Care Home: Pathways

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What the care home does well Service users have a large measure of control over their daily lives, and are able to make choices and decisions for themselves. The home supports service users to live valued and fulfilling lives, for example through access to a variety of community based social and leisure activities. There was evidence that the home is meeting needs around equalities and diversity issues around culture and disabilities, for instance through food, music and the efforts made to aid service user communication. Staff have a good understanding of their roles and responsibilities, and have built up good relations with individual service users. One relative informed the inspector that "The staff are all very nice, they answer my questions." While another relative commented in their survey that "The staff that work in the home are very good." What has improved since the last inspection? There have been improvements to the home since the previous inspection, and the overall number of requirements set has fallen from seventeen to seven. In particular, the homes physical environment has improved, and is now much better. Other areas of improvement include the provision of training around autism and epilepsy, and ensuring that pre admission assessments are now carried out for any prospective service users. CARE HOME ADULTS 18-65 Pathways 11 Gloucester Drive Hackney London N4 2LE Lead Inspector Rob Cole Unannounced Inspection 20th August 2008 09:15 Pathways DS0000065292.V369590.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 Pathways DS0000065292.V369590.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. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pathways Address 11 Gloucester Drive Hackney London N4 2LE 020 8800 2619 020 8802 6862 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) www.pathwayscare.net Care Support Service Ltd trading as `Pathways` Post vacant Care Home 8 Category(ies) of Learning disability (9) registration, with number of places Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service user with a Learning Disability aged 16-60 years, can be accommodated within the home. 30th August 2007 Date of last inspection Brief Description of the Service: 11 Gloucester Rd is registered with the Commission for Social Care Inspection to provide care and accommodation for eight adults who have learning disabilities and was registered in July 2004. The home is in a quiet residential road in the Finsbury Park area of the London Borough of Hackney and is well positioned to access a range of community amenities, local parks and transport links. The aim of the home is to provide a specialised service in working with service users with complex needs, in particular challenging behaviour and autism. The current range of fees charged by the home is between £1540 and £1939 per week. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. This inspection took place on the 20/08/08 and was unannounced. The inspector had the opportunity of speaking with a relative of one of the service users, staff from the home, and the homes deputy manager was present throughout the course of the inspection. The inspector also had a follow up telephone conversation with the organizations area manager who has responsibility for the home. The home currently has four service users, all of whom have very limited verbal communication. Therefore the inspector was unable to speak directly with service users. To help gain an understanding of the experiences of service users, staff were observed in their interactions with service users during the course of the inspection. The inspection also included an examination of records and other documents, along with a tour of the premisis. Prior to the inspection the home supplied the CSCI with an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. The CSCI issued questionnaires to service users and their relatives prior to this inspection, and two of these were returned. All of this has contributed to the overall inspection process, and to the judgments made within this report. What the service does well: What has improved since the last inspection? There have been improvements to the home since the previous inspection, and the overall number of requirements set has fallen from seventeen to seven. In particular, the homes physical environment has improved, and is now much better. Other areas of improvement include the provision of training around Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 6 autism and epilepsy, and ensuring that pre admission assessments are now carried out for any prospective service users. 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. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 7 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 Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 8 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): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are generally provided with sufficient information to make an informed choice as to move in to the home or not. This information is provided through the opportunity of visiting the home and through written documentation, although the Statement of Purpose needs to be revised. EVIDENCE: The home has a Statement of Purpose in place, which is written in plain English. This includes the homes mission statement, which is “Providing care, support and accommodation for people with complex needs, through creative individualised therapeutic approaches.” The Statement also includes the aims and objectives of the home and the arrangements for fire safety. However, the Statement is not in line with National Minimum Standards (NMS). It has not been reviewed since April 2006, and contains inaccurate information, for example around the organisation that runs the home, and around the registered manager. Further, it does not include all required information, for example it does not include information on the arrangements for