Care Home: Sadlers Place

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What the care home does well The service ensures that potential service users have the information they need before making a decision about moving in to the service and tailors transitional plans to meet individuals` needs. Support plans are developed from assessments of care and person centred approaches have been adopted by the service. People who use the service are supported to be involved in care planning. Social, occupational and recreational plans are in place for each service user, they are audited regularly to ensure that they remain applicable to the individual. Service users said, "my key worker talks to me about the things I want to do." The diverse needs of service users are known and provided for. Health and personal care needs are recorded and health professionals say that, "the service provides a comprehensive package of care to service users." The standards in relation to the management and administration of medication are good. Complaints information is available to service users and they confirmed that they knew who to go to if they had any concerns. Relatives also confirmed this in surveys and from discussion. Adult protection information is available in the home; staff said that they had received training this was confirmed from records. The environment provides a spacious and comfortable home for the people who live there it is adapted to meet the differing needs of the service users, and is clean and well maintained. Service users were observed to have free access to all areas of the home. Staffing levels are good and staff said that they receive the training they need to meet the need of service users, this is confirmed from records. They have regular one to one support with their manager and meet monthly as a team. The service has policies and procedures in place as required and recommended, staff training is up to date, health and safety audits are carried out and the service has an experienced manager in post. What has improved since the last inspection? This is the first key inspection of Sadlers Place. What the care home could do better: Look at other ways in which service users can be involved and take ownership of their care plans, and make them available to them in a format that can beeasily understood. This also applies to the statement of purpose and service user guide and any relevant policies and procedures. They should research the local area to find social, recreational and occupational opportunities where service users can integrate and participate as members of the community. At least 50% of the care staff should have a care qualification at NVQ level 2 and the service should take advice from fire safety officers regarding the night time fire drills and evacuations. CARE HOME ADULTS 18-65 Sadlers Place 38 Rowland Street Walsall West Midlands WS2 8SU Lead Inspector Wendy Jones Unannounced Inspection 15th May 2008 13:30 Sadlers Place DS0000070710.V362581.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 Sadlers Place DS0000070710.V362581.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. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sadlers Place Address 38 Rowland Street Walsall West Midlands WS2 8SU 01922 611352 01922 723286 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) Milbury Community Services Ltd Mrs Hayley Whitehouse Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home Only (Code PC) To service users of the following gender Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability (LD) 8 The maximum number of service users to be accommodated is 8 Date of last inspection This is the first key inspection of this service. Brief Description of the Service: Sadlers Place provides 8 places for people with learning disabilities who have additional physical disabilities. It is situated in Walsall town and has ready access to local healthcare services and shops within the area. The home can also gain access by road to nearby towns. The service provided is primarily for younger adults, between the ages of 18 and 65, of mixed gender. The house is on 2 floors and has 8 en-suite bedrooms accessible by a lift. The current fee range for the service is recorded as £1,562 and £1,600 per week in the service user guide; additional information regarding any other costs is also given. Sadlers Place DS0000070710.V362581.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 2 star. This means the people who use this service experience good, quality outcomes. This was the first key inspection site visit of this service undertaken on 15 May 2008 and included feedback to the manager. In total the visit took approximately 8 hours, all key standards were looked at. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included looking at information the service provides for prospective service users, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, service users, staff, relatives and an independent advocate were spoken to and a brief tour of the building was undertaken. We also looked specifically at issues around the safeguarding of service users, where we asked specific questions and looked at specific records. This is to determine how skilled the service is in recognising abuse, responding to allegations and protecting the people who use their service. This methodology is known as a thematic probe and is used in a very structured way to look at the identified topic between a specified time period. On this occasion the methodology was to be applied to any key inspection that was carried out between the 5th and 16th May 2008. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to residents, relatives, staff and any professional that has involvement in the service. One service user, one relative, 9 staff, one health professional and one social worker survey have been received. The main points are included in this report. Throughout the report people who use the service are referred to as service users, this is a term that is used in the service and they are familiar with. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Look at other ways in which service users can be involved and take ownership of their care plans, and make them available to them in a format that can be Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 7 easily understood. This also applies to the statement of purpose and service user guide and any relevant policies and procedures. They should research the local area to find social, recreational and occupational opportunities where service users can integrate and participate as members of the community. At least 50 of the care staff should have a care qualification at NVQ level 2 and the service should take advice from fire safety officers regarding the night time fire drills and evacuations. 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. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will receive information about the home that provides enough detail for them to make a decision about moving in. They can also be confident that they will receive a thorough assessment and transitional arrangements to meet their specific circumstances. This means they can be sure the service can meet their needs. EVIDENCE: The service has a Statement of Purpose and a service user guide. These documents give prospective service users the information they need before deciding if the home may be suitable for them. The service user guide has been produced in a format that is more easily understandable for the resident group. The manager reported that they were looking to introduce other formats as well; this may include audio versions for those who have a sensory impairment. The records show that all prospective service users receive an assessment from the placing authority and from the service. The manager confirmed that she visits the prospective individual in their place of residence to do this and talk to them, their relatives and supporters to ensure that the assessment is accurate. The service provides people with an opportunity to visit the service as often as they feel is necessary, this can include an overnight stay, it is Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 10 usually tailored to the needs of the individual. One service user and an independent advocate confirmed that this was the case. A service user said, “ I was asked if I wanted to come here and I liked it when I came to visit. I picked my own room and have been able to have what I want in it.” Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their care needs are recorded and plans have been put in place to enable staff to meet their needs. The service delivers a person centred approach to care for each individual and should ensure the service user is supported to take a lead role in deciding the care they receive. EVIDENCE: The service uses a person centred format that ensures the individual and diverse needs of service users are met, but should ensure that the records show that service users are involved with the implementation and reviews of any care plans that are developed to support their care. One service user said she didn’t know about care plans and didn’t know where the information was kept. The manager was asked to look at methods of ensuring that services users can be fully engaged in care planning to ensure that they lead their care. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 12 A member of staff said that service users have individual one to one sessions with their key workers to discuss aspects of their care. A relative confirmed that the service has discussed all aspects of their relatives care with them and has been happy with how this has been managed. A relative said, “They support our relative needs and always take the time to listen to us as parents as well. All the staff have made Sadlers Place into a Family environment. One big happy family - there is always laughter in the house.” Individual risk assessments are in place for any identified area of risk, this means that staff have the information they need to ensure service user safety. Sadlers Place DS0000070710.V362581.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the service will respect their social, recreational, dietary and cultural needs by ensuring that they have opportunities to participate in activities of their choice. But more work should be undertaken to improve the community presence and participation of service users in socially valued and integrated activities. EVIDENCE: In addition to the PCP information the service uses a Daily Activities Record, which is in the format of a booklet. This contains daily records of all aspects of the daily life of service users including activities, food provided, health monitoring, etc. The manager and her deputy routinely audit this information on a weekly basis; evidence of these audits was seen. Any issues are managed promptly again evidence of this was provided for inspection purposes. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 14 From the record of daily activities and discussion about lifestyles, it was found that most service users attend day services during the week, Monday to Friday. In a sample of the records additional social and recreational opportunities included; the Monday evening social club, Tuesday evening disco, Wednesday evening, (in house) 1:2:1 session, Thursday evening (in house) relaxation, Friday evening (in house) karaoke. From further discussion it became evident that none of the activities were within the local community. The Monday evening social club is for people with learning disabilities as is the Tuesday evening disco. And while the in house karaoke is reported to be particularly enjoyed by service users, there are lots of these types of evenings arranged in the community. In addition staff said that a hairdresser comes to the home, again it is recommended that service users have access to local services in the community and to generally improve service users community presence, participation and integration. It is noted that due to the home being reasonably new staff have yet to fully explore the community facilities available in the locality. In one service user’s records and assessment information, it stated that the individual enjoys swimming; there is also a risk assessment in place for this activity. When checking this against records of engagement there is no evidence that the individual had been involved in this activity since they had been admitted to the home. This was discussed with the manager who said that, due to the health needs of the individual they had to seek agreement from the GP and are also waiting for an assessment from a physiotherapist. It seems a shame that the risk assessment in this case has not enabled the activity to take place, and the manager is urged to pursue this matter. There are photographs in the home of service users enjoying a day out a Chester zoo and a service user said that they were going on holiday. It is understood that holidays are being arranged for two service users to go to North Wales and two others to Paignton. Other service users will decide where they want to go. During this visit when service users returned from the day centre and while waiting for their evening meal they were engaged in discussion with one another and staff and watching the television. Two service users said they were going to play dominoes after the evening meal and challenged a member of staff to a game. There was much good-natured banter between staff and service users that is indicative of the relaxed atmosphere in the home during this visit. Relatives confirmed that they visited at any time during the day and are always made welcome. Menus are pre planned and displayed in the home, to ensure that service users can make an informed decision about their meal choice. A choice of main meal is available at every mealtime. This is evidence of the meals provided in Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 15 the daily activities records for each individual. Hot or cold choices are available at each meal. Because most service users attend day service Monday to Friday and usually take a packed lunch with them. The range of hot meals available in the home show a varied diet is offered and where a service user has special dietary needs for example for cultural reasons, there is evidence that the service has discussed the diet with the family and where possible the individual and included this in the dietary choices for the individual. It was noted that for one individual a care worker from the same ethnic background has been nominated as key worker to ensure cultural needs are respected. Accompanying the menu plans the service has produced photographs of the meals available to support service users to make an informed choice of meal. One service user currently has artificial nutritional arrangements this means that the individual receives nutrition directly in to the stomach via a “peg”. Staff have received training to undertake this procedure, to maintain the site of entry and to recognise where there are problems and to act in an emergency. Health professionals have said that the service always contacts them if they need advice and ensure that any health advice is followed. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their personal and health care needs are met by a well trained staff team and that their medication is managed safely. EVIDENCE: Personal and health care needs have been assessed and care plans put in place to ensure that the staff team have the information they need to deliver appropriate care. Training has been given in specific areas for example Peg feeds and epilepsy. All of the service users have physical and mobility difficulties with some having more complex needs in addition including partial sight, limited verbal communication and epilepsy. The records show that the service has liaised with relevant health professionals and is working in conjunction with them to ensure that they deliver the care service users need. This is reflected in the care and health records. Health professionals say, “ Because of the service users complex needs. Sadlers place has been proactive in seeking the advice on how best to meet them. This has taken the form of multi disciplinary meetings and NHS Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 17 helpline.” A health professional said, “We all need to learn new skills. As regards to physiotherapy they appear willing to take information and competent to continue to undertake what is asked of them.” Another said, “staff appear motivated and interested and competent, they always respect the dignity of service users and their privacy.” Staff have received training in the administration and care of medication before they are allowed to administer it. This was confirmed from discussion with staff and from the records available. Observation of a medication round during the visit provided evidence of very good practice and the records are of a very good standard. None of the current service user group self medicate. The medication storage room should be monitored to ensure that the temperature does not exceed the recommended temperature for medication to be stored at. This is usually a maximum of 25c or below, and this was the temperature in the room on the day of the visit. Records relating to the administration of medication are well maintained and additional information is provided about the individuals’ wishes relating to how they take their medication. They also detail the purpose and effects of the medication that is prescribed and the circumstances under which medication is to be administered when prescribed on “as required” basis. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ( good) This judgement has been made using available evidence including a visit to this service. The service has demonstrated that it is open in its management of complaints and safeguarding issues and people who use the service can be confidant that they will be listened to and protected by it. EVIDENCE: Information provided in the service user guide gives very good information about what to do if service users have any concerns, and provides details of whom they can contact. It also informs service users of what constitutes abuse and how they will be protected from it. Relatives said that they knew how to complain and are confident that the service would act responsibly to resolve any concerns they may raise. An example of a complaint was discussed with the manager and her explanation of the action taken to deal with it was accepted as satisfactory. There was also discussion about how the outcomes of any complaints investigation can be used to change practice in the home and should be included in any quality auditing. The organisation has introduced a user friendly complaints procedure called “letting you know what I think.” In addition the home has a “post box” where anyone with concerns can express them anonymously. This post box was located near to the shaft lift in the main entrance of the home, therefore easily accessible to service users, staff and visitors to the home. One service user was asked if she knew what it was for but she didn’t. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 19 We have not received any complaints about this service and are not aware of any safeguarding issues. The manager confirmed this to be the case. This inspection site visit took place during a period when we are focussing on safeguarding issues, as a result of this a member of staff and the manager were interviewed and gave satisfactory responses to the questions asked. A service user was also spoken to about this area; she confirmed that if she felt anxious or some one was hurting her she knew who to go to. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the Home is suitable to meet their needs and well maintained, which ensures their safety and well being. EVIDENCE: The service is a detached property in a residential area. The environment is purpose built and suitable to meet the needs of the current service user group. At the front of the home the paved driveway has parking for 3-4 vehicles. Adaptations have been made to the interior to accommodate persons with physical disabilities, such as wider hall and door ways, lower light switches, assisted bathing and shower facilities. The bedrooms are all for single occupancy and have en-suite facilities. Some bedrooms have ceiling tracks designed for hoisting service users and to eliminate the need for staff to lift and manually handle them. A sample of bedrooms shows that service users are supported to personalise their bedrooms. They confirmed this. A shaft lift has been installed to ensure that service users can easily access the first floor. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 21 A wireless emergency call system has been fitted, Communal space is offered in the main lounge, the main kitchen diner and another dining room/ lounge, each of these areas is accessed through double doors providing easy access for the service user group. In summary Sadlers Place provides a spacious and comfortable home for service users. It is pleasantly decorated, and as you would expect with a new service very well maintained. Service users were observed to have access to all areas of the home and encouraged to do so. Separate laundry facilities reduce the chance of cross contamination and infection. Commissioning certificates were made available for inspection purposes and no outstanding issues were reported following the registration of the service. Sadlers Place DS0000070710.V362581.