Care Home: Old Registry (The)

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What the care home does well Service users have access to a range of activities and are supported to integrate into their community. Service User plans are detailed and individually developed, involving the views and aspirations of each service user.The environment remains fit for purpose and service users are generally safe in it. The management and staff maintain a sound level of commitment to the service as a whole. Service users overwhelmingly indicated that they are given choices regarding their life at the Old Registry. What has improved since the last inspection? Medication recording now ensures that service users receive good quality support with their healthcare needs. The upstairs bathroom and toilet has been upgraded. A structured induction programme is in place for staff. Carried out an internal audit of the service. Pictorial menus are now available to assist service users in making a more informed choice about their meals. Service user plans are more person centred than previously. What the care home could do better: Ensure that staff sign the medication charts at all times. Carry out Regulation 26 monitoring visits on a monthly basis as required by Regulation and to complete an annual development plan for the service. CARE HOME ADULTS 18-65 Old Registry (The) 70 Aldborough Road South Seven Kings Ilford Essex IG3 8EX Lead Inspector Stanley Phipps 4th to the 18th Unannounced Inspection July 2008 10:00 Old Registry (The) DS0000025931.V364755.R02.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 Old Registry (The) DS0000025931.V364755.R02.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. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Registry (The) Address 70 Aldborough Road South Seven Kings Ilford Essex IG3 8EX 020 8590 7076 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) oldreg@roselock.com Mr Alan John Philp Mr Robert Steer Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 11th January 2007 Date of last inspection Brief Description of the Service: The Old Registry is registered to accommodate 8 adults with learning disabilities. Service Users have high levels of dependency and limited communication and cognitive abilities. The home is operated by Alpam Homes, a private organisation, which operates three other registered care homes for people with learning disabilities in the London Boroughs of Redbridge and Newham. Alpam Homes also own and operate a day care centre (Highview House), for service users who live in their care homes. The service is staffed on a twenty-four hour basis to ensure that service users needs are met as and when required. The home is situated in a residential area of Seven Kings, in the London Borough of Redbridge and is close to shops, places of worship, community facilities and transport routes to central Ilford, London and Essex. The building is in keeping with other properties in the area and does not set service users apart from the local community. It also is well decorated, furnished and maintained. The premises are not fully accessible to wheelchair users, although there are bedrooms and a bathroom/shower room on the Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 5 ground floor. A statement of purpose is made available to all service users in the home and is kept in the main office. This document is also made available to relatives and stakeholders, as they may be important in referring service users to the home. A service user guide is also given to each service user upon admission to the home. Fees range from £995.00 to £1350.00 and may vary dependent on individual levels of need. Fees do not cover newspapers, clothing and personal effects. Old Registry (The) DS0000025931.V364755.R02.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. The inspection was unannounced and was carried out over the period 03/07/08.to the 18/07/08. At the time of the visits the registered manager was unavailable to provide evidence as part of the inspection process. There were seven service users in the home, most of whom looked settled and comfortable in their home environment. An assessment of medication practice, menus, policies and procedures, records required by regulation, service users’ care plans and the environment was undertaken. Discussions were held with the persons –in - charge on both days along with several members of staff. Formal interviews were also held with two members of staff along with telephone interviews with up to three relatives. The inspection also considered: information provided in the Annual Quality Assurance Assessment (AQAA) provided by the registered person, verbal feedback from external professionals, along with comment cards that were returned from staff and service users. Prior to the inspection, an Annual Service Review was undertaken on the 28th March 2008 with regard to this service. This review looked at the operations of the home by assessing the information provided on several documents submitted by the registered provider to the Commission. One such document is the Annual Quality Assurance Assessment (AQAA). One of the main findings of the review was that the registered provider was running the service in breach of Regulation by virtue of the company Roselock Limited – not being registered with the Commission. Consequently, the registered person was instructed to comply without undue delay, following which the registered provider did make the application. Checks made with the Commission’s Central Registration Team subsequently amended the registration certificate. This completed process now means that the service is operating in line with the Care Standards Act 2000 and its associated regulations. What the service does well: Service users have access to a range of activities and are supported to integrate into their community. Service User plans are detailed and individually developed, involving the views and aspirations of each service user. