Care Home: Saivi House

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What the care home does well The service provides good outcomes for the person who currently lives at home. This is based on what the person told us about how the home supported him, and looking at the information the home has about his needs. The statement of purpose clearly sets out the philosophy and objectives of the home. The home understands the importance of having sufficient information when choosing a care home. Admissions to the home are made on the basis of a detailed assessment. This ensures the best outcomes for people who live at the home.Care plans provided specific guidance on how the person living at the home wished to be supported. The home has involved the individual in the planning of care that affects his lifestyle and quality of life. Risk assessments were found to cover all areas that affected the person`s daily life. Risks are managed positively to help the person who lives at home to lead the life he wants. The menu is prepared weekly with the person who lives at home. A variety of meals are provided that reflect his individual preference. Care plans outlined the support the person requires to maintain his independence when being supported with personal care. Personal support is responsive to the varied individual needs and preferences of people who live at the home. We found that records for the administration of medication were complete. People`s medication administered in a way that ensures their continued well being. The complaints policy is available in a pictorial format. The person who lives at the home had been supported to share their concerns. The home has an open culture that allows people to express the views and concerns in a safe and understanding environment. The person told us that he could challenge and raise concerns about the way they were treated. People feel safe and well supported by an organisation that has their protection and safety as a priority. Training records confirmed that all staff has all the statutory required training. All staff receives relevant training that is focused on delivering improved outcomes for people. A system is in place to monitor the quality of the service provided by the home. Ongoing quality assurance is carried out to make sure that the home provides improved outcomes for people. The registered manager makes sure that the safety risks to the person living at the home and staff is identified. People living at the home are aware of safety arrangements and have confidence in the safe working practices of staff.Saivi HouseDS0000070086.V360442.R01.S.docVersion 5.2Page 7 What has improved since the last inspection? This is the home`s first key inspection. Therefore, there are no areas for improvement that had been identified prior to this key inspection. What the care home could do better: No areas for improvement have been identified at this inspection. CARE HOME ADULTS 18-65 Saivi House 39 Doveridge Gardens Palmers Green London N13 5BJ Lead Inspector Tony Brennan Unannounced Inspection 13th February 2008 11:30 Saivi House DS0000070086.V360442.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 Saivi House DS0000070086.V360442.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. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saivi House Address 39 Doveridge Gardens Palmers Green London N13 5BJ 0208 245 7212 0208 245 7212 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) Saivan Care Services Limited Sanjaye Nath Ramsaha Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Saivi House DS0000070086.V360442.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 - Code LD The maximum number of service users who can be accommodated is: 5 N/A Date of last inspection Brief Description of the Service: Saivi House is a private care home. The home consists of a large house in a quiet street in Palmers Green. There are five large single bedrooms. There are five large single bedrooms. There is a lounge and dining area. There is a kitchen. The home is appropriately furnished. There is a back garden that is partly paved and accessible to users. The home is close to a good selection of shops, restaurants, transport links and other community facilities. The home’s stated aim is to support people with learning disabilities to live in the community. The fees are between 1000 and 1200 pounds a week. This report is available through the internet. Copies may also be obtained from the provider of this service. Saivi House DS0000070086.V360442.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 announced key inspection was undertaken as part of the annual inspection programme. This is the first key inspection since Saivi House was registered with the Commission. Prior to the inspection the home had completed its annual quality assurance assessment. The annual quality assurance assessment provided us with information about the home and how it was seeking to provide the best outcomes for people. The inspection took place over one day. We were assisted by the registered manager, Sanjaye Nath Ramsaha, with the inspection. We spoke with the one person who is currently living at the home, and one member of staff. We observed care practice and interaction between staff and person living at the home. We toured the building and examined a number of records relating to the care, health and safety and management of the home. At the end of the inspection feedback was given to the registered manager. We would like to thank the member of staff that assisted us by answering questions about the running of the home. We would also like to thank the person who lives at the home who discussed his views of the service he receives. What the service does well: The service provides good outcomes for the person who currently lives at home. This is based on what the person told us about how the home supported him, and looking at the information the home has about his needs. The statement of purpose clearly sets out the philosophy and objectives of the home. The home understands the importance of having sufficient information when choosing a care home. Admissions to the home are made on the basis of a detailed assessment. This ensures the best outcomes for people who live at the home. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 6 Care plans provided specific guidance on how the person living at the home wished to be supported. The home has involved the individual in the planning of care that affects his lifestyle and quality of life. Risk assessments were found to cover all areas that affected the person’s daily life. Risks are managed positively to help the person who lives at home to lead the life he wants. The menu is prepared weekly with the person who lives at home. A variety of meals are provided that reflect his individual preference. Care plans outlined the support the person requires to maintain his independence when being supported with personal care. Personal support is responsive to the varied individual needs and preferences of people who live at the home. We found that records for the administration of medication were complete. People’s medication administered in a way that ensures their continued well being. The complaints policy is available in a pictorial format. The person who lives at the home had been supported to share their concerns. The home has an open culture that allows people to express the views and concerns in a safe and understanding environment. The person told us that he could challenge and raise concerns about the way they were treated. People feel safe and well supported by an organisation that has their protection and safety as a priority. Training records confirmed that all staff has all the statutory required training. All staff receives relevant training that is focused on delivering improved outcomes for people. A system is in place to monitor the quality of the service provided by the home. Ongoing quality assurance is carried out to make sure that the home provides improved outcomes for people. The registered manager makes sure that the safety risks to the person living at the home and staff is identified. People living at the home are aware of safety arrangements and have confidence in the safe working practices of staff. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 7 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. Saivi House DS0000070086.V360442.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 Saivi House DS0000070086.V360442.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): 12 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support required. EVIDENCE: The registered manager had commented in the annual quality assurance assessment that “ Our statement of purpose now sets out the aims, objective and our services and facilities, and terms and conditions clearly.” The statement of purpose clearly sets out the philosophy and objectives of the home. I found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The statement of purpose also identified the skills and staffing resources that are available to meet the needs of people living at home. As is outlined in the following outcome areas these resources effectively meet the needs of people living at the home. The home provides a statement of purpose that is specific to individual home and the resident group they care for. The statement of purpose positively promoted the rights of people living at the home to express their diversity. We discussed the issue of equalities and Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 10 diversity with registered manager who demonstrated that he would respond positively to people’s diverse and varied needs. The annual quality assurance assessment stated, “Resident is given opportunity to visit places of worship.” The person currently living at the home is from the Bangladeshi community. He told us that staff “understood” him. We looked at his initial assessment and care plan and found that they reflected his need to maintain contact with his community. We spoke to the member of staff on duty who showed that he understood person’s cultural needs. A weekly activities plan had been drawn up with the involvement of the person. This included visits to an Asian centre and areas connected with the Bangladeshi community. Peoples diversity is respected and supported. The person who lives at the home has only recently moved there. He told us that he had visited on three occasions, and spent time at the home. This had allowed him to see what the home was like before deciding to live there permanently. In the annual quality assurance assessment it had been noted that “All new service users will be given a trial period to access the facility available at the home. This will help them to decide about the placement.” The registered manager showed us records of the three visits made by the person living at the home. We found that these recorded in detail how the person felt about the visit and the home. Perspective residents are given the opportunity to spend time in the home so that they can make a positive decision about whether they wish to live there permanently. The registered person had stated in the annual quality assurance assessment, “All service users will have a comprehensive needs assesments carried out reflecting their individual needs.” We case tracked the person who lives at the home and found that there was an assessment from the home and care management. He commented that the home was a “nice place to live”. Initial assessment identified his needs. This included a history of his needs and any resulting behavioural management issues. Detailed initial assessments of peoples needs make sure that they are supported to maintain their independence. The member of staff on duty told us that he was the key worker for the person living at home. He was able to describe in detail the persons needs and how he was meeting them. The member of staff explained that he had been spending time with the person. This has allowed him to understand the persons needs. The member of staff told us that he had been able to see the initial assessment information and with the person had drawn up a detail care plan. Staff have the skills and ability to meet the assessed needs of the person living at the home. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 11 Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 12 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): 679 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provided detailed information on the needs of people living at home. People are supported to make decisions about their lives. Risks to service users are assessed to ensure their safety and independence. EVIDENCE: In the annual quality assurance assessment it was stated, “An individual care plan which is drawn up in partnership with family, professionals and service users will be developed.” The care plans of the person living in the home were personalised and detailed how his needs would be met. The registered manager explained that staff were being trained in person centred planning. Care plans were found to provide detailed information on the support provided to meet the needs of individual. His care plans were personalised and referred Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 13 to his cultural needs of people. This included whether or not he wish to take part in religious activities. The person living in the home had a key worker to make sure that his individual needs are met. He told us that staff understood his needs. He said, “ staff are helpful.” We found that care plans had been developed with the involvement of people living at home. We observed that staff took time to understand people and do things in the way they had been asked. The home involves individuals in the planning of care that affects their lifestyle and quality of life. Details of the person’s behaviour that might challenge the service were identified in his risk assessments and care plans. Actions to address and manage these behaviours are outlined in detail. This included giving detailed guidance on how to respond to specific behaviours. The person living at the home had been consulted about how he wished to be assisted to manage his behaviour. Staff spoken to understood the specific needs of person living at the home with regards to managing challenging behaviour. Behaviour that may challenge the service is addressed sensitively to support and maintain people’s well being. Risk assessments were found to cover all areas that affected the person’s daily life. Risk assessments identified the specific risk facing the person living at the home. These are reflected in care plans. Risks are managed positively to help the person living at home to lead his life the way he wants. Staff were able to describe how they prevented risks to make sure that the person was safe and supported to exercise control over how he lives. Risks relating to behavioural issues were identified and actions to lessen the level of risk were identified. I observed that staff engaged with person living at home in an appropriate adult way. A comprehensive risk assessment is in place to ensure the safety and independence of people living at the home. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to engage in a range of activities that meet their needs. People have community contacts and are supported to maintain personal relationships. People are supported to have a nutritious diet that reflects their personal choice. EVIDENCE: The person confirmed that he had created a list of activities that he likes. We found that there was a programme of activities. These included visits to local Asian Centre and the local Bangladeshi communities. The registered manager had confirmed in the annual quality assurance assessment that people would be supported to be involved in a range of activities. These would consist of going to the pub or other local community groups. Daily notes and care plans confirmed that the person had since moving into the home been involved in Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 15 activities. The persons daily note showed that he had visited day centres. Staff will support the person currently living at home to decide whether or not he wishes to attend a day centre. The registered manager explained that when more people come to live in the home an activities plan would be drawn up in the weekly house meeting. The person living at home as fully involved in planning his lifestyles and the activities that he participates in. The person currently living at home has an individual activities plan. This outlined what activities he is involved in throughout the week. The support he needed to participate in these activities was outlined in his care plan and risk assessment. The person who lives at the home is involved in meaningful daytime activities of his own choice, according to his individual interests and capabilities. Daily notes showed that since moving into the home the person had been involved in the cleaning of his bedroom and cooking. Daily records also showed that he was supported to maintain contacts with family and friends. People living at home were enabled to develop their daily living skills and maintain contacts with the local community. The menu is prepared weekly with the person living at home. The registered manager explained that since only one person is living at home all the meal choices are based on what he has told staff he likes. Daily notes showed that the person’s preferences were recorded. Staff explained that they had agreed with the person a regular time to go shopping for food. On the day inspection the person, accompanied by a member of staff, went to do some shopping. The person confirmed that he had been involved in preparing the menu. The menu is varied and reflected the cultural and dietary needs of individuals. The person told us, “ the food is good.” We observed that there were fresh vegetables and fruit available. A variety of meals are provided that reflect the individual preferences of people who live at the home. Saivi House DS0000070086.V360442.