Care Home: Shining Star

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What the care home does well There is a pre- admission assessment process, to ensure the service can fully meet the needs of people admitted to the home and trial visits are offered to all prospective residents. Routine risk assessments are undertaken, to ensure residents are supported to take risks, as part of an independent lifestyle. On speaking to the representatives of residents, their comments evidenced that staff were very knowledgeable on the care needs of residents and on what they liked and disliked doing. Residents are supported to be as independent as possible and to be involved in the day to day running of the home. The home is well decorated and furnished and provides a very homely environment for its residents. What has improved since the last inspection? At the last key inspection 1 requirement was made in relation to medication, which specified that handwritten amendments or additions to Medication Administration Records (MAR) sheets must be signed and dated by the person making the entry. At this inspection this requirement had been complied with. CARE HOME ADULTS 18-65 Shining Star 562 Green Lane Seven Kings Ilford Essex IG3 9LW Lead Inspector Harbinder Ghir Announced Inspection 2 4th June 2008 10:00 nd Shining Star DS0000070932.V364528.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 Shining Star DS0000070932.V364528.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. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shining Star Address 562 Green Lane Seven Kings Ilford Essex IG3 9LW 020 8590 4235 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.mencap.org.uk Royal Mencap Society Marion Wathingira Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Shining Star DS0000070932.V364528.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: 4 27th June 2007 Date of last inspection Brief Description of the Service: Shining Star is a home for four people with severe learning disabilities. Residents have profound lack of verbal communication skills, and limited ability to make decisions about their lives. The property is a two-storey house, which is well furnished and decorated. The bedrooms are individually decorated and personalised, according to the residents’ likes. The house is situated in a quiet residential area in the London Borough of Redbridge. It is close to local shops and public transport. The residents are encouraged to be as independent as possible. They also have daily activities. This includes going to day centres, attending college courses and participating in leisure activities. Two men and two women have lived together in the home since it opened in 1994. The scale of charges is £1280-60 per week. This information was obtained at the time of the visit. Information about the service provided is contained in the service users guide. Shining Star DS0000070932.V364528.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 stars. This means the people who use the service experience good quality outcomes. This was an unannounced inspection undertaken by Regulation Inspector Harbinder Ghir over the course of two days. The first day of the inspection was unannounced and started at 10.00 am. It took place over 6 hours. A second arranged visit took place a day later. The purpose of this was to have further discussions with staff and meet the remaining three residents. The registered manager of the home was available throughout both days of the inspection and feedback was provided to the registered manager at the end of the inspection. During the inspection the inspector was unable to talk to residents residing at the home due to their limited communication. Staff on duty during the day was spoken to and were also observed carrying out their duties. A third day was also spent contacting relatives and professionals by telephone for further feedback; their feedback has been included in the report. Two social workers for two residents were contacted, one at The London Borough of Hounslow and one at the London Borough of Waltham Forest. A learning disabilities nurse was also contacted as part of the inspection. Their feedback has been included in the report. The Commission for Social Care Inspection received a completed Annual Quality Assurance Assessment prior to the inspection. The inspector would like to thank everyone involved in the inspection process. What the service does well: There is a pre- admission assessment process, to ensure the service can fully meet the needs of people admitted to the home and trial visits are offered to all prospective residents. Routine risk assessments are undertaken, to ensure residents are supported to take risks, as part of an independent lifestyle. On speaking to the representatives of residents, their comments evidenced that staff were very knowledgeable on the care needs of residents and on what they liked and disliked doing. Residents are supported to be as independent as possible and to be involved in the day to day running of the home. The home is well decorated and furnished and provides a very homely environment for its residents. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 6 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. Shining Star DS0000070932.V364528.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 Shining Star DS0000070932.V364528.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): 2, 3, 4, 5 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service completes comprehensive pre-admission assessments, to ensure they can fully meet the needs of prospective residents. Trial visits are offered to all prospective residents, to ensure residents have information on the services and facilities provided at the home. Each resident has an individual written contract of the statement of terms, to ensure they agree to the services provided at the home. EVIDENCE: It was not possible to examine up to date pre-admission assessments, as all four residents have resided at the home since it opened in 1994. However, the service has a comprehensive pre-admission policy and procedure in place and admissions would not be made to the home until a full needs assessment has been undertaken. The policies and procedures highlighted that admissions to the home would only take place if the service is confident that staff have the Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 9 skills, ability and qualifications to meet the assessed needs of prospective residents. New prospective residents would