Care Home: Spring Grove Road, 233

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)

What the care home does well The home is based within a busy community, providing the residents with access to shops, day and leisure services. This has provided a long-term home for the people living there and enabled them to have consistent surroundings and activities, which suits their needs. The home had retained a regular staff team who know the needs of the residents well and with whom they can communicate. What has improved since the last inspection? The bathroom has been refurbished. What the care home could do better: The kitchen units have needed replacement for some time. To promote hygiene, this work needs to be completed in the near future. Only one staff member currently has a National Vocational Qualification and the staff must have the opportunity to undertake NVQ training. The RegisteredProviders need to provide a timetable to show how the target of having 50% of the staff trained will be achieved. Not all of the employment records were in place when checked. The Registered Providers must ensure that there are systems to keep information up-to-date. The Registered Providers must ensure that the fire risk assessment is fully completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. CARE HOME ADULTS 18-65 Spring Grove Road, 233 Isleworth Middlesex TW7 4AF Lead Inspector Ms Jane Collisson Key Unannounced Inspection 5th August 2008 9:50 Spring Grove Road, 233 DS0000022907.V368579.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 Spring Grove Road, 233 DS0000022907.V368579.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. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Grove Road, 233 Address Isleworth Middlesex TW7 4AF 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) 0208 568 0263 Voyage.com Milbury Care Services Ltd Post Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 23rd July 2007 2. Date of last inspection Brief Description of the Service: 233 Spring Grove Road is a detached house situated on a busy road in Isleworth, near to the London Road and the A4. There are local shops and public transport links within walking distance. Hounslow Town Centre and Brentford are within easy reach. The home is registered for three people with learning disabilities. The owners and care providers are Voyage (formerly Milbury Care Services) and the home has been in operation since 1995. The home has three bedrooms, one on the ground floor and two on the first floor. There is a bathroom and toilet on the first floor and a separate toilet on the ground floor. The communal space consists of a lounge/dining room, kitchen and an area between the two rooms, which currently houses the fridge/freezer. There is a small office on the first floor and the sleeping-in room is in the loft. The washing machine and dryer are housed in an alcove next to the bathroom. There is a small garden to the rear with a lawn, shrubs and seating. The management team consists of the Manager and a Senior Support Worker. The Manager also manages 231 Spring Grove Road, a neighbouring home for two people with learning disabilities. There are a team of day and night support workers, with one waking and one sleeping-in staff during the night. There is a minimum of two staff on duty during the day. The team supports the people living in the home with personal care, practical tasks, leisure and social activities. Local day services, run by Voyage, are accessed and a house car is available for outings, shared with 231 Spring Grove Road. The current weekly fees range from £1476.23 to £1483.15. Spring Grove Road, 233 DS0000022907.V368579.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 unannounced inspection took place on the 5th August 2008 from 9.50am to 1.50pm. Two of the residents were in the home with three staff. The third person was at the day centre and one of the residents went later to the Feltham Bowling centre with a staff member. All three men have lived in the home since it was opened in 1995 and all have little or no verbal communication. The third resident was met on the 6th August when a visit was made to inspect the neighbouring home at 231 Spring Grove Road and, at 4pm, to complete the inspection at 233. The men were all at home. They were seen to be quite relaxed during the two visits, and one person was in his room listening to music. Another resident was helping with small tasks around the home. They all have the opportunity to participate in outings and activities which suit their needs. The home has been without a Registered Manager since December 2007. The Acting Manager, who has been the Deputy Manager of 231 and 233 Spring Grove Road for some years, was present. We will refer to him as the Manager for the purpose of this report. We discussed the current management and staffing situation in the homes as he is currently running both. He said he was about to commence the process of applying for registration with the Commission for Social Care Inspection. Since the last inspection, in July 2007, there have been staff reductions and these took effect in April 2008. The Manager has twenty hour per week management time at 231 and the remainder, including shifts, at 233 Spring Grove Road. The staff no longer have responsibility for the supported living houses previously managed by the Registered Manager and the Deputy Manager. Both homes have their own staff teams, who occasionally work across the two houses but staff and training records, and the newly acquired computer, are in the office of 231. We also examined the care planning files, medication, rotas, and maintenance records and toured the home. The inspection took a total of five hours. No major changes have taken place to the environment with the exception of the bathroom being refurbished. Some areas of the home were in need of upgrading. This included the kitchen units and some of the carpets which will need to be replaced on due course. Although there have been some improvements over the years, the lounge would still benefit from being made more homely. The small garden has also been improved by staff, but would benefit from pruning and weeding. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 6 Three staff were met, in addition to the Manager. The majority of the staff have worked in the home on a long-term basis, three for more than ten years, and only one new staff has been recruited in the last few months. We had some discussion with them about training as the company now provides most training using a laptop computer system. Staff were quite positive about this. There is very limited National Vocational Qualification training being offered and the home does not meet the target of having 50 or more of the staff team trained in NVQs. The Acting Manager completed the Commission for Social Care Inspection’s Annual Quality Assurance Assessment, but this was generally about the organisation rather than the individual service. There was only one requirement at the last inspection, in July 2007, in relation to the bathroom and kitchen refurbishment. We were informed last year that the budget had been agreed. However, only the bathroom has been upgraded, although the Manager said the kitchen has been assessed. There was a long-standing recommendation for the home to have access to a computer to assist with the record keeping, keeping staff up-to-date with information, and also to help provide visual documentation for the residents. A computer has recently been installed at the 231 Spring Grove Road office for use by both of the homes but does not yet have access to the internet or email. There have been four requirements made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: The kitchen units have needed replacement for some time. To promote hygiene, this work needs to be completed in the near future. Only one staff member currently has a National Vocational Qualification and the staff must have the opportunity to undertake NVQ training. The Registered Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 7 Providers need to provide a timetable to show how the target of having 50 of the staff trained will be achieved. Not all of the employment records were in place when checked. The Registered Providers must ensure that there are systems to keep information up-to-date. The Registered Providers must ensure that the fire risk assessment is fully completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. 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. Spring Grove Road, 233 DS0000022907.V368579.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 Spring Grove Road, 233 DS0000022907.V368579.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has information for prospective residents but it is in the process of being updated. Efforts are made to make it user-friendly. New assessment procedures are in place but, as there have been no vacancies, this National Minimum Standard could not be fully assessed. EVIDENCE: We were informed that the Service Users Guide and Statement of Purpose are in the process of being updated. The home had only just acquired a computer and the Acting Manager was adding items to the documentation. When these documents are completed, copies need to be forwarded to the Commission for Social Care Inspection. The pictorial Service Users Guide, produced with photographs, is also out of date and will require updating. All of the people living in the home have lived there since the home was opened in 1995 and there have been no vacancies. Therefore, the procedures could not be assessed. However, the company has new, comprehensive procedures in place should they be required. Spring Grove Road, 233 DS0000022907.V368579.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place but are in the process of becoming more “personcentred” with the introduction of a new system. People are supported to participate in activities outside of the home and, in accordance with their abilities, within the home. Reviews take place, involving families. People are supported to improve their independent living skills. EVIDENCE: We examined the care planning files for all of the residents, including a new Person Centred Plan file for one person. This was partly completed and it is planned that all of the people living in the home will have a similar one. This is written on behalf of the person and contains visual images. All of the care planning files for the people in the home, and those for their health needs, were examined. We looked at a sample of the daily records which provided us with information about activities undertaken by the men. These are recorded on individualised Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 11 forms which correspond to their personal lifestyles. The vocabulary of one of the men, although usually limited to single words, has improved in recent years and these are recorded. Two of the people in the home have had recent reviews of their support with a Social Services care manager present. The third person was awaiting a review which had been postponed because of finding a suitable time for his family to attend. There is a key worker system in place and it was discussed with the Acting Manager that a system of monthly reviews by the key staff would help to provide evidence that the activities detailed in the care plans are being carried out. The people living in the home have very limited verbal communication, but staff show a good understanding of their needs. For one person, the extent to which he will participate in outings has greatly improved and a programme of outings with the day centre and the home is in place. One person was seen to be involved in getting money from the office for visiting the shop. We were informed this was a recent skill and recognised as a positive achievement. None of the men are able to go out alone and all require escorting at all times. They are encouraged to help round the home, and undertake small domestic tasks. Risk assessments are in place to support the activities undertaken. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. Families are encouraged to be involved. Where appropriate, residents are involved in the domestic routines of the home. There is access to activities outside the home and holidays. Menus are varied and in accordance with the meals the residents are known to like. EVIDENCE: We found that the residents have continued to carry on with the activities they enjoy. We saw the programme for the three people, which include regular visits to the local day centre, run by Voyage. One person prefers to go only on drives with the centre and this is accommodated. However, it is hoped that the person can be encouraged to use the centre eventually. As this person has progressed from seldom going out to undertaking regular outings, this has been an achievement. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 13 One person is able to visit the local shops for sweets and a magazine, and he does this on a regular basis. Use is made of the Feltham bowling centre and the Heston sports centre. One person had been on holiday and a holiday is planned, although not yet booked, for the other residents. Another resident is encouraged to follow his culture, with suitable music in evidence. He was observed on the second visit enjoying this music in his room but he also has a wide variety of other music from which to choose. None of the residents attend any religious establishments. We found that there have been no major changes to any activities within the home. One person has the television on, together with a radio. This has been a long standing activity. One person likes to spend time looking out of the window although was seen to be more relaxed on this inspection, sitting in his room and also in the garden. There has been some reduction in the staff hours, but the Acting Manager said that they try to accommodate the activities wherever they can. One person goes out one evening a week. The staff are very aware of the meals that are enjoyed by the men and a good variety of food was seen on the menu. Staff share the cooking duties. There is a large dining table with space for the residents and staff. There are no specific cultural needs to be met in regard to meals. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to access a range of community health services and the specialist services they require. The medication procedures were satisfactory but monitoring is required. EVIDENCE: The residents have personal care delivered in accordance with their individual needs. Two require all assistance. Support plans are in place to show how they are supported. There are suitable bathing facilities which meet their needs. We found from the records examined that people are supported to attend all of the health services that they have required. These include chiropody and dentists as well are more specialist services, such as psychology. Only a small amount of medication is used in the home and the majority is contained in a Monitored Dosage System. The Medication Administration Record sheet were checked and found to be satisfactory. However, there is no Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 15 auditing system in place and the Manager needs to introduce a system to ensure the medication is checked regularly. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are complaints systems in place, but they would not be able to be used by the residents because of their disabilities. Safeguarding adults’ training has taken place to ensure staff are aware of adult protection issues. EVIDENCE: There have been no complaints in the home, or through the Commission for Social Care Inspection, since the last inspection in July 2007. Because of their lack of verbal communication, the residents would not be able to make a complaint. The use of visual aids would not necessarily be suitable for the residents but staff are very familiar with their non-verbal communication and should be aware of any concerns. All of the residents have families who they see on a regular basis, and who would be able to advocate on their behalf. There has been one issue raised since the last inspection, which resulted in safeguarding adults’ meetings. This was primarily to do with the nonregistered supported living services, which were being managed by the management team. These services are no longer being managed by Voyage and no further action was taken in relation to the 233 Spring Grove Road service. Staff have undergone the training recently for safeguarding adults, using the computerised training system. Certificates were seen in the files in relation to this training. The system for managing the residents’ money was introduced before the last inspection in 2007. None of the men would be able to manage their own Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 17 finances. Their money is managed by the Local Authority, with only their personal allowances paid to Voyage regularly. Where larger sums are required, for holidays for instance, these have to be applied for from the Local Authority. Spring Grove Road, 233 DS0000022907.V368579.