Care Home: Prince Bishop Court

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What the care home does well The service does well in all outcome areas covered by National Minimum Standards for Younger Adults, especially concerning: Individual needs and choices, Lifestyle, Environment, Staffing, plus Conduct and management of the home. Typical comments received included: "I am very happy here." "I get to choose what I do each day." "The staff are very good and support me to do things I want to do." "I want to do IT and cookery at college, cross roads safely and learn how to use a mobile phone; staff are helping me with all these things." (Service users) "I would talk to my Key Worker or Neil (manager) if I had a problem or wanted to complain." (Service users) "There were 3 homes all decorated nicely. People`s bedrooms were nice and were sensible sized rooms. People could choose their own decorating and this is good. All the rooms had locks and this is good because people could have their own privacy and people could not go in without asking." (Expert by Experience) "Training is at hand all the time and is always relevant and helpful in our roles." "The service promotes choices and independence. It treats each person as an individual. It realises potential in staff and gives training to enhance staff skills. It encourages service users to reach goals and ambitions. Training needs are met." (Staff) "I found the home to be clean and tidy and nicely decorated. I think people were well supported by staff to achieve goals but maybe people with higher levels of needs could have more opportunity to socialise outside. The homes were all welcoming and friendly. I preferred the house where people were given the opportunity to live independently but still supported by staff for cooking. I like that people go shopping and plan their meals for the next day. It is good that people go out by themselves and can get support to go out. I think the person centred plans should definitely be accessible to people who they belong to." (Expert by Experience) What has improved since the last inspection? The service has expanded by adding a third unit of 3 beds, providing people with the opportunity for greater independence and personal fulfilment, in keeping with their assessed needs. The service has achieved accreditation with the Investor in People Award, in recognition of its strong commitment to quality assurance and positive outcomes for its service users. CARE HOME ADULTS 18-65 Prince Bishop Court 3 Eureka Terrace Kimblesworth Chester Le Street Durham DH2 3PZ Lead Inspector Mr Stephen Ellis Key Unannounced Inspection 17th March 2008 2:00 Prince Bishop Court DS0000007498.V360888.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 Prince Bishop Court DS0000007498.V360888.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. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Prince Bishop Court Address 3 Eureka Terrace Kimblesworth Chester Le Street Durham DH2 3PZ 0191 3718860 0191 3719263 neil@pasltd.eclipse.co.uk 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) Positive Approach Services Limited Vacant (Acting manager: Neil Hardy) Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Prince Bishop Court DS0000007498.V360888.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: Either Whose primary care needs on admission to the Home are within the following category only: 2. Learning Disability - Code LD, maximum number 15 The maximum number of service users who can be accommodated is: 15 18th December 2006 Date of last inspection Brief Description of the Service: Prince Bishop Court is a private sector care home for up to 15 adults with learning disabilities. It is situated in the village of Kimblesworth, halfway between Durham City and Chester le Street. There is good access to local community facilities, such as cricket club, shops and post office. The premises consist of what were originally 2 adjacent houses, converted into one and extended to the rear, plus a separate house (with 3 bedrooms) to the side. The home has some well-developed, outside space to the sides and rear, for parking and leisure use. Prince Bishop Court has ground and first floor facilities. It does not have a lift, but the first floors are not intended for service users with mobility problems that would prevent access. The home is divided into 3 units of 5, 7 and 3 service users. Each unit is selfsufficient, with kitchen, laundry, lounge, dining, toilet and bathing facilities. This division supports better outcomes for service users with a range of dependency needs at Prince Bishop Court. The current scale of weekly charges varies between £407 and £1,600, depending on the individual level of care and support required and the specific circumstances of the service user. These fees cover all accommodation, meals and personal care. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This unannounced fieldwork visit to Prince Bishop Court Care Home on 17th March 2008 took place over 5 hours, as part of the statutory inspection of the service. Information received prior to the fieldwork visit was used in preparation and during the visit, including 7 questionnaires completed by service users, 3 questionnaires completed by staff, and the home’s own, annual quality assurance assessment completed by its management. The visit to the home included a tour of the 3 units, examination of some of the records that the home is required to keep, and interviews with service users and staff. This inspection benefited from the input of an ‘Expert by Experience’ (Lee Fiskell, supplied by Darlington Association on Disability: ‘DAD’) who independently visited the home on the same day, toured the premises and spoke to service users and staff, before feeding back his observations and comments to the inspector and management team in person. In total, comments were received from 12 service users and 8 staff. What the service does well: The service does well in all outcome areas covered by National Minimum Standards for Younger Adults, especially concerning: Individual needs and choices, Lifestyle, Environment, Staffing, plus Conduct and management of the home. Typical comments received included: “I am very happy here.” “I get to choose what I do each day.” “The staff are very good and support me to do things I want to do.” “I want to do IT and cookery at college, cross roads safely and learn how to use a mobile phone; staff are helping me with all these things.” (Service users) “I would talk to my Key Worker or Neil (manager) if I had a problem or wanted to complain.” (Service users) “There were 3 homes all decorated nicely. People’s bedrooms were nice and were sensible sized rooms. People could choose their own decorating and this is good. All the rooms had locks and this is good because people could have their own privacy and people