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): 18 19 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People are supported with their personal care needs to maintain their independence. People are able to access the medical care they need. People are protected by safe procedures for handling medication. EVIDENCE: Care plans outlined the support the person living at home requires to maintain his independence when being helped with personal care. The member staff explained that he provided support and encouragement to help the person with washing and dressing. The registered manager explained that male and female carers are being employed in the home to ensure that people have same gender care. The person currently living at home had his preference to have same gender care is recorded in his care plans. The annual quality assurance assessment highlighted that, “We will support service user to receive personal care in a manner that maintains their dignity and privacy. ” Staff were able to Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 17 explain the personal support needs of the person living at home. Personal support is responsive to the varied individual needs and preferences of people who live at the home Medical needs had been identified as part of the initial assessment and were referred to in care plans. The annual quality assurance assessment stated that, “routine access to health care practitioners including GP, Optician, dentist, community nurse, OT and speech therapist will be arranged.” Daily notes recorded that the person had registered with a local General Practitioner. The general practitioner would be seeing the person to review his medication and carry out the necessary health checks. People are supported to access the healthcare they need. Peoples health needs are addressed to ensure their well being. The medication policy contained all the required information. We found that records for the administration of medication were complete. Records of medication received and returned were also complete. All medication was held securely. Training records and discussions with staff confirmed that they had received training on the safe administration of medicines. Advice was available for staff on the side effects of medication. Medication is administered by staff that are properly trained to ensure the safety of people living at home. Saivi House DS0000070086.V360442.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): 22 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People can be confident that their complaints are listened to and acted upon. Adult protection procedures protect people from abuse. EVIDENCE: The complaints policy explained how to make a complaint and how it would be dealt with. The complaints policy is available in a pictorial format. The person who lives at the home is supported to share his concerns. Copies of the complaints policy were available around the home for the person to consult. The complaints procedure is available in a number of formats to help anyone living at home to complain or make suggestions for improvement. Staff explained that the person living at the home is encouraged to discuss his views of the service at the weekly meeting. The home has an open culture that allows residents to express the views and concerns in a safe and understanding environment. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 19 We observed the way that staff approach people. This was done appropriately and sensitively. There were policies on handling abuse and adult protection. Training records showed that staff had received training in adult protection. I spoke with staff and they demonstrated their understanding of adult protection issues. Other training around dealing with physical and verbal aggression has been made available to staff. People living in the home feel safe and well supported by an organisation that has their protection and safety as a priority. Saivi House DS0000070086.V360442.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): 24 25 26 27 28 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: There were separate dining and sitting rooms that were comfortably furnished. The person living at the home was able to choose where he wished to sit, or whether he wished to spend time in his bedroom. Daily notes recorded that he had spent time in his room listening to music. Three bedrooms have en suite facilities. The other two bedrooms have a bathroom with toilet near to them for ease of access. The homes environment promotes the privacy, dignity and autonomy of people. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 21 The person living at home had chosen how he wanted his bedrooms decorated. The registered manager explained that when people come to live at the home they would be supported to choose how they want their rooms decorated and furnished. The person was pleased with his bedroom. He had chosen items of furniture for his rooms. People who use the service are encouraged to personalise their bedrooms. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. Appropriate infection control procedures make sure that people are safe in the home. Saivi House DS0000070086.V360442.