providing social and leisure activities or on attending religious services. In order to Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 9 provide service users with relevant information about the home, it is required that the Statement of Purpose is up to date and accurate, and subject to regular review. The Service User Guide has been produced in written and pictorial form, thus making it more accessible to service users, and helping to meet needs around equality and diversity issues. All service users are offered their own copy of the Guide. It includes details of the homes physical environment and of the facilities and services provided. Individual contracts/statements of terms and conditions were in place for all service users. These included details of fees payable and the conditions of occupancy. Contracts have been signed by the service users and a representative of the home. The home has an admissions procedure. This makes clear that service users will have the opportunity of visiting the home prior to moving in. There has been one new admission to the home since the previous inspection. There was evidence of a detailed transition plan, which involved the service user visiting the home on several occasions, including for an overnight stay. They originally moved in to the home on a trial basis, after which a placement review meeting was held, to which the service users social worker was invited. The inspector was pleased to note that the home had carried out a pre admission assessment for this service user, thus meeting one of the requirements made at the previous inspection. This was of a satisfactory standard, and included needs around mental health, relationships, personal care and social and leisure activities. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users have a large measure of control over their daily lives, care plans are of a good standard, as are risk assessments. EVIDENCE: Individual care plans are in place for all service users, these are clear and comprehensive and of a good standard. The inspector was pleased to note that since the previous inspection these are now subject to regular review. Plans provide detailed information on how the home is able to meet the needs of service users, for example with personal care, and they also cover needs around equality and diversity issues, for example around disabilities and relationships. Plans indicate that the home strives to develop and improve service user skills and lifestyle, with goal setting around things such as social interaction and community participation. The AQAA supplied by the home Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 11 states that all service users have an annual review in conjunction with their placing authority, which feeds in to the care planning process. Risk assessments are in place for all service users, and as with the care plans, these are of a good standard and subject to regular review. Assessments cover risks around using public transport, accessing the community and challenging behaviours, and it was positively noted that individual guidelines were in place around managing any challenging behaviours that service users present. Assessments identify any potential risks, and include strategies to manage and reduce those risks. There was evidence that service users are supported to take risks. For example, it has been identified that one service user enjoys going horse riding, even though this presents some risks. A risk assessment has been drawn up around this, to ensure that any risks are minimised, and the service user is able to take part in this activity. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives, for example when to get up, go to bed, take a meal etc, and this was also detailed in care plans. All of the current service users have complex communication needs, with very little verbal communication. The inspector was impressed with efforts made by the home to help enable service users to communicate, and therefore to have more control and choice over their daily lives. Service users have had access to speech and language therapists, and various techniques are employed to aid communication, including Makaton, object referencing and picture exchange systems. The home also attempts to work closely with service users family, who have provided important information around the likes and dislikes of service users, and ways in which they communicate. There was evidence that service users have some involvement in the day to day running of the home. Service users are involved in the daily routines of the home, such as cooking, laundry and keeping bedrooms tidy. The home holds regular service user meetings. Recent meetings included discussions around activities, menus and holidays. It is planned that service users will be going on holiday to Centreparks in September of this year, and there was evidence that this had been planned around the needs and choices of service users. Service users also have a weekly one to one meeting with their keyworker, which gives them the opportunity of discussing anything of importance to them. Since the previous inspection the home has had a considerable amount of redecoration work carried out, and a lot of new furniture has been purchased. While the inspector was pleased to note that this has happed, it was disappointing to note that service users had very little opportunity of been involved in choosing any new décor or furniture. The deputy manager informed the inspector that with the various communication systems that have been developed, there could have been scope for much greater service user involvement in this process. It is required that in future, service users are Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 12 consulted over new decoration in the home, or over the purchasing of new furniture. Pathways DS0000065292.V369590.