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 7 The environment remains fit for purpose and service users are generally safe in it. The management and staff maintain a sound level of commitment to the service as a whole. Service users overwhelmingly indicated that they are given choices regarding their life at the Old Registry. 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. Old Registry (The) DS0000025931.V364755.R02.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 Old Registry (The) DS0000025931.V364755.R02.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): (2,5) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit by having detailed assessments carried out on them, prior to coming to live at the Old Registry. Evidence must be made available to indicate that service users receive information about their fees and who is responsible for paying them. EVIDENCE: At the time of the inspection, there were no additions to the service users living in the home and such the assessment and admission practices were not used. However, random files were selected from the current service user group and it was clear that each individual has a thorough assessment prior to agreeing to live at the Old Registry. There was also evidence that assessment summaries were obtained from referring authorities. Given the clear processes in place, there is little room for service users to be move into the home without the home being satisfied that they could provide for the needs of the individual. The admissions process is robust and protects prospective service users from being inappropriately placed. There was evidence provided following the second site visit to confirm that service users had access to information regarding their fee structure and who has responsibility for paying them. Although information provided on the Annual Quality Assurance Assessment (AQAA) document did not indicate how the registered persons complied with this requirement, hard copy of a service users contract was seen with the information required by regulation on it. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 10 Service users and/or their relatives now have this information, which would keep their mind at ease, with regard to how. fees are broken down and determined by the registered persons. Old Registry (The) DS0000025931.V364755.R02.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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit from having their needs (including their specialist needs), reflected and reviewed in their individual plan. There was evidence that they take decisions with support, and maintain their safety and independence within a risk management framework. EVIDENCE: Three service user plans were assessed and they detailed the needs of individuals. There was evidence of service use involvement in the development of the plans, which is coordinated through a key worker system The care plans viewed were updated, with evidence that they were reviewed and borne out of the assessments carried out initially with them. One of the positives with the care planning system is that they being developed more and more on a person centred basis, which means that service users remain at the core of all activity. In one case it was noted quite clearly that a service user with an ethnic background did not wish to carry out a particular aspect of his culture and this was documented and respected, which is positive. Service users needs are varied, as are their abilities and staff were quite aware of what those needs, which included things like communication, mode of dress, Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 12 favourite activities, preferred times for going to bed and waking up. Staff were also had a good understanding of when a service user was uncomfortable and/or unhappy and so actions were in place to ensure that appropriate interventions were carried out to alleviate distress and promote a sense of well-being. Service users’ meetings, regular care plan reviews and the use of the complaints procedure ensure that service users’ views are taken on board in providing a service, both individually and collectively to them. In essence service users are given support to retain control of their lives as far as their capacity allows them to. They also have access to advocacy services as and when they need it, which is positive. A system for risk assessment and risk management is in place at the Old Registry. In all cases they were linked to each of the service users’ plans. Staff demonstrated an understanding as to the importance of risk assessments in ensuring that both the independence and safety of service users are promoted. There was good evidence to indicate that links are made between risk assessments and service user care plans, which ensures that staff remain knowledgeable about individual service user needs, risks and strategies for their safe management. Both the care plans and risk assessments were updated. There is a missing person’s procedure in place at the home. Old Registry (The) DS0000025931.V364755.R02.