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): 32 34 35 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Sufficient staff with the necessary skills are available to meet the needs of people. A training plan is in place that identifies all areas of training needed to meet the needs of people living at home. People are protected by the home’s recruitment procedures. EVIDENCE: We found that the rota showed that a consistent staffing level was being maintained. Sufficient staff are provided at busy times of the day and to meet the needs of a person living at home. The registered manager explained that two staff are on duty to support the one person who is currently living at the home. The registered manager will review the staffing level as new people come to live at the home. The rota also showed that staff were on duty to provide escorts to appointments and support with activities when this was necessary. The member of staff told us that they felt sufficient staff are available to support the person’s needs. The home make sure that enough Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 23 staff are available at all times to support the needs, activities and aspirations of people. Discussions with the member of staff on duty and training records showed that all the necessary training on health and safety issues had been provided. The annual quality assurance assessment stated, “All staff are competent and experienced and have required skills to meet the clients holistic needs.” The registered manager explained that the organisation was affiliated to Skills for the Care and the London care Consortium. Skills for Care induction is in place for new staff. A certificate is given after completion of the induction programme. The registered manager will be using these sources of training to make sure that staff continue to have the skills necessary to meet the needs people. Records show that staff had attended training on diversity issues. The registered manager showed us details of a further course on this topic. He is planning for staff to attend this training. There has already been training on person centred planning. The registered manager has attended a course on this subject and will be cascading what he has learnt to staff. The registered manager will also be getting staff to attend training on person centred care. All staff receive relevant training that is focused on delivering improved outcomes for people living at the home. The annual quality assurance assessment highlighted that, “The home has a work force development plan in place prepared with the support of a training and development broker.” The registered manager provided us with a copy of the current training plan. This identified future training needs and how these would be addressed. Staff commented that the registered manager positively encouraged them to go on training to develop their skills and understanding of the needs of people. Training records showed that 50 of staff has either level 2 or 3 in the National Vocational Qualification in care. The home emphasises the importance of training in making sure that staff are able to meet the individual needs of people in a person centred way. We looked at four staff files and found they contained all the necessary documentation relating to their recruitment and appointment. All staff have enhanced CRB and references taken prior to starting employment at the home. Staff go through a detailed interview process. We found there were notes in staff files to confirm this. People can be confident that they are protected by the home’s recruitment procedures. Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Effective management systems are in place to make sure that people’s will being and safety is promoted. People’s views of the service are sought and used as the basis for improvement. People who live at home and staff’s health and safety is always promoted and safeguarded. EVIDENCE: The member of staff and the person who lives at the home told us that the registered manager is supportive and approachable. Training records showed that the registered manager has the skills and experience to manage the home to meet the needs of people. The registered manager and proprietor have Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 25 both completed the registered managers award. Records showed that staff receives regular supervision from the registered manager. Staff meetings were held to discuss practice issues in the home. Both the registered manager and the proprietor have experience of managing residential services. We discussed with the registered manager how he would be developing the service. He showed us that he had a clear vision of how the aims and objectives would be met. The registered manager demonstrates a clear understanding of people’s needs and uses the available resources to ensure their well being. A system is in place to monitor the quality of the service provided by the home. In the annual quality assurance assessment the registered manager stated, “ residents will be encouraged to be involved in quality assurance.” The registered manager said that independent advocates would be involved to support people living at home share their views of the quality of the service. The advocates will help people living at home complete the annual quality assurance questionnaires. The registered manager explained that he would carry out quality monitoring on a regular basis. Effective monitoring of the quality of the service makes sure that people live in a home that listens and acts on their views. The registered manager ensures that the safety risks to people living at the home and staff are identified. Measures are put in place to provide a safe living and working environment. Records showed that fire equipment was tested regularly and maintained. Fire drills were taking place. The fire risk assessment provides details of potential risks of fire. All health and safety policies were available. Certificates for gas and electrical testing were in date. COSHH guidance is in place and chemicals were stored safely. Training on health and safety topics was complete. People living at the home are aware of safety arrangements and have confidence in the safe working practices of staff. Saivi House DS0000070086.V360442.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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 3 Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 27 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. 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. Refer to Standard Good Practice Recommendations Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Saivi House DS0000070086.V360442.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!