Care Home: Regis House

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What the care home does well The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. The home has very good assessment procedures and care planning systems in place and service users are confident that their personal needs are understood and can be met. The plans are devised to assist the service users to have a full and active life The staff are seen to have excellent relationships with the residents interacting naturally, with empathy and delivering care as the person wishes, achieving a high level of satisfaction and sense of wellbeing amongst the residents. Residents take part in making choices about their meals and staff encourage healthy eating. The home makes sure that residents get routine as well as specialist health care. Staff are recruited and selected in ways that ensure safe skilled individuals are employed and the home demonstrates a good commitment to staff training. What has improved since the last inspection? The home has been proactive in addressing all the previous requirements and recommendations and these are listed below. Comprehensive care plans for behaviour have been introduced based on each person`s needs and capabilities including detailed and specific instructions for staff. The home has obtained professional advice regarding its menus and evidence that all specific dietary requirements are being catered for. The home has improved systems for the management of behaviours this includes: Recording investigations and outcomes for incidents, recording of aggression, verbal or physical. Completing physical intervention forms when as required medication is used for controlling behaviour. Agreed interventions within a multi disciplinary forum. All staff have undertaken non-violent crisis intervention training, as per the homes written policy. Staff must undertake infection control training. The staff personnel files contain all documentation as detailed in the Care Home Regulations 2001. New staff receive structured induction training. What the care home could do better: The home has been very successful in raising standards over the past year and comply with all standards and exceed many. The manager should look to expand the number of information document made available in pictorial format and or other aids to communicating these. The environment is well managed clean, safe and hygienic and has contingency plans to respond to problems arising such as the current break down of the washing machine, the repair or replacement needs to be addressed quickly and the contingency arrangement kept under close scrutiny that it is proving successful. CARE HOME ADULTS 18-65 Regis House 29 Causeway Rowley Regis West Midlands B65 8AA Lead Inspector Richard Eaves Key Unannounced Inspection 21st January 2008 09:00 Regis House DS0000056464.V351569.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 Regis House DS0000056464.V351569.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. Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regis House Address 29 Causeway Rowley Regis West Midlands B65 8AA 0121 559 6667 0121 559 6512 regishouse@highfield-care.com 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) Southern Cross Healthcare Centres Limited Angela Bennett Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report of 17.9.03 may be accommodated at the home in the category of MD. This will remain until such time that the service users placement is terminated. One service user accommodated at the home may be in the category LD(E). This will remain until such time that the identified service users placement is terminated. 27th February 2007 2. Date of last inspection Brief Description of the Service: Regis House is a 2 storey Victorian property situated in a residential street in Blackheath, close to shops and local community facilities. Southern Cross has recently acquired Regis House and there is a sense of optimism for the future amongst the management and staff. The home is registered to provide care and accommodation for 6 residents with a learning disability, 1 person with a learning disability who is over 65 and 1 person with a mental disorder. The lounge and dining room are on the first floor with bedrooms and bathroom on the ground floor. There is a toilet available on both floors. The home does not have a lift and would therefore not be suitable for people with physical disabilities. The home has a minibus to enable residents to access community facilities. The aim of the home is to enable residents to maximise their life opportunities and choices within a risk management framework. The weekly fees are £671, the fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the agency. Regis House DS0000056464.V351569.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 star. This means the people who use this service experience excellent quality outcomes. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: reports from the organisation relating to the conduct of the home, records maintained at the home, the annual quality assurance self assessment and meeting and speaking with service users and staff. The inspection involved a full tour of the property including, a number of bedrooms, the communal rooms and service areas and provided an opportunity to speak with most of the service users. What the service does well: What has improved since the last inspection? The home has been proactive in addressing all the previous requirements and recommendations and these are listed below. Comprehensive care plans for behaviour have been introduced based on each person’s needs and capabilities including detailed and specific instructions for staff. The home has obtained professional advice regarding its menus and evidence that all specific dietary requirements are being catered for. Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 6 The home has improved systems for the management of behaviours this includes: Recording investigations and outcomes for incidents, recording of aggression, verbal or physical. Completing physical intervention forms when as required medication is used for controlling behaviour. Agreed interventions within a multi disciplinary forum. All staff have undertaken non-violent crisis intervention training, as per the homes written policy. Staff must undertake infection control training. The staff personnel files contain all documentation as detailed in the Care Home Regulations 2001. New staff receive structured induction training. 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. Regis House DS0000056464.V351569.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 Regis House DS0000056464.V351569.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): Standards 1 – 5 Quality in this outcome area is excellent. The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission, access to the community could be restricted due to the lack of clarity in the contract for one service user. Service users are invited to visit and trial the home before commitment to staying at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes statement of purpose and service user guide are good sources of information, including the rate of weekly fees and provides details of the service enabling service users and families to make informed decisions about admission to the home. A picture format was seen to be available. Both documents were reviewed during September 2007. The home now accommodates six service users, the double room having been adapted for single occupancy. On the day of inspection five of the six service users were available to meet and two of these were selected for case tracking. Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 9 All have been resident at the home for a number of years and all have had a full review of the assessment process and are subject to regular reviews. Each file case tracked had detailed assessments for learning disability and autism spectrum, language and communication, imagination and thinking, social interaction and social understanding, obsessions and rituals, behaviours and environmental factors. Other disabilities such as health conditions, mobility and personal care, the level of independence such as self care skills and home care skills and life skills such as reading, writing, numeracy and money, time and measuring and finally the level of inclusion, home and community based leisure. These extensive assessments are supplemented with good social histories and pen portraits that provide real insight to the individual. Through observations of care practices and interactions between staff and service users, discussion with staff and the service users, the level of staff skills, as portrayed by the high levels of training and qualifications and a review of documentation it can be confirmed that as in previous inspections, the home is meeting the assessed needs of service users accommodated there. Conditions of registration are being adhered to and services offered reflect current good practice and legislation. There have not been any new admissions for a considerable time, however the policy provides for extensive trial periods and introductions. An emergency admission policy is also available. Standard compliant contracts and terms and conditions were seen to be included in the service users files. A form of contract with the Social Services team was also seen. Regis House DS0000056464.V351569.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): Standards 6 - 10. Quality in this outcome area is excellent. Care needs are comprehensively identified in Care Plans and the necessary directions of actions required to ensure that service users care needs are fully met and health is promoted. Care Plans are regularly reviewed and revised as necessary. Service users are fully involved in all aspects of life at the home and are supported to make decisions for themselves and encouraged to be as independent as possible, even though this may mean taking risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two service users were selected for case tracking and other case files were used to confirm that the standard is consistent. The care plans were found to be derived through a person centred approach, are assessed needs based and promotes choice and independence and encourages a responsible approach to taking risks to increase independence and decision making. Each of the service users case tracked had extensive range of individualised care plans one having 16, there was also good evidence of service user involvement in the development of the plans, the range of plans include all areas specifically Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 11 required by the standard. Plans are available for behaviour interventions and staff have all received training in non violent crisis prevention intervention and the care plans focus on positive behaviour. In conversation with service users it was clear that they knew of the level of help they individually need and of what they can achieve for themselves. The care plans were seen to be subject to monthly reviews. In conversation with the service users, observations of care practices and inspection of the files confirm that service users are supported in decisionmaking processes. The files include good information about rights and choices and each of the service users was seen to express theses over the day with two engaged outside the home at different centres and three going out to the shops for a walk and generally for some exercise. Records confirm that service users meetings take place on a monthly basis where topics including the home, activities and staff are discussed. The minutes of these now include agreed actions and timescales for undertaking. The topics included in the meetings include how to make a complaint, community opportunities, daily living activities such as vacuuming own bedroom or caring for the rabbits, Holiday and outings planning and birthdays. Surveys undertaken under the quality assurance are in pictorial format for service users and responses to that undertaken during November confirmed they make decisions about what they do. An extensive range of risk assessments and risk reduction plans were in place for each individual and individual service user, training is included in the plan of care. Confidentiality of records and other aspects of personal information are maintained securely and those inspected seen to be accurate and up to date. The topic is given the necessary priority and included in staff training and staff sign for their copy of the policy. Regis House DS0000056464.V351569.