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) People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users are encouraged and supported to participate in their community, in appropriate activities and are able to maintain and develop social and personal networks of their choosing. They are also supported to exercise their rights, which are respected and promoted by staff in the home. The Old Registry provides meals that are reflective of service users’ choice and nutritional requirements. EVIDENCE: There was evidence that service users were supported to develop and maintain their living skills however restricted they might be. This is true despite having varied levels of needs, abilities and motivation. Staff were adept to the challenges that faced them, as all service users were embraced. From observation they carried out their duties with confidence. Service users have an individual programme of activity, which is specific to their choice and interests and all staff are required to work in accordance with this. From speaking with some service users they were satisfied with how the staff supported them to participate in activities that were best suited to them. One hundred per cent of the written feedback provided by service users, most of Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 14 whom were supported to complete their surveys informed that they were pleased with the opportunities for personal development. Most of the service users attend a day care facility where they learn and develop various creative and life skills. One individual attends college and was quite pleased with this. Another spoke of his joy of being on holiday at Clacton –on – Sea, where he went clubbing at nights. He also spoke vividly of his room, which was a single room and wad really pleased that he had the experience. All service users confirmed that they have significant opportunities to access the community for things like shopping, entertainment, education and religious persuasions. As a matter of fact one individual attends church most times on a Sunday and quite looks forward to this. One of the positives about the service users’ engagement in the community is the fact that many of them have grown quite a bit in confidence and are thus more able to assert themselves and make more choices. However, the registered persons informed that they would like to improve in this area by enabling service users to make greater choices within a wider range of community facilities. Service users spoken to confirmed that they enjoy going out into the community with their key workers. This is a strong area of the homes operations. From talking to service users, staff, community professionals, and assessing individual service user records, it was noted that service users are encouraged to develop and maintain relationships with their friends and families. Relatives are also invited to and in some cases attend social events in the home such as birthday events. The management and staff have a positive approach to involving relatives in the best interests of service users, which is positive. Service users were observed being addressed by their preferred names and are able to choose what they wear and the times they wakeup and go to bed. It was noted that on Fridays service users decide what form the activities should take and this is important although it may be more informal. Staff were observed checking with various service users in the home on the day, about their preferences around personal support. Advocacy information is made available to service users and the key worker system is used as a means of ensuring that their rights and needs are respected and provided for. It was clear from the documentation seen and the feedback provided by service users, that their rights are maintained through the level of involvement that they have in the home. Though meals were not observed feedback from service users in this area was quite positive. All service users were happy with the quality, range and quantity of the food provided at the Old Registry. Decisions around the menus are made at service user meetings with a degree of flexibility built in should service users change their minds. The menu on the first day of the inspection Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 15 was Jerk Chicken, potato wedges, salad and fruit juice. This meal is diverse and, which is positive as an outcome for service users living there. From the menu options, it was clear that service users had choices and with staff guidance and support healthy options were also made available to service users. Staff demonstrated a good understanding of service user’s specialist dietary needs. Checks carried out indicated that there was a good supply of food and drink, which is accessible to all service users. Service users could eat where they preferred, and the mealtimes were flexible. Old Registry (The) DS0000025931.V364755.R02.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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy personal support in a manner that is generally suited to them. Arrangements are in place to provide for their physical and emotional health needs, as staff continued to maintain effective links with external professionals in achieving this outcome. Some improvement in the handling of medication is required to enhance the health and welfare of service users living at the Old Registry. EVIDENCE: Feedback received from all service users was positive with regard to how they received personal support, which is coordinated through the key-worker system used in the home. For many they are able to independently manage their personal care. Staff were observed throughout the course of the inspection offering personal support to individuals that needed it and this was carried out in a safe and dignified manner. It was also clear that the staff had a system for determining individuals’ preferences and dislikes, which made the relationship between them – a positive one. Service users have their individual style of dress, which was consistent with their choice, culture and personality, and this was promoted in the home. Service users are generally given good support to ensure that their health needs including their special needs (Learning Disability) are provided for, e.g. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 17 the psychologist, dentist, GP and opticians. From looking at the records and staffing interviews it was clear that staff were capable of making interventions to promote the health and welfare of most of the service users in their care. Service users also have the benefit of getting support to attend their outpatients’ appointment should they require this. As a matter of fact, on the day of the visit one service user had just returned from seeing his GP. Feedback received from external professionals was positive about the staffing awareness of service users’ needs. Records bore evidence that all community appointments were documented as they occurred. Good support is provided in relation to the healthcare needs of service users at the Old Registry. At the time of the visit, none of the service users were handling their medication independently. A satisfactory medication policy is in place to guide staff responsible for administering medication. Medication safety is enhanced by: ensuring that staff receive training in drug administration prior to supporting service users in this area. Medication storage in the home is good, however, there were at least two missing signatures on the medication charts viewed. Improvement is therefore required in the recording of medication to ensure that service users receive the support necessary to promote their health and welfare. Old Registry (The) DS0000025931.V364755.R02.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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A satisfactory complaints procedure is in place and widely available to all service users and staff. Safeguarding adults’ practices within the home generally protects service users from abuse, EVIDENCE: A satisfactory complaints procedure is in place at the home and is made widely available in appropriate formats to all service users. Despite one service user stating that he did not know who to complain to, there was evidence that the complaints procedure is made widely available to all, as it is posted in a user friendly format throughout the home. All other service users confirmed that they knew who to complain to if they were unhappy with any aspect of the service. There were no complaints since the last inspection and staff spoken to, were aware of their role in enabling service users to complain should they need to. There were no safeguarding issues in the home at the time of the inspection and other aspects of the home’s operations e.g. recruitment, ensures that service users are protected from abuse. Staff spoken to had a good understanding of how they would deal with abuse or allegations of abuse. They also showed a good understanding of how and when they would invoke the whistle blowing procedure. Service users therefore have some assurance that they would be protected from abuse, particularly if the refresher training on ‘safeguarding adults’ had been provided on the 2/10/08, as previously scheduled. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24,27,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users live in a clean, purpose built and suitably designed home that matches their needs and lifestyles. Improvements to the decorative finishing in the upstairs bathroom add to the pleasantness of the environment. Service users enjoy using their facilities including their individual and communal spaces, which are homely and personal. The home is clean and hygienic and fit for its purpose. EVIDENCE: Although the inspection was unannounced, the home was clean bright and airy on the day of the inspection. At the time of the visit the upstairs was in the process of being decorated and it must be said that the upstairs floor covering looked in a better state than previously. From the surveys received all service users responded extremely positive about their environment, which they make full use of. This includes the communal spaces of which the garden looked very homely. There is ramp access to the garden and service users were pleased with this facility, which is well utilised particularly in the summer. Furnishings and fixtures were generally in good decorative order throughout the home and staff reported that a set of dining chairs were on order. The home remained generally well maintained and is therefore fit for its purpose. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 20 There are more than adequate toilets and bathrooms for the benefit of all service users, some of whom are more independent than others. They are strategically cited, which enables quick and easy access. to them. There was evidence that some work had been carried out to enhance the outlook of the upstairs bathroom, which is positive. The laundry facilities are designed to promote the service users’ independence as far as possible and this area was also well maintained. An infection control policy is in place and service users and staff are encouraged to work within this e.g. hand-washing. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The layout of the home is such that foul linen is well away from food preparation and so the risk of the spread of infection is minimised. The services and facilities do comply with the Water Supply Regulations 1999. It must be noted that the feedback received service users, staff and professionals was quite positive about the cleanliness and quality of the environment. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users receive care and support from a staff team that is motivated to work with them. Their welfare and best interests are promoted by ensuring that generally; staffing levels and staff induction do reflect their needs and that of the service overall. Good recruitment practices means that service users are protected from the risk of - all forms of abuse. EVIDENCE: At the time of the visit service users, were supported by a staff team that worked closely with them. There were good levels of engagement and interaction with each service user. From observation staff demonstrated a good understanding of the service users’ needs and their communication strengths. All service users looked happy and reported positively about the staff that supported them. From the records viewed staff were capable of making interventions to support service users with both their special and personal needs, including their healthcare needs. There was good evidence of the robustness in the recruitment