be able to visit the home as many times as they like and have an opportunity to stay overnight. Relatives and family would also be invited to visit the home. All residents were provided with a statement of terms and conditions. This set out simply and clearly and in detail about what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a comprehensive care planning system in place, which provides staff with the information needed, to meet the needs of residents. The right for residents to exercise choice and control is promoted by the service and they are actively consulted on, and participate in, all aspects of life in the home. Risk assessments are undertaken routinely, to ensure residents are supported to take risks as part of an independent lifestyle, and are always updated according to residents’ changing needs. Service users’ financial interests are safeguarded, but improved systems need to be in place to ensure that records of residents’ outgoings and incomings of money are recorded correctly. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 11 EVIDENCE: Two care plans were closely examined. Care plans seen evidenced that the service involves individuals in the planning of care that affects their lifestyle and quality of life. Care plans were comprehensive; person centred and clearly set out residents’ health, personal and social care needs. Information was found specific to the religious, cultural and social care needs of residents and how the service was to meet these needs. One resident was from a Cypriot background and their care plan included pictures of their home country. The information provided in care plans was very detailed and individualised, and clearly recorded and described how residents wanted their needs met. For example one resident’s care plan informed how they would like to be communicated to. The care plan stated, “When signing to me ensure that you are on my good side and in clear view of my right eye and ensure that you have contact with me, I am very assertive and I am able to make clear choices especially when in a familiar environment.” Another resident’s care plan included a list of the makaton signs they are able to use independently and with support. Care plans were written from the residents’ point of view and concentrated on promoting the independence and aspirations of residents. The documents also included information in picture formats and included information on residents’ likes, dislikes, how they communicate and what they are able to do independently and tasks they require assistance with. A key worker system also allows staff to work on a one-to-one basis and contribute to the care plan for the individual. However, information was not found specific to residents’ sexual needs in their care plans. The registered manager informed that all residents do express the sexual needs, which are respected. A recommendation will be made in relation to including this information in the care plan to ensure all staff working at the home are aware of residents needs and to ensure that these are respected at all times. Care plans were working documents and are reviewed on a three monthly basis or as and when required. In addition to this key workers also write a monthly key worker report. Evidence was seen of reviews taking place with care managers also involving the resident and their representatives. Reviews focused on asking what has worked for the individual, where progress is being made, achievements, and concerns and identified action points. Evidence was seen of reviews being arranged to fit in with the availability of family so that they could be involved in the process. For example one resident’s review was held when his family were visiting from South Africa. Another relative spoken to said “We are always invited to attend meetings at the home. We have met Y’s social worker numerous times at these meetings. The home, the staff have been brilliant.” Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 12 Risk assessments were completed for residents and identified risk areas in care plans including, the event of a fire, risks that may be presented by the building, mobility, falling and wandering. For one resident who was at risk of consuming cigarette butts, COSHH products and tea bags, the service was very proactive in putting in place a comprehensive risk assessment and ensured all COSHH storage cupboards were kept locked at all times. Assessments included clear guidelines for staff to follow in managing risks posed to people who use the service. Risk assessments were reviewed regularly and amended. Daily case recording notes were examined which are linked to the care plan and focus on the specific needs of residents rather than recording information in a general manner. Each resident has a personalised case recording sheet which may focus on their challenging behaviour, their diet or the risks they are posed to, which provided specific information about each resident which is used to monitor their care needs or their behaviour on a on-going basis. However, very little information was found on the times residents actually got up or went to bed. Therefore it is Recommendation 1 that the service records this information to reflect the daily routines of residents. Residents were involved in the daily running of the home as far as their abilities allowed. One resident was observed choosing her lunchtime meal and setting the table. A rota was also seen in the homes kitchen which described what days residents were responsible for setting the table, participating in cleaning tasks, emptying the dishwasher, clearing and laying the table and cooking. Residents were also supported to bring their laundry down and place it in the washing machine. One care plan also included pictures of one resident hovering their room and participating daily activities. Residents’ rights to make choices were actively promoted; by them being supported to choose what to wear, to eat and which activities they would like to participate in. The service is responsible for the finances of residents. Two residents’ records of money held were checked with the money held in safekeeping. One resident’s recorded balance was recorded incorrectly. The manager audited the finances and recordings and identified that members of staff had recorded the balance incorrectly. On reading the review of a resident’s care at the home. Information highlighted that residents had paid for the flat screen television in the lounge and one resident had paid half of the amount