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): Standards 11 – 17 Quality in this outcome area is excellent. Staff support service users to access opportunities for their personal development and appropriate activities. The involvement of family and friends is encouraged in agreement with the service users wishes. The home provides a varied leisure, social and recreational activities that provide interest and pleasure for service users. Service users follow a lifestyle appropriate to their age. Meals at the home are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users and information within the case files show that opportunities are provided for each to develop life skills both within the home and through attendance at day care and training courses. The case records clearly identify individual interests and means of accessing these. Individual programmes are prepared of personally meaningful activity both within the home and externally. One service user attends an art course and proudly showed Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 13 examples of her work, which were displayed in the home and the inspector was impressed by the quality of the art. The home encourages and assists the service users to be involved in the community including fulfilment of spiritual needs with regular church attendance. A number also access the ‘Lighthouse’ where they develop friendships and access training. The home is located close to the town and local events information is displayed on the notice board. During the morning a number of service users were observed to be involved in cleaning and tidying their rooms without prompting, taking a pride in their rooms appearance. Staff rotas are devised to ensure staff are allocated in numbers to ensure individual and group activities are all met. The electoral role has been completed on behalf of the service users for this year. The service identifies an allowance it contributes towards individual holidays. The company has a policy that promotes personal relationships and service users identify with their friends at the home and places they visit. Family relationships are promoted and there is evidence of a lot of sibling contact and involvement in the home and service users lives. The home are clear that there are no house rules only individually agreed plans, in discussion with service users and observing staff at work it was clear that privacy and dignity are well respected. Staff receive training in this and in respect of attitudes and understanding of the impact of their interactions. The case file identifies the individuals preferred name and assessment and agreement is arrived at in respect of holding own key. There is a policy of freedom to move about the home as they wish and risk assessments of the environment are in place for this. Service users wer seen accessing most areas over the course of the day and involving themselves in household chores as they wished. Meals are prepared by care staff and choices are shown daily, and records kept of meals taken as many lunches are taken away from the home. The main meal is service during the evening. In a changed since the last inspection staff say they now enjoy preparing meals. Breakfast is provided at a time to suit the individual and they have a free choice. A light lunch is prepared from a choice of two although individual wishes are taken into account. Over the past year a dietician has been involved in assessing the needs of individuals and the development of the menus. Two staff have undertaken catering for special diets training and the manager has achieved the intermediate level 3 food hygiene award. Two Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 14 service user attend classes to promote balanced healthy eating and the home together are working towards a healthy food/eating award (5 for life). Speaking with service users all available confirmed that they enjoyed the meals and had choice at each meal. The small pleasant designated domestic dining room is mostly used during the evening meal, which service users said that it was a social event after a day when each had followed their own activities. Regis House DS0000056464.V351569.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): Standards 18 – 21 Quality in this outcome area is excellent Service users are assisted to maximise their independence and control over their lives and staff respect their privacy and dignity and give support to achieve this. Healthcare needs are well documented and are compiled with the input of the individual service user. The care plans give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. Service users wishes in respect of the time of death are sensitively obtained and they are supported at the time of illness and death at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has an individual care plan that address the areas of personal care and support and clearly identifies where assistance is needed and developed with promoting independence as a priority. All interventions are undertaken in privacy and through observation and talking with service Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 16 users they said that their bedroom is private and staff only enter when they are wanted. The principals of respect, privacy and dignity are well established in the home. They also said that they have their own routines and these include getting up and going to bed, they also choose how and when they spend the day such as attending day centre on certain days, these routines are documented in the individuals files and staff said they were conversant with what each service users routinely did. Examples given included one out at day centre, another leaving to attend a course while others had plans to