practices undertaken by the organisation. This was determined upon the examination of a sample of two of the staff recruitment files. All checks required by regulation were undertaken prior to staff taking up duty at the Old Registry. Service users are therefore assured that all staff are thoroughly screened prior to engaging Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 22 with them. They are therefore more protected from the risk of coming to harm, which is a positive outcome for them. A training and development profile is in place for the staff, which generally is line with the needs of the service user group. Staff have had some training e.g. hand hygiene and infection control. The registered persons planned to provide ongoing training to staff to enhance their skills and knowledge and this was documented in the registered persons’ Annual Quality Assurance Assessment (AQAA) document. All staff have a copy of the General Social Care Council’s code of conduct. There was also an improvement in this standard as a clear induction - training programme was now in place for all staff. Service users generally receive care and support from a staff team that is supported to so do. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,42,43) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Management systems are in place to provide a quality service at the Old Registry. Quality assurance systems are in place to develop the service although some improvement is required in this area. Health and safety practices within the home protect service users living at the Old Registry. EVIDENCE: The registered manager was unavailable throughout the course of the inspection, although access was provided to key documents required for the purposes of the key inspection. The inspection found that the home was generally run in the interests and satisfaction of service users and the staff working there. Feedback obtained from external professionals, the staff team and service users were positive about the input of the registered manager in delivering the service objectives at the Old Registry. Due to the manager’s absence it has not been possible to determine the training he undertook to develop his skills and knowledge, since the last inspection. Policies and Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 24 procedures and other systems were in place for the benefit of staff and service users. There were mechanisms in place for quality monitoring and quality assurance at the home. This included service user surveys, annual quality audits, service user reviews and Regulation 26 monitoring visits. However, the latter of these systems were not carried out in line with Regulation. From the records presented at the inspection, Regulation 26 monitoring visits were not on record for April, May and June 2008. The potential impact of this could mean that service users could potentially receive a compromised level of service, which could go unnoticed over such a period. This needs to improve and must be carried out as required by Regulation – on a monthly basis. There was also an annual development plan for 2008 was made available to the Commission, as agreed, following the site visit. The health and safety file was assessed and all records on; appliance safety, fire safety and electrical safety were in order. There was evidence that staff have as part of their induction, appropriate training in health and safety. Safety signs were also appropriately displayed throughout the home and all areas of the home were safely accessible to the service users. Risk assessments were in place for all service users to ensure their safety and independence. Health and safety policies were updated and available to all staff. Service uses therefore have some assurance that they would be safe living at the Old Registry. Finally, at the last inspection a requirement was made for the registered manager to receive supervision in line with the National Minimum Standards (43.3) for Younger Adults and the Care Homes Regulations 2001. As the registered manager was unavailable for the inspection, the only evidence to determine whether this requirement has been satisfied was taken from the Annual Quality Assurance Assessment (AQAA) that was provided by the registered persons. This document under the ‘Conduct and Management’ indicated that: ‘the registered manager, the area manager and other managers have regular meetings to update the homes policies, aims and objectives ect.’. Without confirmation and concrete records that supervision has been taking place, the inspector could only through inference conclude that the registered manager has been having group supervision. This would be followed up at the next inspection of the service. Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X 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 3 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 X 3 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 4 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x 3 X 2 X X 3 3 Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 26 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. 1. Standard YA20 Regulation 12,13 Requirement The registered persons are required to ensure that staff record medication as given at all times. This would be in the best interests of all service users receiving support with their medication. The registered persons are required to carry monthly Regulation 26 monitoring visits in line with the Care Homes Regulations 2001. This is to ensure that service users benefit from the impact of monthly monitoring of the service including the promotion of their welfare. Timescale for action 31/12/08 2. YA39 26 31/12/08 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 Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 27 Old Registry (The) DS0000025931.V364755.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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