for his bed. This was discussed with the registered manager who evidenced by showing residents’ bankbooks that all three residents had been refunded the full amounts that they had contributed towards purchasing the television and the money had been refunded to the individual who had paid towards his bed. It is Requirement 1 that the manager checks the recordings of expenditure to ensure they are correct and all incomings and outgoings of money are recorded correctly to ensure their accuracy. On speaking to relatives very positive feedback was received regarding the care provided at the home. “The home has been brilliant, we have had no Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 13 problems. The move to the new premises was great. The staff are really nice, if I have any concerns they always do something about it. Y has been a lot happier since being at the home. When we bring Y to visit us, Y wants to go back, so the home must be doing something right. The staff have been brilliant” informed one relative. Shining Star DS0000070932.V364528.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): 11, 12, 13, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life, promoting their opportunities to be part of the local community. Residents are offered meals that promote their choices and respect their individual preferences. Residents are supported to maintain family links and relationships inside and outside the home. EVIDENCE: Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 15 The service has a strong commitment to enabling residents to develop and maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. Two residents have been supported to go horse riding regularly, which they really enjoy. Some residents also go to pottery classes and items they have made can be seen around the home. Residents are also supported to attend local day centres, clubs in the evening, go swimming, out to pubs and restaurants. During the inspection one resident was seen going out shopping with the support of staff, which is a favourite past time of theirs. This resident also chooses not to attend day centres and their decision is respected and therefore is supported to participate in activities of their choice. People who use the service have the opportunity to develop and maintain important personal and family relationships. Residents are supported to contact family by telephone and by email. Evidence was seen of residents supported to visit and stay with family. Compliments received by the home included the following comments “Wow what a wonderful house and boy what a lot of work and thought has gone into the decorating, we take our hats of to you all there must have been a good team spirit getting everything right.” Another relative wrote, “We are very happy with the way things are run and are very happy with the staff and manager. X shows us that they are very happy at the home.” A social worker spoken to from the London Borough of Hounslow spoken to as part of the inspection informed “ I have met the staff at the home, who are always very warm and easy to talk to. They always provide you with the information you need. I am very satisfied with the care provided at the home and felt the staff are very good.” The home provides meals, which are varied and nutritious and meet the dietary needs of residents. There was plenty of fresh fruit and vegetables at the home. During the second visit staff were seen to prepare the evening meal, which was chicken curry and rice. The food smelt and looked appetizing. Residents choose their meals from an extensive folder of pictures of foods, meals and ingredients and staff support residents to devise the weekly menu. Residents can also refuse their choice of meal on the menu on the day and staff prepared alternative meals specified by the resident. One resident at lunchtime was observed choosing her meal out of the fridge to give to staff to cook, which they supported the resident to do. Residents also go out and do the shopping with the support of staff. Evidence was also seen of residents going out to local restaurants and being provided with take away meals of their choice. Shining Star DS0000070932.V364528.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, 21 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive personal support and care in the way they prefer and require. The service must ensure that procedures and guidelines are in place for any medication leaving the home, to ensure residents are safeguarded when not at the home. The ageing, illness and death of service users are handled with respect and as the individual would wish. EVIDENCE: Residents at the home receive personal care and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Each resident has a devised Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 17 health plan which identifies the healthcare needs of residents including specialist health, nursing and dietary requirements, which are clearly recorded and act as an indicator of change in health requirements. The plan also identified residents’ daily routines including the type of support they need in relation to personal hygiene and according to their level of care needs. All residents have a designated key worker to promote their privacy and dignity, and all personal care is provided in private. Attention is paid to personal preferences in relation to the provision of personal care, for example whether one prefers a shower or a bath. Personal support takes account of individual preferences and residents’ choice of dress and appearance is respected. Residents were well dressed and groomed. Residents are supported by staff to attend appointments with healthcare professionals and their health is closely monitored and prompt referrals are made. There was evidence of staff taking female residents to well women checks and the involvement of multli-disciplinary healthcare professionals where required were made to dentists, chiropodists, GP’s and community psychiatric nurses. A learning disabilities nurse was spoken to who visited the home about a year ago. She said, “ When I was there, the residents were very comfortable. Staff new the residents very well and took on any instructions I made. They are very prompt in contacting health professionals; my experience with the home was very positive.” Steps have been taken to find out the wishes of residents in the event of their death, including contacting relatives or representatives where the resident is unable to express their views. There are policies