go shopping, two together and one alone. Each service user was observed to have an individual style of appearance in dress and hairstyles and were happy to talk of recent purchases Since the last inspection all care files have been fully reviewed and wishes in respect of ageing and death ascertained and documented. Service users are all registered with a GP and access allied healthcare such as dentist, optician, chiropody and others as required and receive health checks annually, other screening is obtained through the GP. Service users have behaviour plans in place as appropriate that clearly identify how staff should intervene and how incidents will be recorded, examples of incident recordings were seen, the process provides for critical debrief. Protocols are in place for as required medication used for behaviour control, although none have been required since its implementation neither have there been any requirement for physical interventions. All staff have received nonviolent crisis intervention training and this is established as an annual refresher. None of the service users have been assessed as able to self medicate. The home uses the ‘Boots’ monitored dosage system and have the support of their pharmacist who undertakes quarterly audits, these were seen to be satisfactory. The inspection shows that there are no controlled drugs used at the home. Arrangements for the receipt, storage, administration, recording and disposal of medicines comply with the homes policy and this standard. Monitoring of the room and fridge temperatures show that these remain within guidelines over time. The medicine administration charts were inspected and seen to be very well completed with no omissions. While controlled drug compliant facility is available there are no current controlled drugs used in the home. Regis House DS0000056464.V351569.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): Standards 22 & 23. Quality in this outcome area is excellent. The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Staff demonstrate excellent knowledge and understanding of adult protection issues which contributes to an environment that is safe from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear and concise Complaints Procedure is displayed in the main hallway, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details. There is evidence of recording minor concerns and good evidence of a positive response to these concerns. One complaint has been received by the home responded to positively with clearly documented record and outcome. The service user monthly meeting includes some approach to complaints or concerns as a standing item. In viewing the numerous places where the procedure is included the inspector did not see a pictorial version. Responses to a survey show that service users know how and who to complain to, in conversation those responding went to some length to express that there is no reason to complain but did confirm that they new they could speak with the manager or any member of staff. Staff also demonstrated that they understood the support needs of service users who may have concerns or worries. Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 18 Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. Staff training files indicated that Staff had received training in respect of these Policies. The home has good guidance on managing verbal and physical challenging behaviours and staff are trained in non violent crisis prevention and intervention and this is to be an annual requirement. In conversation with staff it was clear that they had the knowledge and confidence that they had been well prepared to respond effectively to the types of challenges that may present at the home. Regis House DS0000056464.V351569.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): Standards 24 - 28 & 30 Quality in this outcome area is excellent The Home provides a comfortable, attractive, safe and ‘homely’ place to live. The home is clean, hygienic and free from odours. Residents live in a comfortable home that offers them a life style suited to their age. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Regis House is a 2 storey Victorian property situated in a residential street in Blackheath, close to shops and local community facilities. The home does not have a lift and would therefore not be suitable for people with physical disabilities. Since the last inspection a bedroom has been adapted from double to single and the kitchen has been refitted. A tour of the building was undertaken with no major issues identified. The home was clean and no offensive odours were present. The inspector was invited to view five of the six bedrooms, the other service user not being at the Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 20 home and found them to be individually decorated to a good standard with much personal items to make each one homely and attractive. A formal cleaning rota is in place and the tour of the building confirmed that good standards of cleanliness and hygiene are being achieved. We saw that staff receive infection control training. The Control Of Substances Hazardous to Health (COSHH) cupboard we observed to be locked. The dining room is jointly used for communal activities and is fitted to accommodate both. A toilet is adjacent to the lounge and dining room on the first floor. The ground floor provides all the bedrooms, toilets, bathroom and shower. The laundry is also situated on the ground floor, currently the washing machine is out of order and a contingency plan has been implemented satisfactorily. The corridor is decorated with artwork produced by one of the service users enhancing the sense of being home. Records show that maintenance is up to date and monitoring of the environment is undertaken. It was seen that the homes own recording of hot water temperatures show levels below the required standard on two service user outlets without evidence of adjustment. Regis House DS0000056464.V351569.R01.