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that there is sufficient staff provided to meet their needs and appropriate employment checks are carried out. This should give them confidence in it. EVIDENCE: The statement of purpose says: “The staffing complement will comprise: 1 full-time Manager (37 .5 hours per week) who will be completely off rota. 1 full-time Deputy Manager (37.5 hours per week). 2 full-time Senior Support Worker (37.5 hours per week). 427 hours of Support Workers on days. 140 hours of support workers on nights (2 staff per night) The service will aim to have 5.5 staff on duty during waking hours in addition to the full time manager, who is off-rota. (Taken from the statement of purpose).” The manager stated that her staffing hours have some flexibility; she is allowed 11 staff between 8am-10pm to be deployed according to service user Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 23 need. There is 2 waking night staff between the hours of 10pm-8am. She also said that based on current occupancy there are no current vacancies for staff but they have been actively recruiting and will be interviewing for additional staff to take up posts when the planned admission of another service user is confirmed. The service has not needed to use agency staff but does retain one person to do occasional shifts. Nine staff surveys have been received comments include, “always kept informed 100 . Made very enjoyable,” “The induction by the management team was excellent.” “ I was nervous but told I would be shown as many times as required to do the task confidently.” “ More staff are being employed we are just waiting for their information but when we are fully staffed it will run smoother. At the moment there is enough staff for the service users we have in at the minute and we are co-operating together.” The organisation maintains confidential recruitment information at its head office, this has been agreed this with us. However some records are retained in the home and they have a checklist or pro-forma for each member of staff that records all of the pre employment checks they have carried out. A sample of 5 staff records and pro-forma’s show that all include application forms, 2 written references, evidence of a Criminal Records Bureau check (CRB) and a check of the Protection of Vulnerable Adults list (POVA). They also include job descriptions, evidence of staff contracts, induction and supervision of staff. The manager stated that she plans staff supervision monthly and usually manages to achieve this, staff meetings are also planned monthly staff are required to attend at least 6 per year. New staff have an appraisal after 6 months following that they have one every 12 months. Information in the AQQA indicates that 6 staff have an NVQ qualification at level 2. And additional information in training records shows that mandatory training is up to date or is planned. Supplementary training has also been provided specific to the needs of the service user group this can include, Diabetes, epilepsy and autism. Service users said they knew who their key worker was and from observation throughout this visit there is evidence of good relationships between service user and staff. A relative confirmed that their experience of the staff team was very positive. Sadlers Place DS0000070710.V362581.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home in which they live is properly managed and monitored this should give them confidence that their health and safety is assured. EVIDENCE: The manager is experienced in social care and is registered and approved by us. She has completed the recommended training. Information in the AQAA indicates that all equipment and etc is in working order, and commissioning certificates, for fire safety system, gas and electrics were made available during this visit to confirm that they are satisfactory. Fire safety records show that regular checks of the alarm system and equipment are carried out. There is evidence that staff have been involved in fire drills and staged evacuations of the home. The manager stated that the night staff Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 25 have been involved with fire drills but have not yet completed a staged evacuation or drill at night she has been seeking advice from fire safety officers about how this can be managed. In addition to general risk assessments relating to the environment and individual risk assessments relating to service users, the service also provides a fire safety risk assessment for the home and again for each service users the plans include an emergency contingency plan. There is evidence that a representative of the organisation visits the home on a monthly basis to undertake and audit of the service s performance. A report of the conduct of the home completed and copy retained in the home. A sample of this information was looked at during this visit. Issues arising included some minor discrepancies around the record keeping of service users monies. These matters were discussed with the manager, who stated that all matters had been resolved, no monies were missing and staff had been reminded of the procedures for recording financial transactions made on behalf of service user. She also stated that she undertakes an audit of service user financial records three times per week to ensure accuracy. And reported that this had been successful. The service has its own quality monitoring system in place, surveys are sent to service users, staff, families and friends and other parties involved in the life of service user this includes health professionals, every 6 months. The service has also produced a survey for service users that is in a format that can be more easily understood by them. The manager stated that the outcomes of the surveys will inform the annual quality audit for the service and be used to plan the annual development plan for the following year. As the service is so new this information is not yet available. Sadlers Place DS0000070710.V362581.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 3 2 4 3 4 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 x Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Not applicable STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard YA1 YA6 YA14 YA32 YA42 YA20 Good Practice Recommendations The service should make further efforts to produce information for service users in a format that they can easily understand. The service should ensure that service users take a lead role in decision-making and care planning. The service should support service users to access local facilities and to improve their community presence and participation. The service should make arrangements for at least 50 of care staff to be trained to NVQ level 2. The service should follow advice from fire safety officers regarding fire drills and evacuation for night staff. The service should monitor the temperature of the area where medication is stored, and take action if necessary to ensure it does not exceed the recommended storage temperature. Sadlers Place DS0000070710.V362581.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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