could not go in without asking.” (Expert by Experience) “Training is at hand all the time and is always relevant and helpful in our roles.” “The service promotes choices and independence. It treats each person Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 6 as an individual. It realises potential in staff and gives training to enhance staff skills. It encourages service users to reach goals and ambitions. Training needs are met.” (Staff) “I found the home to be clean and tidy and nicely decorated. I think people were well supported by staff to achieve goals but maybe people with higher levels of needs could have more opportunity to socialise outside. The homes were all welcoming and friendly. I preferred the house where people were given the opportunity to live independently but still supported by staff for cooking. I like that people go shopping and plan their meals for the next day. It is good that people go out by themselves and can get support to go out. I think the person centred plans should definitely be accessible to people who they belong to.” (Expert by Experience) 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. Prince Bishop Court DS0000007498.V360888.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 Prince Bishop Court DS0000007498.V360888.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. People who use the service experience good quality outcomes in this area. Prospective service users and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager and staff confirmed that there had been thorough assessments of service users’ needs prior to admission. Comprehensive and detailed assessments were found in service users’ case files. The manager and staff confirmed that the home’s admission policy is followed, so that only people whose needs are known and whose needs can be met, are admitted, bearing in mind the needs of other service users. The aspirations of service users were well known by staff and well reflected in their plans of care and daily lives. The home has developed very good person centred planning, which focuses on personal goals and aspirations, as well as the activities of daily living. The service user guide was very helpful and had many pictures in support of the plain English text. The information can be provided in other versions and formats, such as audio, if required. Seven service users who completed Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 9 questionnaires said that they got enough information about the home before they moved in so they could decide if it was the right place for them. Prince Bishop Court DS0000007498.V360888.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 and 9. People who use the service experience excellent quality outcomes in this area. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The service takes a person centred approach to each service user, which aims to help people reach their personal goals and aspirations in life. It has a charter of rights and responsibilities that provides the value base for the home’s policies and procedures, reinforcing the principles of dignity, choice, independence, rights, privacy and fulfilment. There were numerous examples of people exercising choice and making decisions about each aspect of their lives, from menu planning, food shopping and cooking to colour schemes and decoration of bedrooms. Service users lead active lives, taking responsible Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 11 risks, participating in a variety of recreational and educational activities, including adult centres, colleges, holidays and outings to places of interest. Residents confirmed that they exercise choice and act independently, with support and encouragement from staff (such as choice of clothing, times of getting up and going to bed, choice of menu, choice of activities etc.). There is input from external specialist staff, such as psychologist, physiotherapist, speech and language therapist, occupational therapist and community nurse, as required. External, health and social care professional staff and residents’ relatives are routinely involved in reviews of care needs and the suitability of the service, making recommendations for improvements wherever appropriate. It was observed that service users were treated with respect and their individuality was acknowledged and promoted. Members of staff adopt a ‘person-centred’ approach, with attention given to promoting people’s dignity and privacy. Each resident had a person centred plan of care and support, and these documents were of excellent quality, being highly detailed, comprehensive and individual. They would, however, benefit from the use of illustrative pictures, as recommended by the Expert by Experience, and endorsed by some service users, who said that they would find it helpful to have a pictorial guide to their person centred plan of care, which they could refer to whenever they liked. All residents confirmed that they discussed their needs and personal goals with staff, and staff took note of these issues and helped them. There was much evidence of such communication and personal care planning found in the plans of care. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience excellent quality outcomes in this area. People who use services are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individuals’ expectations. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Comments received from service users and staff confirmed that all residents take part in a range of activities, that are personally chosen, rewarding and satisfying, including pottery, card making, part time working in administration, theatre visits, going for walks, attending football matches, shopping, bowling, outings to places of local interest, holidays, parties, social clubs and discos, and attendance at local adult centres and colleges. Residents’ sexuality is acknowledged in their holistic plans of care (that is, plans of care that address Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 13 the needs of the whole person, in a person-centred way, bearing in mind the individual’s needs, interests and relationships, in the past, present and future where possible) as part of their activities of daily living and personal aspirations where appropriate. Several residents said that they received visits from relatives and friends, sometimes going out with them. Visitors were welcome at any reasonable time. There are good links with the wider community, with evidence of service users visiting local shops, library, theatres, pubs and clubs. Activities and support on a one-to-one basis are also provided, in accordance with individual needs. The service champions individuals’ rights whilst encouraging people to act responsibly and to show consideration to others. Residents said that they enjoyed their meals and all took part in menu planning, shopping and meal preparation, with support from staff as required. Residents mainly dined together in the dining areas. They could, however, eat their meals elsewhere and at different times if required. Records are kept of meals served, available for inspection. Staff and records confirmed the varied, appetising menu. