCE: The home has a staff team that is well balanced in terms of gender and ethnicity to ensure support needs of service users can be met in a flexible and responsive way. Service users are encouraged to be independent in terms of managing their personal care. Prompting is provided as required and is addressed as part of individual care plans. As mentioned the home operates a key work system that provides consistency of support. Generally service users had received key work sessions on a regular basis. It was reported that the aim is for key workers to meet with service users at least monthly. However, it was noted from personal files that for individual service users key work sessions held had been patchy at times. Also, service users had not always signed records of sessions. It is advised measures are taken to address this (See Recommendations). DS0000025652.V357818.R01.S.doc Version 5.2 Page 17 Service users’ health and emotional needs are very well met with evidence that these are addressed as part of service users’ care plans and monitored in key work sessions. A consultant forensic psychiatrist and community psychiatric nurses/ social workers working with individual service users attend the weekly psychiatric clinics held at the home where service users’ mental health is carefully monitored and their medication regularly reviewed. Service users are supported to register with a local G.P and are actively encouraged to take responsibility for their own physical health care needs and to make their own appointments and ensure they attend any hospital appointments although prompting is given where needed. The medication policy and procedures used by the home are robust. All staff have to undergo a comprehensive medication proficiency assessment and do a test prior to being allowed to administer medication. Service users are supported to take responsibility for their own medication within a risk management framework where it is assessed to be appropriate. A decision to allow service users to self- administer is made in consultation with the consultant psychiatrist, other mental health professionals involved in their care as well as input from key workers. Regular spot checks to ensure service users are taking their medication as required are carried out and recorded. A sample of Medication Administration Records (MAR) sheets were inspected and all were found to be accurate. At the last inspection there was evidence that fridge temperatures for the cold storage of medication had been recorded daily but the room temperatures where medication is kept had not been recorded. At this inspection this had been addressed. It was reported that the deputy manager undertakes monthly audits of the medication although a record of these had not been maintained. It is advised audits carried out and the outcomes of these are recorded (See Recommendations). DS0000025652.V357818.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&23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users complaints had been listened to and acted on appropriately. Service users are protected from abuse. EVIDENCE: The home has a robust complaints policy and procedure. All service users are issued with a copy of the complaints policy. The complaints log was inspected and two complaints had been recorded since the last inspection. One was made by a service user about the behaviour of another service user towards them and one was from a service user concerned about the behaviour of a visitor of one of the service users. Both complaints had been investigated and were appropriately and efficiently addressed. Furthermore, it was noted within one of the personal files how one of the service users had expressed concerns about a worker from a support service that has links with the home about their attitude towards them. Positively, the service user was being supported by their key worker to take this complaint forward. There is a comprehensive adult protection policy and procedure in place at the home and service users are provided with information about POVA (Protection of Vulnerable Adults). The home has not had any adult protection issues since the last inspection. All staff have received training on adult abuse/protection and the staff spoken to on the day of the inspection had good knowledge and understanding of adult abuse and procedures to follow if abuse was either identified or suspected. DS0000025652.V357818.R01.S.doc Version 5.2 Page 19 As mentioned in respect to Standard 7 all service users take responsibility for managing their own finances. DS0000025652.V357818.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): 24,28 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers an environment that is safe, comfortable and well maintained. There are shared spaces that complement service users’ individual rooms. The home is clean and hygienic. EVIDENCE: The home offers accommodation to a very good standard. The premises are suitable for its stated purpose, comfortable, safe and well maintained. The décor of the home is bright and airy. Service users’ individual rooms are supplemented by a number of shared spaces that include a large lounge with a television that also has Sky channels, a smaller lounge where service users can listen to music or use the computer. There is a dining room, which is sometimes used as a meeting room to hold CPA reviews, two kitchens domestic in nature, one of which also has a dining table where service users can eat. Finally, there is a small attractive garden at the rear of the property. DS0000025652.V357818.R01.S.doc Version 5.2 Page 21 The home was clean and hygienic on the day of the inspection. The home employs two of the service users as housekeepers to clean communal spaces. DS0000025652.V357818.