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): Standards 31 – 36. Quality in this outcome area is excellent. Staff are clear as to their individual roles and responsibilities and are enthusiastic, sufficient in numbers, well trained, supportive and committed to maximising the service users quality of life. The recruitment practices and staff training contribute to ensuring service users benefit from the skills and knowledge of the staff. This is further enhanced by up to date and relevant formal supervisions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rotas confirm that staff numbers across the 24hour period are appropriate to the needs of service users and past evidence supports the fact that numbers are adjusted according to the presenting needs of the service users. In addition to the manager, two staff cover across the day and evening with one waking night staff and another sleeping in. The current NVQ 2 qualification exceeds the standard at 69 . Those without this qualification are enrolled. Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 22 A sample of two staff files including a recently employed staff, show these to be completed to a very good standard with all appropriate pre-employment checks being undertaken such as Criminal records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) first. There has been no turnover of staff in the past year with only one new appointment and staff sickness is very low. The 12-week induction programme is to skills for care standard. The staff files also include a copy of the contract of employment, the job description, the completed induction document, receipts for issued staff handbook and General Social Care Council code of conduct. Also on file are the records of supervision and training certificates. Staff training shows that all mandatory training is provided and certificates held on file. Other training undertaken by staff over the past 12 months include; Infection Control, all staff, POVA all staff, NVCI all staff, Dementia and advanced dementia training, mental capacity and autism awareness. Staff have received food hygiene training 91 , with the manager having completed the advanced course Supervision and appraisals were seen to be up to date and meet the six sessions for the year rule, the most recent staff member had completed 4 supervisions during 7 months. In addition staff have an annual appraisal. The home has a relaxed atmosphere and every one appears happy, staff told us that morale is high and service users in conversation and in their survey responses say that staff are friendly and treat them right and another said that ‘if they can’t do something the staff will help, I never wish to leave’. Regis House DS0000056464.V351569.R01.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): Standards 37, 39 & 42 Quality in this outcome area is excellent Leadership of this home is good and staff, demonstrate an awareness of their roles and responsibilities. The manager’s approach is open and positive and develops positive relationships amongst service users and with staff. The home regularly reviews its performance, which includes seeking the views of service users, families and other stakeholders. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is led by a well qualified and experienced manager whose leadership style promotes efficient and relaxed home and is well regarded and liked by the service users and staff alike, this is apparent from speaking with service Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 24 users and staff as well as observing the interactions over the day. The manager evidence that she undertakes ongoing periodic training to maintain and update her knowledge and skills. The home has a comprehensive quality assurance system that ensures high standards of practice and a safe environment. The system includes monthly internal audits and regulation 26 visits. Valuation audits are undertaken by the operations manager. Service users, relatives and other stakeholders’ views are sought and over the past year their views used to inform the review and update of the business plan for this year. Consultation and involvement of service users in the introduction of new care plans promoted ownership of the plans which are person centred. Health and Safety is given appropriate priority with a broad range of monitoring and maintenance in place with all staff receiving health and safety training at induction and ongoing at appropriate intervals. During the tour of the building it was observed that all corridors were clear of obstructions and the premises are kept in a safe condition. Appropriate arrangements are in place for the monitoring, recording and reporting of accidents. An inspection of the service and inspection certificates identified these to be up to date. Documentation also show that most of staff working at the home hold up to date certificates in first aid, manual handling, food hygiene and fire. Very good fire drill records are in place that detail start times, responses, the involvement of service users and staff and any identified issues. Regis House DS0000056464.V351569.R01.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 4 3 4 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 4 32 4 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 X 3 X X 3 X Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 26 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 5 Requirement The responsible person should expand the use of pictorial formats to include all communications with service users such as all the information documents. Menu’s, complaints. Timescale for action 31/05/08 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 YA30 Good Practice Recommendations The responsible person should arrange for the repair or replacement of the unserviceable washing machine without delay and monitor the effectiveness of the contingency plan in operation. The responsible person should ensure that hot water supplies are adjusted when identified during monitoring as outside of the safe range of 41°c and 44°c. 2. YA24 Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Regis House DS0000056464.V351569.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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