Care Home: Southfield House Care Home

What the care home does well The needs assessment process at the home is robust and thorough, enabling people who access the service to be confident that their needs can be met. Residents said they felt well cared for and that the staff were kind. The home provides a comprehensive plan of care for each individual and this is regularly updated. Residents are involved in the care planning process and are regularly consulted. People living in the home are given the opportunity to make decisions about their lives and the day to day running of the home. They said that the manager and staff ask them what they think about things, through individual discussion, surveys and service users meetings. The home`s administration, handling and storage of medicines is well managed. Good contact is kept with service users` family and friends. This means that they are never out of touch with the people that they care for. People living in the home have the opportunity to take an annual holiday. They also go on regular outings and access a wide variety of adult learning courses and community based events. The home is well managed, with trained staff that are supported and have a good understanding of service users needs. 83% of the staff team have achieved a National Vocational Qualification at level 2 or above. What has improved since the last inspection? The home has worked to address the number of requirements made at the last site visit. People living in the home now have a care plan developed on admission to the home, identifying how their needs should be met. An application form, two written references, a Criminal Records Bureau check and a Protection of Vulnerable Adults check are undertaken prior to a person starting employment. The risk of harm to people is minimised due to the stringent procedures in place. There has been some redecoration and new flooring purchased, improving the environment for the people living there. Two bathrooms have also been completely refitted, improving the facilities for the service users. Work on building a new extension has begun, which will provide all en-suite accommodation in the home. What the care home could do better: Staff said that they felt that they would benefit from further training in aspects of Mental Health, particularly in dealing with difficult situations, when they are on their own. Previously there was a waking member of night staff and a second sleeping in, As individual needs have changed the staffing levels have been changed, resulting in one sleeping in staff being available throughout the night. Previously a large proportion of the domestic tasks were completed at this time, however since the change in the night staffing hours there have been no additional domestic hours identified. This has led to deterioration in some areas of cleanliness in the home. Although the staff maintain a good level of cleanliness in the kitchen, bedrooms and bathrooms, there are areas that can be improved upon. The carpet to the corridor outside of the lounge is in need of a thorough deep clean, window frames have mildew on them and need more regular cleaning, the old flooring in the corridor outside of the office needs a thorough clean along the edges to remove the debris that has collected there. The downstairs bathroom has been refitted and redecorated, but the ceiling had not been finished, due to the contactor not having the correct brush. However, some time had lapsed since and the ceiling had still not been finished. The staffing levels in the home need to be reviewed to ensure that there are adequate numbers of staff available at all times to meet individual needs. Although the staff team plan for and work flexibly to support people living in the home with external evening activities, there is only one staff member on duty in the evening, which does not allow for impromptu external activities to take place. Also not everyone living in the home wishes to go out in the evening and cannot be left on their own, which can compromise other individuals` wishes. Although the staff team handover information to each other on a daily basis and the manager is always available, regular staff meetings are not held. The conservatory was previously used as a dining area and this has been demolished to allow for an extension to be built. As a result of this meals arenow taken in the lounge or corridor on folding garden furniture that can be easily stored when not in use, which is not ideal. The people living in the home do not have any concerns about this arrangement and had been consulted about it before it was introduced, they were also aware that this is a short term arrangement. CARE HOME ADULTS 18-65 Southfield House Care Home Albert Street Brigg North Lincolnshire DN20 8HU Lead Inspector Ms Wilma Crawford Unannounced Inspection 6th November 2007 09:00 DS0000002817.V355212.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 DS0000002817.V355212.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. DS0000002817.V355212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southfield House Care Home Address Albert Street Brigg North Lincolnshire DN20 8HU 01652 653708 01652 653708 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Mrs Sandra Robinson Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places DS0000002817.V355212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2007 Brief Description of the Service: Southfield House provides accommodation for up to 8 younger adults who experience mental health problems. The home is a converted two-storey property situated in Brigg. It is within easy walking distance of local shops, and amenities. The home is not registered to provide nursing care, however the home has developed good working relationships with local health care professionals and agencies. Each of the bedrooms are for single occupation, one has en-suite facilities. The home also has a range of communal facilities, which service users and visitors can access. The home has a large rear garden complete with patio and flowerbeds. Work is currently underway to provide an extension to the home. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. DS0000002817.V355212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 9th January 2007, including information gathered during a site visit to the home. The site visit was unannounced and took place over eight hours including preparation time. Six people living in the home, and two staff were spoken with during the visit. The manager was available throughout the visit. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at, a sample of maintenance and other records examined, including those of three residents and two staff. An Annual Quality Assurance Assessment (AQAA) document asking for information about the home was sent out before this visit and information from this was included as part of the inspection process of this service. Sixteen surveys were sent out to people living in the home and staff, eight of these were completed and returned. The comments from these and from discussions during the site visit are also included in the report. The range of fees charged is £319 — £350 per week. What the service does well: The needs assessment process at the home is robust and thorough, enabling people who access the service to be confident that their needs can be met. Residents said they felt well cared for and that the staff were kind. The home provides a comprehensive plan of care for each individual and this is regularly updated. Residents are involved in the care planning process and are regularly consulted. People living in the home are given the opportunity to make decisions about their lives and the day to day running of the home. They said that the manager and staff ask them what they think about things, through individual discussion, surveys and service users meetings. The home’s administration, handling and storage of medicines is well managed. Good contact is kept with service users’ family and friends. This means that they are never out of touch with the people that they care for. People living in the home have the opportunity to take an annual holiday. They also go on regular outings and access a wide variety of adult learning courses and community based events. The home is well managed, with trained staff that are supported and have a good understanding of service users needs. 83 of the staff team have achieved a National Vocational Qualification at level 2 or above. DS0000002817.V355212.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Staff said that they felt that they would benefit from further training in aspects of Mental Health, particularly in dealing with difficult situations, when they are on their own. Previously there was a waking member of night staff and a second sleeping in, As individual needs have changed the staffing levels have been changed, resulting in one sleeping in staff being available throughout the night. Previously a large proportion of the domestic tasks were completed at this time, however since the change in the night staffing hours there have been no additional domestic hours identified. This has led to deterioration in some areas of cleanliness in the home. Although the staff maintain a good level of cleanliness in the kitchen, bedrooms and bathrooms, there are areas that can be improved upon. The carpet to the corridor outside of the lounge is in need of a thorough deep clean, window frames have mildew on them and need more regular cleaning, the old flooring in the corridor outside of the office needs a thorough clean along the edges to remove the debris that has collected there. The downstairs bathroom has been refitted and redecorated, but the ceiling had not been finished, due to the contactor not having the correct brush. However, some time had lapsed since and the ceiling had still not been finished. The staffing levels in the home need to be reviewed to ensure that there are adequate numbers of staff available at all times to meet individual needs. Although the staff team plan for and work flexibly to support people living in the home with external evening activities, there is only one staff member on duty in the evening, which does not allow for impromptu external activities to take place. Also not everyone living in the home wishes to go out in the evening and cannot be left on their own, which can compromise other individuals’ wishes. Although the staff team handover information to each other on a daily basis and the manager is always available, regular staff meetings are not held. The conservatory was previously used as a dining area and this has been demolished to allow for an extension to be built. As a result of this meals are DS0000002817.V355212.R01.S.doc Version 5.2 Page 7 now taken in the lounge or corridor on folding garden furniture that can be easily stored when not in use, which is not ideal. The people living in the home do not have any concerns about this arrangement and had been consulted about it before it was introduced, they were also aware that this is a short term arrangement. 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. DS0000002817.V355212.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 DS0000002817.V355212.