and procedures for staff to follow in the event of a death; to ensure the death of a resident is handled with respect and as the individual would wish. Medication administration records (MAR) were closely examined. Medication records were fully completed, contained required entries, and were signed by two members of staff. The medication file contained photographs of each individual, a medication pen picture and information about each medication. All of the residents have regular medication reviews conducted by the General Practitioner, which is very good practice. The service did not have a policy on any medication leaving the home. In compliance with Care Homes Regulations 2001 and The Administration & Control of Medicine Guidance the home must produce a written policy that includes the procedures to be followed and the precautions to be taken, including a witness to the transfer, when transferring medication to be taken out of the home. There was also no record of signatures by family receiving the medication and staff accepting medication. As with any medication taken out of the home a signature of the person accepting receipt and any return is required. It is Requirement 2 that medication practices are reviewed to ensure the safety of residents. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 18 Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 19 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 using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured their views are listened to and acted on. The service needs records all complaints and concerns to ensure any dissatisfaction with the service is recorded regardless of source. All staff have received up to date training in Safeguarding Adults, which ensures the protection of residents. EVIDENCE: People who use the service are supplied with a complaints procedure, which is in picture format. The complaints procedure is clear, concise and easy to follow and was displayed around the home. However due to the complex communication needs of residents it would be unlikely that they would be able to make a complaint without support. A complaints logbook is kept by the home, which was viewed. One recent formal written complaint was logged. The service investigated the concerns highlighted satisfactorily, and clearly recorded details of the investigation and any actions taken. The Commission for Social Care Inspection was informed of this complaint by a regulation 37 notification. Evidence was also seen of verbal Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 20 complaints and concerns recorded by the service and what actions they took to resolve the concerns. All staff had attended Safeguarding Adults training which is also covered in the induction programme. The service has comprehensive Safeguarding Adults procedures and protocols in place. The service has obtained Safeguarding Adult procedures devised by The London Borough of Redbridge, which is the host authority for the service. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable environment and décor is of a good standard and provides a homely and pleasant living environment enhancing residents’ comfort. But further outdoor maintenance would improve the environment of the home. EVIDENCE: The residents have recently moved to new premises at Green Lane. The home is a large house located in a residential area of Redbridge The house was comfortable, bright, airy, clean and free from offensive odours. Furnishings and fittings in communal areas were of good quality, domestic and unobtrusive. The home provides a main lounge, a kitchen and two communal bathrooms. Residents’ rooms were seen during the inspection. The rooms were comfortable with good quality furnishings and were also personalised by residents. The service had been very thoughtful in decorating the home to meet residents’ needs. Residents had also chosen the paint colours for the Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 22 bedrooms and decorated their rooms to their own preferences. One resident liked to collect teddy bears and liked the colour pink, which was also the colour they had chosen to paint their room, which was also full of teddy bears. Another resident was provided with an extra long bed to accommodate his height. Another resident who previously pulled down blinds around the home due to wanting to look out the window was now provided with roll up blinds around the home and windows had stencilled shapes on them to provide an element of privacy for other residents. Specialist equipment for residents was provided where required and bathrooms and toilets were fitted with appropriate aids and adaptations to meet the needs of people who use the service. The home has a good-sized rear garden, which provided adequate garden furniture. However the rear garden and lawns at the front of the property were over grown and needed attention. During a further tour of the home a log of fridge and freezer temperatures was seen, which staff did not consistently complete, as there were no recordings for some days, which could increase the risk of infection. All parts of the home to which residents have access to must be so far reasonably practicable made free from hazards and unnecessary risks to residents are identified and so far as possible eliminated, This will be stated as Requirement 3. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 23 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, 33, 34, 35, 36 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment practices are robust and ensure residents are in safe hands at all times. Adequate staff training is provided to all care staff, to ensure they are equipped with the skills and are competent to do their jobs. The service has a good skill mix of staff, ensuring adequate numbers of staff are on duty to meet the needs of residents. EVIDENCE: Three staff files were closely examined, which also included the files of two recently recruited members of staff, which were all in good order. References and Criminals Records Bureau checks had been obtained for all three members of staff. Staff files also contained interview questions and interview notes from the panel. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 24 Staff supervision records evidenced that staff were supervised at least six times a year, ensuring staff are provided with the skills, training and knowledge to perform the tasks required by their employment role. Members of staff spoken to also commented that they were supervised regularly. Staff meetings are organised on a monthly basis and staff spoken to confirmed that they always take place, allowing them an opportunity to discuss issues or any concerns they have. Files viewed all evidenced that staff had been on induction programmes and all received ongoing training, including training in manual handling, POVA, medication administration, fire safety, first aid, person centred care, autism, and understanding challenging behaviour and epilepsy awareness. Staff rotas evidenced there are sufficient numbers of staff on duty to meet the needs of residents during the day. There are always one to two members of staff on duty during the day and this is increased to three to facilitate activities at the home. A Community Service Volunteer has also been placed at the home and works alongside staff to support residents in activities. One sleep in member of staff is on duty during the night; with access to a Life Line pendant and Mencap’s 24-hour emergency on call service. The registered manager has also completed lone working risk assessments to ensure people working at the home and residents are safeguarded. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 25 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 using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from an experienced manager who recognises their needs and adequately manages the home. The systems for service user consultation are in place, but must also include views from stakeholders to ensure the home is run in the best interests of residents. The welfare of staff and residents is promoted by the home’s policies and procedures. EVIDENCE: Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 26 The registered manager and the deputy manager are in the process of completing their Registered Managers Award. The registered manager communicates a clear sense of direction, leadership and openness. The manager trains and develops staff that are generally competent and knowledgeable to care for people who use the service. The service works in partnership with families or close friends, as appropriate and professionals. “Since Miriam (the manager) has been at the home, the home has been fantastic. Y seems a lot happier since she has been there. Miriam always shows me anything I want to see. The staff have been brilliant” informed a relative. Staff spoken to as part of the inspection also spoke very positively about the manager at the home. One member of staff said, “The manager is really nice. I have supervision about every two months and we are supported very well.” A newly recruited member of staff was spoken to who informed “ I have been here for two months now. I have had an induction and also have formal supervision. I am enjoying it very much. The residents are unique and I have always felt that there’s enough people on shift.” Annual quality assurance systems are in place, and questionnaires completed by family and their representatives were seen. Survey formats for residents were simple and easy to read and were also in picture format, but residents due to their communication needs were unable to complete these. The results of surveys that had been completed by relatives and representatives had been analysed and actioned and an improvement plan had been devised by the organisation. However, it was identified that stakeholders had not been included in the quality assurance programme. Health professionals, social services and any other stakeholders in contact with the home must also be involved in quality assurance surveys, to ensure their views are sought on how the home is achieving goals for residents. This will be stated as Requirement 4. Health and Safety records were inspected. All documentation was in order and appropriately completed. Fire drills were completed regularly. Monthly regulation 26 visit reports were available to view at the home. Visits had been completed on a monthly basis and provided comprehensive information on the day-to-day operations of the home. All sections of the annual quality assurance assessment were completed except for the data section about staff. This was discussed with manager who was not aware that this information was not provided. Overall information gave a good picture of the current situation within the service. The evidence to support the comments made was satisfactory, and supporting evidence was provided to illustrate what the service has done in the last year, or how it is planning to improve. Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 27 Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 28 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 x 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 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 2 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 2 x x 3 x Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 29 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7 Regulation 16 (l) 17 3 (a) Requirement The registered persons must ensure that they check the recordings of expenditure for residents to ensure they are correct and all incomings and outgoings of money are recorded correctly to ensure their accuracy. The Registered Person must ensure that procedures and guidelines are in place for any medication leaving the home. The Registered Persons must ensure that all parts of the home to which residents have access to must be so far reasonably practicable made free from hazards to their safety and unnecessary risks to residents are identified and so far as possible eliminated. The registered persons must ensure that quality assurance systems also seek the views of health professionals, social services and any other stakeholders in contact with the home to ensure their views are sought on how the home is DS0000070932.V364528.R01.S.doc Timescale for action 31/08/08 2 YA20 13(2) 31/08/08 3 YA30 YA24 13 (4) (a) 31/08/08 4 YA39 24 31/10/08 Shining Star Version 5.2 Page 30 achieving goals for its residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the service records the times residents go to bed and get up to reflect their daily routines. It is recommended that care plans include information, which is specific to residents’ sexual needs, to ensure all staff working at the home are aware and ensure they respect residents wishes. 2 YA6 Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shining Star DS0000070932.V364528.R01.S.doc Version 5.2 Page 32 - 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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