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): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live valued and fulfilling lives, with regular access to the community. EVIDENCE: No service users are involved in any formal employment at the present time. One service user attends college where they study life skills, for example around cooking and laundry. Another service user attends a day centre three times a week, and where there on the day of inspection. They are involved in a variety of activities at this centre, including music therapy, exercise classes (basketball and trampoline) and sensory sessions. One service user is of Greek Cypriot ethnic origin, and the home has taken steps to meet their cultural needs around this, for example they attend a Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 14 Greek Orthodox Church, the home prepares Greek food, and they have access to Greek musical tapes. Service users have access to a variety of community based social and leisure activities, as detailed within their care plans. Service users have access to horse riding, swimming, cinema, pubs and bowling, and the home organises occasional day trips, recent day trips have included Southend and Epping Forest. Service users are supported to take a weeks annual holiday away from the home, as mentioned, it is planned that three service users will be going to Centreparks for a holiday in September of this year. Service users have access to community based facilities, including libraries, shops, cafes and parks. Service users use public transport, and the home has it’s own unmarked vehicle. It was noted that one service user went out for lunch on the day of inspection. In house, service users have access to a variety of activities, including puzzles, television, music, musical instruments, one service user was observed to be playing a keyboard during the course of the inspection. A music therapist and an aroma therapist visit the home, and one of the staff at the home is trained in massage and reflexology. The home arranges various parties, for example to celebrate birthdays or special occasions such as Christmas or Halloween. Visitors are able to visit at any reasonable time, and service users can see visitors in private if they so wish. During the course of the inspection the inspector had the opportunity of speaking with a visiting relative, who expressed satisfaction with the home. They said “I don’t have any problems with the house.” And “My sons room is always kept clean and tidy.” Service users are able to visit relatives in their homes, including for overnight stays. Service users have access to use of a telephone, and staff support them with reading any mail they receive. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. The home provides traditional British and Greek food, thus helping to meet the equality and diversity needs of service users. Service users are involved in food preparation, including choosing and buying food at the shops. On the day of inspection service users were seen to be offered a choice of meals. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is generally able to meet the health and personal care needs of service users. Service users have access to health care professionals as appropriate, and are supported to manage their own personal care as much as possible. EVIDENCE: Care plans indicate that service users are supported to manage their own personal care as much as possible, and where it is provided, it is done so in a way that promotes the individuals dignity and privacy. All service users are registered with relevant health care professionals, including dentists, opticians and GP’s. Health Action Plans are in place as part of care plans, detailing how the home is able to meet service users health needs. Comprehensive records are maintained of medical appointments, including details of any follow up action necessary. Records indicate that service users have access to health care professionals as appropriate, including Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 16 chiropodists, opticians and psychiatrists. The home access services provided by the Local Authorities Learning Disability Services Team, service users are currently working with Speech and Language Therapists and Behavioural Therapists. Medication is stored in a locked cabinet inside the office. The home has a comprehensive medication policy in place, and all staff undertake training before they administer medication. A notification from the home to the CSCI identified that a medication error had occurred. The systems in place picked up on this in a timely manner, and appropriate action was taken. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Records are in place, those checked by the inspector were accurate and up to date. Although protocols were generally in place around administering medications for service users, there was found to be one exception. One service user has been prescribed LORAZAPAM on a PRN basis, but there were no protocols or guidelines in place around when this should be given. In order to ensure that PRN medications are only ever administered as appropriate, clear guidelines must be in place around their administration. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home has taken appropriate steps to help ensure service users are safeguarded from the risk of abuse. Policies and procedures are in place around complaints and adult protection, and staff have undertaken training around safeguarding adults. EVIDENCE: The home has a complaints procedure in place. This makes reference to the CSCI and includes timescales for responding to any complaints received. All service users have been offered their own copy of the procedure, and it has been produced in pictorial form to help make it more accessible to service users. Since the previous inspection a copy of the procedure is now on display within the home. The home maintains a complaints log, this indicated that complaints are recorded and investigated as appropriate. The home has an adult protection procedure, and since the last inspection it has now also obtained a copy of the Local Authorities adult protection procedure. All but one of the staff working at the home have had training in adult protection issues. Staff spoken to by the inspector demonstrated a good understanding of their roles and responsibilities with regard to adult protection. The home holds money on behalf of service users in a locked cabinet. Records and receipts are maintained of any financial transactions involving service user Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 18 monies. The inspector checked the financial records for two service users, and these were found to be accurate and up to date. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. People who use this service experience adequate in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the homes physical environment has improved considerably since the previous inspection. There are however some issues that must be addressed, including ensuring that the stairway carpet is made safe. EVIDENCE: The home is located in a quiet residential street in the Finsbury Park area of the London Borough of Hackney. The home is close to shops, public transport networks and other local amenities. The home is built over three floors, and is in keeping with other homes in the vicinity. Communal areas consist of a quiet room, dinning room, two small outdoor areas at the rear of the property, (one of which contains garden furniture), and Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 20 the kitchen. The home has seven bedrooms, although only four of them were occupied at the time of inspection. It was positively noted that a considerable amount of work has been carried out to the homes physical environment since the previous inspection. At the last inspection the environment was found to be in a very poor state, and this has largely been addressed. All communal areas have been redecorated, as have bedrooms. New furniture has been purchased, and the general décor throughout the home is considerably better then it was. There are however some environmental issues that must be addressed: • One of the bedrooms currently in use has no curtains. • The toilet on the ground floor is broken. • The lighting at the top of the stairs is not working. • The carpet on the stairs is loose. Of these issues, the loose stairway carpet and the lack of lighting at the top of the stairs are of particular concern, as they pose a threat to the health and safety of service users and others. Indeed, one service user has been assessed as been at risk from falling down stairs anyway due to their poor vision, and this only compounds that risk. The issue has been highlighted by senior managers within the organisation. The inspector viewed a Regulation 26 visit report from the 30/07/08, which highlighted the issue of the loose stair carpet, and stated that it was a “trip hazard”. The report went on to say that the carpet must be replaced by the week commencing the 4/08/08. However, on the date of this inspection, it had still not been addressed. In a follow up telephone conversation with the area manager, the inspector was informed that work to make safe the stairway carpet would be carried out on the 1/09/08. In order to help ensure the health and safety of service users, it is required that the stairway carpet is made safe, and that the lighting at the top of the stairs is fully operational. Failure to comply with this requirement may lead the CSCI to take enforcement action against the home. Toilets and bathrooms are located around the home, service users have a choice of bath or shower. Bathrooms were clean, tidy and free from offensive odours, and all had working locks fitted that included an emergency override device. All service users have their own bedrooms. For those service users who wanted it, they contained adequate furniture, including chest of draws, wardrobes and chairs. Rooms had adequate natural light and ventilation. All bedrooms have central heating, and since the previous inspection radiators are now fitted with protective covering. Bedrooms meet National Minimum Standards on size requirements. There was evidence that the home has taken steps to help prevent the spread of infection. Staff have undertaken training in infection control, and protective Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 21 clothing such as gloves and aprons are available to staff. Laundry facilities are appropriate in scale for the home, and hand washing facilities are situated throughout the home. Pathways DS0000065292.V369590.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): 31,32,33,34 and 35. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that staff have a good understanding of their roles and responsibilities, and that they have built up good relations with individual service users. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. Usual staffing levels at present are two care staff on the early shift 7am to 3pm; two staff on the late shift 2pm to 10pm, one staff on the middle shift 11am to 7pm and one waking night staff and one sleeping night staff. The inspector believes that staffing levels are adequate to meet the needs of service users. As the home currently has three vacancies, staffing levels would need to be reviewed if there are any further admissions to the home. However, both the deputy manager and the senior support worker who were on duty during the course of the inspection informed the inspector that they were routinely expected to carry out administrative and management duties Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 23 while they were on shift. This means that time that was allocated for staff to spend with service users is instead spent on other matters. It is recommended that any senior staff who are expected to carry out any management/administrative duties are allocated adequate time on the rota specifically for this purpose, so that it does not impact on the levels and standard of care and support provided to service users. Through observation and discussion there was evidence that staff have built