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 &35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are qualified and competent to meet the needs of service users. The home’s recruitment practices protect service users Staff are all inducted and are provided opportunities to undertake regular training. EVIDENCE: There was evidence that the majority of the staff working at the home had achieved a National Vocational Qualification (NVQ) Level 2 or 3 or had a qualification that was above the level of NVQ, for example one of the staff had completed a degree in psychology whilst another was in the process of studying social work. Three staff files were checked belonging to staff that had commenced employment at the service since the last inspection. There was evidence that all required checks and information including Enhanced Criminal Record Bureau (ECRB) checks and two references had been obtained prior to allowing staff to commence working in the home. Subject to a previous requirement photographs for staff were in place. Also, at the last inspection it was found that for one staff member who had been recruited internally that the staff file DS0000025652.V357818.R01.S.doc Version 5.2 Page 23 was not available for inspection as it had yet to be transferred from the home where they worked previously. At this inspection all staff working at the home had a file in place. There was evidence that staff receive an induction that meets with Skills for Care specifications. Skills for Care work booklet that had been completed was seen in the file of one staff member whilst two other staff recently employed that were spoken to confirmed they were working through the booklet. A four week in- house induction programme is also completed with all new staff that is very comprehensive. A record of this is kept in staff files. At the last inspection it was identified that not all staff had completed training in mandatory topics including food hygiene, fire safety, health and safety and first aid. At this inspection, there was evidence that staff had undertaken training in these areas apart from those that had recently started working at the home who were still to do food hygiene training although the registered manager was to arrange this. A comprehensive training plan was in place and overall it was evident from staff files and in discussions with the registered manager and staff themselves that their training needs are well addressed and that they attend training courses to enable them to effectively meet the individual and joint needs of service users. These have included challenging behaviour, boundaries and good practice, diversity and equality, introduction to personality disorders amongst others. DS0000025652.V357818.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 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and is run in the best interests of service users. The home has good quality assurance systems in place that ensures service users views underpin self-monitoring, review and development. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager was working at the home as a deputy manager when they took up the post. Consequently, they were experienced and familiar with the running of the home. They reported that they were presently studying for the Registered Manager’s Award (RMA). It was evident from the inspection that the home is very well managed and is also run to benefit service users. The home has good systems in place to ensure that a quality service is delivered. These include a residents’ representative who is paid to attend a DS0000025652.V357818.R01.S.doc Version 5.2 Page 25 monthly tenants forum and also attends staff meetings that are held fortnightly on a monthly basis. As mentioned in respect to Standard 7 resident meetings are held monthly. The AQAA completed by the home and sent to CSCI prior to the inspection was thorough and provided comprehensive evidence demonstrating how the home achieves positive outcomes for service users. In addition, the home had completed a customer satisfaction survey with service users in March 2007 but only one completed survey was received back and it was reported that another survey had been completed with service users in December 2007. The service user spoken to confirmed this and a copy of the survey provided to service users was seen. Completed surveys had still not been received back at the time the inspection was held. Furthermore, surveys had not been issued to relatives and professionals and it is advised that future surveys carried out should address this. The results of the surveys are included in the home’s ‘project goals’ aimed at improving service delivery. These are reviewed every year and it was reported they were to be looked at in January. At the last inspection it was identified that monthly provider reports had not been carried out regularly and copies of reports had not been sent to CSCI. However, at this inspection this had been addressed with evidence in place that reports had been completed on a monthly basis apart from a couple of months missed due to annual leave and sickness (See Recommendations). The home has comprehensive health and safety policies and procedures in place and regular health and safety checks/risk assessments had been carried out of the building/environment and also in respect to fire safety meeting the previous requirement specified in this area. Also, the home had carried out weekly tests on fire alarm call points and fire drills had been carried out regularly. There were up to date maintenance certificates in place for gas, fire and electrical wiring. At the last inspection a Portable (electrical) Appliances Testing (PAT) certificate could not be identified but at this inspection this was in place. Finally, at the last inspection it was noted from records of water temperatures that had been tested that they had regularly exceeded the recommended 43c. Subject to a previous requirement that water temperatures must be delivered close to 43c unless risk assessments indicate service users are able to check these for themselves, it was identified at this inspection that this had been addressed with risk assessments having been completed. Furthermore, since the last inspection the home had had new boilers fitted and it was reported these had valves fitted to keep the water at a regular temperature. DS0000025652.V357818.R01.S.doc Version 5.2 Page 26 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 4 2 3 3 X 4 4 5 3 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 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 3 X DS0000025652.V357818.R01.S.doc Version 5.2 Page 27 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. 2. Refer to Standard YA12 YA18 Good Practice Recommendations The registered person should consider the provision of health and safety training for those service users carrying out housekeeping jobs. The registered person should try to ensure that key work sessions for all service users are held monthly as aimed by the home and service users sign key work sessions notes to indicate their agreement and understanding of issues discussed and any plans/ goals agreed. The registered person should try to ensure that records of medication audits carried out within the home are kept. The registered person should try to ensure that when customer satisfaction surveys are carried out relatives and professionals are included. 3. 4. YA20 YA39 DS0000025652.V357818.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000025652.V357818.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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