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, 25, 26, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to meet the current needs of the people who live there. No specialist equipment is required. The personal spaces are generally pleasant and personalised but the lounge would benefit from being made more homely. The kitchen units are in need of replacement. EVIDENCE: We did not find any major alterations to the home since our visit in July 2007, with the exception of the newly refurbished bathroom. The lounge and dining area would benefit from making more homely and this was discussed with the Manager. The residents are able to use all of the rooms, including their bedrooms freely. We saw also their bedrooms. One is in need of redecorating and could have more of interest. However, the other bedrooms were nicely furnished and one resident was seen, sitting comfortably and enjoying music, in his bedroom. Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 19 We gave a requirement in 2007 for the bathroom and the kitchen to be refurbished within a reasonable timescale. The bathroom has been retiled and has a new suite. This was clean and bright. However, the kitchen has not been done and is in need of replacing. Most of the surfaces of the cupboards are chipped and there are damaged edges which have no washable surface. This does not help to maintain hygienic conditions. The replacement of the cupboard must be given a high priority and work commenced within the timescales given. All of the men are mobile and are able to use the bathing facilities on the first floor. None of the residents require any special equipment. There is also a toilet on the ground floor. All of the facilities are shared with the staff. Care staff undertake the cleaning of the home and we found it to be clean and tidy, but the stair carpet in need of replacement as it is quite stained. Spring Grove Road, 233 DS0000022907.V368579.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, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing cuts may affect the opportunities for outings for residents, particularly any spontaneous ones. Monitoring is required to ensure the needs and routines of the people using the service are being met. There is a consistent staff team which benefits the people using the service. Staff are able to undertake basic training courses but insufficient opportunities are available for National Vocational Qualification training. EVIDENCE: The staff team, with the exception on a person commencing this year, are all long term. Three have been in post for more than ten years. This has ensured there is a staff team who know the residents very well, and are able to communicate with them. The Manager reported that there is one staff vacancy. The Manager is currently managing both 231 and 233 Spring Grove Road and there is a senior support worker in each house. Since the inspection last year, the Registered Providers have introduced a new system of training, which consists of courses undertaken on a laptop computer. The staff spoken to were positive about this. We saw in the staff files Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 21 examined the certificates which have arisen from this training. These included a health and safety foundation course, which has modules which include first aid, fire awareness, risk assessments, law, infection control, manual handling and ergonomics. New courses are to be added and some training was to be arranged externally for the practical aspects of manual handling and first aid. Training in non-violent crisis intervention is also carried out by attendance at a course. We noted that little advanced training in learning disabilities has been available. Some staff are undertaking induction units in learning disabilities (formerly Learning Disability Framework Award). This has to be completed prior to the National Vocational Qualifications being taken. There was no training and development plan available for each staff member, or a training matrix to show when staff last had their training. We recommended to the Manager a matrix or spreadsheet would help to demonstrate that the staff have the required training. Now that the home has the use of a computer, this should be easier to keep up-to-date. Only one staff member has a National Vocational Qualification, which is at Level 3. Another member of staff is undertaking Level 2. The target of having 50 of the staff team, or above, with the qualification has not been met. The Registered Providers need to provide a timetable to show how this target will be met to ensure staff have the opportunity to develop their skills. We found that the staffing numbers have been reduced since April 2008 from 392 to 336 hours per week. Prior to this, there had been three staff on duty when the three residents were present. This has been reduced to two at all times and three for part of the time. We discussed with the Manager that the opportunity for spontaneous outings will be less. None of the residents is able to ask to go out, although one can indicates that he wishes to go to the shops. The home needs to demonstrate that none of the residents are disadvantaged by this cut in staff hours. Although fewer than previous, there are occasional incidents involving the people living in the home and these also need to be monitored to ensure that there are sufficient staff on duty to deal with them. We checked the staff records and found that the majority were in order. However, one person had a work permit which was out of date. This was checked with the Manager and the Voyage Operations Manager confirmed, the day after the inspection that this was now in order. The Manager needs to ensure that there are checks in place to ensure that all of the staff have the necessary and current documentation and it is available for inspection. In the files we examined there was evidence of supervision having taken place. The supervision had been very regular before the Registered Manager left, but there was evidence of supervision being undertaken since then, although it does not meet the National Minimum Standards of six a year. The Manager said that he is aiming for supervision meetings every two months. Spring Grove Road, 233 DS0000022907.V368579.