up good relations with service users, and a good ability to communicate with service users, who have very complex communication needs. Staff were observed to interact with service users in a respectful and friendly manner during the course of the inspection. At times service users made it clear they wished to be on their own, and staff were seen to respect this. The AQAA supplied by the home states that three of the eight care staff have achieved an NVQ Level 2 in Care or equivalent qualification, although the deputy manager informed the inspector that a further three staff were very close to obtaining such a qualification, and should do so before the end of this year. Staff undertake a structured induction programme on commencing work at the home, which includes shadowing more experienced members of the team. Records are maintained of staff training, these indicated that staff have had access to recent training around food hygiene, Makaton and person centred planning, and the inspector was pleased to note that since the previous inspection most staff have now had training around autism and epilepsy. The AQAA supplied by the home indicates that it has all appropriate employment related policies and procedures in place, including on recruitment and selection and equal opportunities. Staff employment records are held centrally by the organisation, although the deputy manager informed the inspector that routine checks are carried out on any prospective staff. Pathways DS0000065292.V369590.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): 37,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that this is a well managed home, with appropriate systems in place around quality assurance. EVIDENCE: The previous registered manager of the home has resigned from their post since the previous inspection. The organisation has appointed a new manager who is now in place. The AQAA supplied by the home states that the manager is currently working towards a combined NVQ Level 4/Registered Managers Award. The area manager informed the inspector that it was planned that the homes manager would be applying for registration with the CSCI in the near Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 25 future. In addition to the manager, the home also has a deputy manager and two senior support workers. The AQAA supplied by the home indicates that the home has all policies and procedures in place as required by the NMS. Those checked by the inspector, including adult protection, complaints and admissions were found to be satisfactory. Record keeping in the home was generally of a good standard. Confidential records are stored securely, staff and service users can access their records as appropriate. Care plan reviews, service user meetings and staff supervisions all contribute to the quality assurance process within the home. The AQAA supplied by the home states that the home works with the organisations quality and performance team to ensure that standards are identified, met and maintained. Copies of previous inspection reports are available to view within the home. There was evidence of monthly Regulation 26 visits taking place. Staff have access to health and safety training, such as food hygiene and first aid. Fire extinguishers were situated around the home, these were last serviced in May 2008. The homes fire alarms are tested weekly, and were last serviced on the 9/06/08. COSHH products are stored securely, and the home tests fridge/freezer and hot water temperatures. The home has in date employer’s liability insurance cover. The home has in date safety certificates for PAT testing and electrical installation. However, there was no evidence that the home has had a landlords gas safety check carried out within the past twelve months, and this must be addressed. Pathways DS0000065292.V369590.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 2 2 3 3 3 4 3 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 2 25 3 26 2 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 3 2 3 Pathways DS0000065292.V369590.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. 1. Standard YA1 Regulation 4 Requirement Timescale for action 31/10/08 2. YA8 12 3. YA20 13 4. YA24 13 and 23 The registered person must ensure that the homes Statement of Purpose contains all information required by Schedule 1 of the Care Homes Regulations 2001, that this information is up to date and accurate, and that the Statement of Purpose is subject to regular review, at least once a year. The registered person must 30/09/08 ensure that service users are given the opportunity of making decisions around the running of the home involving the purchase of new furniture and the decorating of the home. The home must be able to demonstrate how it has consulted service users. The registered person must 30/09/08 ensure that clear guidelines are in place around the administration of any medications service users are prescribed on a PRN basis. The registered person must 07/09/08 ensure that the stairway carpet is made safe, and that the lighting at the top of the stairs is DS0000065292.V369590.R01.S.doc Version 5.2 Pathways Page 28 in full working order. 5. YA26 23 The registered person must ensure that all bedrooms are fitted with curtains, or some other device which will provide privacy to the service user. The registered person must ensure that all toilets in the home are in full working order. The registered person must ensure that the home has a landlord’s gas safety check carried out at least once every twelve months. 30/09/08 6. 7. YA27 YA42 23 13 and 23 30/09/08 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations It is recommended that senior staff in the home are provided with adequate time to carry out any required management/administrative functions, outside of any hours allocated to been on shift. Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Pathways DS0000065292.V369590.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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