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): 1, 2, 3, & 5 People who use this service experience good quality outcomes in this area. A full needs assessment is carried out and people are given enough information about the home and its facilities before admission, for them to be confident that their needs can be met by the service. The judgement has been made using available evidence including a visit to this service EVIDENCE: The home has a Statement of Purpose and Service Users Guide, copies of these are provided by the home to all prospective service users. Copies are also available from the manager. Each individual has a statement of terms and conditions with the home, which are signed by the individual or their representative. The manager or the area manager visits prospective service users and a full assessment is completed. A decision is then made as to whether the individual’s needs can be met and the person is invited to visit the home with their family for a meal or an overnight stay. This gives the individual the opportunity to see what they think about the home, before committing to a decision. Each person living in the home has their own individual care plan which includes a needs assessment from both the home and the funding authority. All of the care plans seen by the inspector included full assessments of those service user’s needs. Care plans are drawn up with input from the individual and their relatives and include identified social and healthcare needs. DS0000002817.V355212.R01.S.doc Version 5.2 Page 10 Comments from relatives and people living in the home commented that ‘the staff are great’. Discussion with the staff, examination of staff training files and discussion with service users, support the evidence that the home is able to meet the assessed needs of the service users living there. The manager has looked into obtaining advocacy services from external agencies. She also involves the local care management team for support with any aspects of advocacy services required DS0000002817.V355212.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): 6,7,8 and 9 People who use this service experience good quality outcomes in this area. People using the service are able to make decisions and everyday choices as part of an independent lifestyle. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Individuals’ care files included care plans detailing how individual needs should be met within the home. Each care plan had been regularly monitored and evaluated and where appropriate new or changed care plans had been implemented. People spoken with by the inspector stated that the staff were able to look after them and that they believed that all of their care plans were being followed by the staff. Verbal feedback from people living in the home, also demonstrated that they have the opportunity to discuss any changes or wishes that they have in relation to their care. Individual care plans are in place and cover health, personal and social care needs. Risk management strategies are in place for all areas of need and cover aspects of daily living as well as specific behaviours. Examination of a sample of 3 care plans showed that they are kept under constant review and updated as needs change. An annual review is also held DS0000002817.V355212.R01.S.doc Version 5.2 Page 12 with each individual and their representatives. However one individuals care plan did not have a copy of their review notes in their record. Staff and the person concerned were able to demonstrate that the review had been held and the topics that had been discussed and where changes had been agreed and made in the care plan. Discussion with staff indicated that they respect the peoples right to make decisions. People living in the home said that they are given the opportunity to make decisions about their lives and the day-to-day running of the home. They said that the manager and staff ask them what they think about things, through individual discussion, surveys and service users meetings, which are recorded. DS0000002817.V355212.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): 12,13,14,15,16,and 17 People who use this service experience excellent quality outcomes in this area. People using the service have opportunities to access a variety of leisure activities, are supported to maintain relationships and have their nutritional needs met. The judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home have the opportunity to engage in a range of activities both in the home and in the local community. The home has a structured activities plan having spent time with the people living in the home and seeking their views as to what type of activities they would like to access. Details of this, were recorded in the service users’ meetings notes. As well as providing activities in the home, some people wanted to access employment and local college and adult education services. These included courses for education, literacy, computers and embroidery. One person had embroidered their own bed cover and served tea at their local church hall. DS0000002817.V355212.R01.S.doc Version 5.2 Page 14 People living in the home enjoy a regular holiday and some had recently returned from a week’s holiday in the Isle of Man. A record of activities is maintained in the home and includes pictures of Halloween parties, day trips, holidays and activities held in the home such as card making, cookery, quizzes, bingo, and board games. Staff have also supported people with home visits, when their relatives are not able to visit themselves. Discussion with people living in the home indicated that they enjoy going out into the community and have their own interests and hobbies, which are supported and encouraged, by the home. People spoken with said that they were very happy about the way that staff looked after them; they said that they felt safe and that their privacy, dignity and choices were respected. Observations of the interactions between staff and people living in the home showed that there is a good relationship between the two groups of people based on trust and friendship. On the day of the visit the service users had planned to visit the local pub for lunch. However there is a menu on display with choices available. This is developed and updated regularly via the residents meetings; records of the meetings supported this. People living in the home said that they enjoyed the food and that there was plenty of choice available, including lighter options if they preferred this. DS0000002817.V355212.