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Comments from service users and staff indicated high levels of satisfaction concerning health care, personal care and social care. Medical and community nursing care was described as being readily available and very helpful. All residents are registered with a GP on admission, reflecting residents’ choice wherever possible. Other, external health and social care personnel, such as dentists, opticians, physiotherapists, occupational therapists, psychologists, social workers, and speech and language therapists, provide inputs as required. Residents spoke highly of the staff, describing them as friendly, understanding and supportive. Each resident has a named key worker of their choice from the home’s team of staff. Staff members confirmed that they have defined roles and responsibilities and are encouraged to recognise their own Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 15 professional limitations. Service users are encouraged to take responsible risks, such as those associated with food preparation activities, visits to local pubs and clubs, and holidays. Typical comments from service users included: “I am very happy here.” “I get to choose what I do each day.” “The staff are very good and support me to do things I want to do.” “I want to do IT and cookery at college, cross roads safely and learn how to use a mobile phone; staff are helping me with all these things.” It was observed that service users were treated with respect and their individuality was acknowledged. Members of staff adopt a ‘person-centred’ approach, with attention given to promoting people’s dignity and privacy. These values were reflected in the home’s charter of rights and responsibilities and in the service users’ person-centred portfolios, providing foundation guidance to staff about service users’ individual needs and how these should be met. Staff training records confirmed wide ranging staff qualifications and training, reinforcing the essential value base, respecting and supporting each person as a unique individual. For example, over 75 of care staff members have achieved National Vocational Qualifications (NVQ) in health and social care at level 2 or above. All members of care staff responsible for medicines have completed Safe Handling of Medicines training. Policies and procedures for the safe storage, administration and disposal of medicines are satisfactory. In practice, residents tend to delegate responsibility for their medicines to the staff, although residents may administer their own medicines, subject to risk assessment. Medicines were observed to be well organised, stored and administered safely. A monitored dosage system is used and there is good support from a local pharmacist. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Records Bureau, plus Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to ensure that unsuitable people are not employed to care for vulnerable adults. New staff members go through induction and foundation training so that they have the right knowledge and skills to do their jobs competently. Residents indicated a caring, supportive atmosphere in the home, and this we observed to be well established. They said that they got on well with each member of staff and felt they could confide in them. Typical comments included: “I would talk to my Key Worker or Neil (manager) if I had a problem or wanted to complain.” The home has a user-friendly complaints procedure leaflet, with pictures illustrating points, which was developed with the help of residents. Good teamwork was again evident, reinforcing the caring culture and provider Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 17 policies concerning adult protection. Staff expressed confidence in the manager and seniors, describing them as being supportive, approachable and understanding. They would not hesitate to approach the manager and/or seniors about any suspected abuse or neglect of residents. Most members of staff have undergone training in the Protection of Vulnerable Adults (POVA), such as ‘No Secrets’ training, and are familiar with the local multi-agency safeguarding adults policy and the lead role played by the Adult Social Services Department. Good arrangements were observed to be in place concerning the handling of service users’ personal monies. Each service user receives a weekly personal allowance, with cash kept in individual containers at the home. Service users have ready access to their cash monies kept at the home, and also have good access to other monies, kept in their individual accounts, when larger amounts are required. The home likes to ensure that service users have about £20 cash available in their personal containers at the home each week, and this money is kept securely on behalf of residents. Five individual containers were examined in front of the inspector, and checked against the corresponding individual cash sheets, and were found to be accurate and as described. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 18 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 and 30. People who use the service experience excellent quality outcomes in this area. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There were no unpleasant odours and the home was found to be clean in all the areas inspected. Residents said that they were pleased with the premises, especially their bedrooms, finding them comfortable and homely as well as practical. Bedrooms were attractively decorated and furnished, reflecting the individuality of service users. Staff confirmed that the home is well maintained, with repairs and servicing being carried out promptly and according to schedule. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 19 The home is well designed with 3 units of 5, 7 and 3 beds. These are semiindependent units, each with its own facilities, such as toilets, bathrooms, kitchens, lounges and dining areas. They have been designed to promote homely, non-institutional accommodation that supports the home’s vision and values of promoting personalised care, independence and fulfilment, based on its charter of rights and responsibilities. Service users said they were regularly consulted about all aspects of life at Prince Bishop Court, including their bedroom décor and furnishing. Communal areas such as lounges were attractively decorated, homely and comfortable. Kitchens were well equipped and practical, as well as being homely in appearance. The expert by experience said: “There were 3 homes all decorated nicely. People’s bedrooms were nice and were sensible sized rooms. People could choose their own decorating and this is good. All the rooms had locks and this is good because people could have their own privacy and people could not go in without asking.” Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 20 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 and 36. People who use the service experience excellent quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Staffing levels were found to be excellent, in accordance with the guidance issued by the Commission for Social Care Inspection and residents’ assessed needs. At the time of inspection, there were 14 residents being accommodated. During the day (approximately 7.30 am to 9.30 pm) there are 5 members of care staff on duty and, at night, that number reduces to one awake and one on call on the premises. Comments received from both residents and staff confirmed that staffing levels and skills were sufficient for the needs of the home. A senior support worker is always deployed on each shift. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 21 A full staff-training programme is provided, including induction and foundation training that is accredited with the Learning Disability Award Framework (LDAF). Other training provided includes National Vocational Qualifications (NVQ) in social care and health at levels 2 and 3, postural care, oral care, Down’s syndrome and dementia, Deafness and sensory issues, sexuality and learning disability, continence promotion, managing challenging behaviour, safe handling of medicines, protection of vulnerable adults, food hygiene, moving and handling, first aid, risk assessment, plus fire safety. Individual records of staff training and development are kept, as well as staff group records. Over 75 of care staff have achieved NVQ level 2 or above in health and social care, which is commendable. The home’s recruitment policy and practice is sound, ensuring that all preemployment checks are carried out as required, including Criminal Record Bureau enhanced checks, Protection of Vulnerable Adults checks and the taking up of two written references. Service users’ views concerning the suitability of new staff are taken into consideration and there is a probationary period of 3 months for new staff to serve. Staff felt well supported and supervised, with a full programme of formal staff supervision (one to one) and appraisal being conducted. Each member of staff receives at least 6 supervision sessions per year (one of which may be an appraisal) and these are recorded. Typical comments from staff included: “Training is at hand all the time and is always relevant and helpful in our roles.” “The service promotes choices and independence. It treats each person as an individual. It realises potential in staff and gives training to enhance staff skills. It encourages service users to reach goals and ambitions. Training needs are met.” Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. People who use the service experience excellent quality outcomes in this area. The management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by an experienced and competent manager. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Residents and staff said they were pleased with the way the home was run and the good outcomes for service users. The manager (Neil Hardy) is not registered as manager, but has achieved National Vocational Qualifications (NVQ) level 4 in management (Registered Manager’s Award) and has the D32 and D33 awards as a NVQ Assessor. He has substantial experience of working Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 23 at a senior level and in management in care home settings. A deputy manager and senior staff members support the manager, and have appropriate qualifications and experience. The home’s previous registered manager left in November 2007. The home is seeking a suitable person to make application for registration as manager in the near future. The service carries out regular quality assurance surveys, seeking the views of a wide range of people about its performance, including service users, relatives, external health and social care staff, and support staff within the home. It does this by reviewing the person centred portfolios for each service user every 6 months, involving the service user and support staff, including the key worker. Annually, there is a big review, involving surveys, relatives, support staff, plus external health and social care staff. A separate survey is carried out each year with relatives, seeking their views on how well the service has performed. Prince Bishop Court has achieved and maintained the Investor in People (IIP) Award, which is an important indicator of good Quality Assurance systems within an organisation. Staff said that they believed the home was safe and run in the best interests of residents, with good communication. For example, there is frequent consultation with service users and their representatives about key issues affecting the lives of residents and the achievement of personal goals. There is a communication book that is used daily to brief staff on these matters, plus an important ‘handover’ meeting each afternoon when a full briefing is given to the new shift leader and service users’ monies are checked against records to ensure accuracy and accountability. There are monthly, staff group meetings conducted by the manager or senior staff, at which a wide range of issues are discussed, including health and safety, plus regular one-to-one supervision sessions and an annual appraisal for each member of staff. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 24 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 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 4 25 X 26 X 27 3 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 4 4 X X 3 x Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 25 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 YA37 Regulation 8 Requirement The home needs to register a manager, to be responsible for the day-to-day conduct of the home. Timescale for action 30/06/08 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 YA6 Good Practice Recommendations Each resident had a person centred plan of care and support, and these documents were of excellent quality, being highly detailed, comprehensive and individual. They would, however, benefit from the use of illustrative pictures, as recommended by the Expert by Experience, and endorsed by some service users, who said that they would find it helpful to have a pictorial guide to their person centred plan of care, which they could refer to whenever they liked. Prince Bishop Court DS0000007498.V360888.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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