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the necessary experience to run the home. They are aware of and work to the basic processes set out in the NMS. A quality assurance system is in place, with an annual service review undertaken. Staff have upto-date training in health and safety and the procedures are in place to protect the people living in the home. The Annual Quality Assurance Assessment (AQAA) gives details about the organisation but limited detail about the home and its residents. The data section of the AQAA was completed, although there were some gaps. EVIDENCE: The home has been without a Registered Manager for eight months. The Acting Manager has many years experience of working in the home, as a support worker and then as Deputy Manager. He said he was commencing the application procedure with the Commission for Social Care Inspection to Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 23 become the Registered Manager. He also hopes to undertake the Registered Managers Award. He has twenty hours a week to manage 231 Spring Grove Road and the remainder of his time is spent 233 Spring Grove Road. The company carries out an Annual Service Review for the home. As none of the men are verbal, it is not possible for them to participate fully. However, two relatives were involved in the 2007 review. This looks at a range of areas, including the environment, and scores are produced which are translated into percentages. It was noted that there were environmental improvements to be made but the detailed list was not in the file. We found that, while most of the information we wanted was in the files, the files were in need of general reorganisation, streamlining and archiving. Some files were not in use. We discussed with the Manager that an improvement in file management would also support the staff with their record keeping and assist the inspection process by providing the evidence needed to meet the National Minimum Standards. The Operations Manager undertakes the monthly Provider visits to the home, under Regulation 26 of the Care Home Regulations 2001. We noted, from information in the Annual Quality Assurance Assessment, that all of the policies and procedures have been reviewed in 2007 or 2008. The Annual Quality Assurance Assessment was completed on a corporate basis and mainly relates to organisational issues rather than providing information about the home and its residents. There were some gaps in the statistical information. Details of some of the maintenance checks were included in the Annual Quality Assurance Assessment form. These include the extinguishers, which were checked in September 2007 and the fire alarms which were checked in February 2008. One senior staff member had attended a 2-day Fire Warden’s course in order to train other staff. The last fire drill noted was in June 2008. From the information available, the Fire Risk Assessment was in need of updating in line with current legislation. Spring Grove Road, 233 DS0000022907.V368579.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 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 2 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 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 2 X Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA24 Regulation 23 (2) (b) 18 (1) (c)(i) Requirement The Registered Providers must ensure that the kitchen units are replaced to promote hygiene. The Registered Providers must ensure that staff are given the opportunity to undertake National Vocational Qualification training and provide a timetable to show the target of having 50 of the staff trained will be achieved. The Registered Providers must ensure that all of the records of employment are in order and available for inspection. The Registered Providers must ensure that the fire risk assessment is fully completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. Timescale for action 31/12/08 30/09/08 YA32 3 YA34 17 (2) Sch.4 (6)(f) 23 (4A) (b) 31/08/08 4 YA42 30/09/08 Spring Grove Road, 233 DS0000022907.V368579.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 Refer to Standard YA35 Good Practice Recommendations That the Manager provides a training matrix or spreadsheet to show the training staff have undertaken, the sates of the training and the date for the refresher training. That the files are streamlined and archived, where necessary, to improvement access and provide evidence of compliance with the National Minimum Standards and Care Home Regulations 2001. 2 YA41 Spring Grove Road, 233 DS0000022907.V368579.R01.S.doc Version 5.2 Page 27 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 Spring Grove Road, 233 DS0000022907.V368579.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. 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!