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use this service experience good quality outcomes in this area. Residents receive appropriate health care and personal support. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The current staff team are all female, which does not offer people a choice of who they prefer to have their care needs supported by. People living in the home said that they did not mind having an all female staff team, but it would be nice to have the option. The information in care plans showed that everyone living in the home has their own preferred routine and discussion with staff demonstrated that they had a good understanding of the wishes and choices made by each individual and were able to describe their care needs and how staff were quick to offer help when it was needed, they also respected their wishes to be as independent as possible. Each individual care plan documents the visits and input each person has received from outside professionals for example GP’s, chiropodist, psychiatrist, dentist, and optician. Staff and service users confirmed that they support individuals with all appointments. DS0000002817.V355212.R01.S.doc Version 5.2 Page 16 The medication policy states that people coming into the home can self – medicate if they wish to after a risk assessment has been completed and agreed. No one currently chooses to administer his or her own medicines. The medication system and records were found to be accurate, up to date and well managed. Training records demonstrated that staff administering medicines are trained and have received safe handling of medicines training. DS0000002817.V355212.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use this service experience good quality outcomes in this area. People using the service feel able to air their concerns without any fear of repercussions. The staff vetting procedure is sufficiently robust to ensure the safety of the service users. The judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure is displayed in the entrance hall of the home. People living in the home spoken with were able to describe how they could use the complaints process and were confident that they could talk to any of the staff if they had any problems. There have been no complaints received by the home during the last twelve months. Staff spoken with showed that they had a good understanding of their role in dealing with Safeguarding Adults issues and how complaints should be managed. A recruitment procedure is in place with the manager overseeing the recruitment process. An application form, two written references, a Criminal Records Bureau check and a Protection of Vulnerable Adults check are undertaken prior to a person starting employment. The risk of harm to people is minimised due to the stringent procedures in place. Two staff files were examined and these were found to be up to date. DS0000002817.V355212.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27, 30 People who use this service experience adequate quality outcomes in this area. The residents have been provided with a homely environment that is generally clean and has been decorated to a reasonable standard. The judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been some redecoration and refurbishment of the home during the last twelve months. This has included redecoration of the office, hallway, lounge and bathrooms and new flooring in the bathrooms, kitchen and toilets. Two bathrooms have also been completely refitted, improving the environment for the people living there. Further refurbishment of the home is planned, to provide more spacious accommodation and all bedrooms with en-suite facilities. During the refurbishment process, regular consultation will take place with people living in the home and their relatives. During a tour of the building there were some areas identified where the cleanliness needs to be improved. DS0000002817.V355212.R01.S.doc Version 5.2 Page 19 Previously there was a waking member of night staff and a second sleeping in, As individual needs have changed the staffing levels have been changed, resulting in one sleeping in staff being available throughout the night. A large proportion of the domestic tasks were completed at this time, however since the change in the night staffing hours there has been no additional domestic hour identified. This has led to deterioration in cleanliness of some areas in the home. Although the staff maintain a good level of cleanliness in the kitchen, bedrooms and bathrooms, there are areas that can be improved upon. The carpet to the corridor outside of the lounge is in need of a thorough deep clean, window frames have mildew on them and need more regular cleaning, the old flooring in the corridor outside of the office needs a thorough clean along the edges to remove the debris that has collected there. Bedrooms are personalised and decorated to suit individual tastes. Each bedroom has a suitable lock that can be used for privacy. Many individuals had personal belongings and furnishings in their rooms, making them feel homely and reflect the personalities of the occupants. Policies and procedures are available for the control of infection. DS0000002817.V355212.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use this service experience adequate quality outcomes in this area. People living in the home are supported by staff who are supervised and undertake training. The staff vetting procedure is sufficiently robust to ensure the safety of the residents. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Five staff have achieved a National Vocational Qualification at level 2 or above. Written and verbal feedback from the staff and residents and relatives state that they feel they feel they would benefit from additional staffing, particularly to support with domestic tasks and in the evening. Although the staff team plan for and work flexibly to support people living in the home with external evening activities, there is only one staff member on duty in the evening, which does not allow for impromptu external activities to take place. Also not everyone living in the home wishes to go out in the evening and cannot be left alone, which can compromise other individuals’ wishes. The staff on duty on the day of the site visit corresponded to the rota for that day. The current staffing levels consist of the manager and a carer or the deputy, working from 7:30 am until 7:30 p.m, when the staffing level goes down to DS0000002817.V355212.R01.S.doc Version 5.2 Page 21 one. This staff member then provides an on call sleeping in cover when the service users have gone to bed. Newly appointed staff complete an organisational induction. Information from the AQAA document and the staff training files shows that the home provides a rolling programme of staff training that covers mandatory subjects and an NVQ programme. Specialist training also takes place. E.g. First Aid appointed person, Fire Safety, Protection of Vulnerable Adults, Infection Control, Safe handling of Medicines, Food Hygiene, Moving and handling and Non Abusive psychological and physical Intervention. Staff supervision files showed that individuals attend regular formal supervision sessions with their line manager. There is a daily handover of information and staff said that they have access to the manager and are encouraged to express their views and opinions. Staff meetings are not held on a regular basis Feedback from professionals was that the staff know the service users very well and take into consideration their needs, likes, differences and opinions. They also felt they have always had a good and productive relationship with the home. Staff said that they would welcome more training on Mental Health, this request has been submitted to the training department, for further action. The manager has also asked a manager of another home to provide some in house training on Dementia. DS0000002817.V355212.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 &43 People who use this service experience good quality outcomes in this area. People using the service benefit from a safe and well managed place to live. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has completed the Registered Manager’s Award and the NVQ4 in care. Service users and staff all confirmed to the inspector that the manager is very open and approachable. All of the staff and service users spoken to by the inspector stated that the manager always had time for them. People living in the home are involved in contributing to the development of the service via the Quality Audit review and through service users meetings, minutes of which are kept. The home has a Prime Life Limited Quality Assurance system in place and audits of the service are carried out on a regular basis. An annual development plan has been created from the results of these audits; however this does not include specific timescales. A DS0000002817.V355212.R01.S.doc Version 5.2 Page 23 development plan is created from the results of this, which is discussed with the staff team at staff meetings. Quality assurance surveys are also completed periodically with people living in the home, relatives, visitors and professionals and the results of these collated and action plans developed from these if required. Progress from these surveys is also discussed at service users meetings. Maintenance certificates are in place and up to date for the utilities and equipment within the building and training records show that staff have attended safe working practice up dates. Information examined in the home corresponds to that provided in the AQAA. Checks of the accident books found that incidents are accurately recorded. DS0000002817.V355212.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 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 3 25 X 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X 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 X 3 X 3 X X 3 3 DS0000002817.V355212.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 16 Requirement Timescale for action 30/12/07 2. YA30 16 3. YA33 18 The registered person should ensure that the redecoration to the ceiling of the downstairs bathroom is completed. The registered person must 30/11/07 ensure that the carpet outside of the lounge and the flooring outside of the office is thoroughly cleaned or replaced. The registered person must 31/12/07 ensure that the home provides a staff team, in sufficient numbers to support service users assessed needs at all times, particularly during the evening to allow for impromptu or planned late activities e.g. to the theatre to take place. The registered person must ensure that the home has an effective staff team, with sufficient numbers to maintain the provision of in depth cleaning within the home, over and above the daily cleaning routines that are met. DS0000002817.V355212.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA6 Good Practice Recommendations The manager should ensure that all care information relating to reviews are maintained on all service users’ individual records. The manager should consider the gender mix of staff team, when staff are being recruited to the home, to enable people living in the home a choice of staff of the same sex to offer them support. The manager should ensure that staff meetings are held at least six times a year. The manager should ensure that the appropriate mental health training requested by staff is provided. YA24 3. 4. YA34 YA34 DS0000002817.V355212.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002817.V355212.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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