Care Home: St Alban`s Cottage

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What the care home does well People have an active lifestyle and get lots of opportunities to go out. Recreational activities include manicures, foot massage, barbeques, going out to the park and for walks, meals out, trips to shopping centres and day trips. Everyone works hard to make sure people are offered choice and given opportunities to make decisions. People who live at the home completed surveys with the help of staff. Surveys were positive about the care they receive. The manager works closely with staff to make sure people`s needs are met in they way they want. What has improved since the last inspection? Each person now has a statement of terms and conditions, with a record of the current range of fees. To make sure people have access to information about their placement. People now have an up-to-date care/service plan that identifies their social, personal and healthcare needs. To make sure their needs are being met. All identified risk has been assessed and a system is in place for them to be reviewed and a plan of care is in place to show how risk will be managed, to make sure people are safe. The transport arrangements have been reviewed to make sure charges to people are recorded, equitable and value for money. There is ongoing discussion with people and their relatives and advocates about the viability of the bus. Each person now has a health care plan that is appropriate for their individual need, to make their healthcare needs are properly met. All staff have safe handling of medication training as part of their induction training and safe handling of medication is regularly discussed at team meetings, to make sure people receive the right amount of medication. A complaints record log is now in place to record the number and nature of complaints so that this can be properly monitored. Most staff have had training on safeguarding adults to make sure they understand the policies and procedures on adult protection. Most of the maintenance issues raised at the last inspection have been addressed. There is now a training plan in place to make sure that staff complete training that will equip them with the knowledge and skills in safe working practice. The acting manager has made application to be registered and has started the registered managers award. To make sure the home has a person who is responsible for the day to day running and is accountable to the Commission. The home is now notifying us of any event that affects the health or well being of any person living at the home. There is now a system in place where staff are responsible for withdrawing money from bank accounts, more than one staff member can sign to withdraw cash to make sure people can access money when it is required. CARE HOME ADULTS 18-65 St Alban`s Cottage 2a St Alban`s Close Harehills Leeds West Yorkshire LS9 6LE Lead Inspector Valerie Francis Key Unannounced Inspection 7 & 15th August 2008 10:00 th St Alban`s Cottage DS0000001496.V370653.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 St Alban`s Cottage DS0000001496.V370653.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. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Alban`s Cottage Address 2a St Alban`s Close Harehills Leeds West Yorkshire LS9 6LE 0113 240 1837 0113 2401837 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.unitedresponse.org.uk United Response Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2007 Brief Description of the Service: St. Albans Cottage is a four-bedroom bungalow, purpose built to accommodate people with multiple disabilities, who do not require nursing care. The bungalow is situated in a quiet residential area just off the York Road in East Leeds, with nothing to distinguish it from the outside as a care home. The area is a short distance from local shopping centres, sports and leisure facilities, with good access via public transport from Leeds. The home accommodates four young adults with learning disabilities and some physical disabilities, all of whom are wheelchair users. The property is managed by a housing association but, United Response, a national charity specialising in the field of learning disabilities, provides the care service. The fee charged by the home ranges between £1377.48 and £2067.25 per week. This information was provided on 07 August 2008, during the inspection. St Alban`s Cottage DS0000001496.V370653.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. One inspector carried out this inspection visit over 2 days from 10am - 4.45 pm and 12:md to 2: 0 pm. During the inspection all of the key standards were looked at to find out if the home gave people a good standard of care. An annual quality assurance assessment (AQAA) was completed by the home and this information was used as part of the inspection. Surveys were sent to staff and their responses have been included in this report. Four surveys were received from people who live at the home. Feedback was given to the manager on the second day. During the visit we looked around the home, spoke to people who live at the home, staff and the manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. There is a new Manager in post, who has applied for registration, and there is close line management supervision from the area office in York . What the service does well: People have an active lifestyle and get lots of opportunities to go out. Recreational activities include manicures, foot massage, barbeques, going out to the park and for walks, meals out, trips to shopping centres and day trips. Everyone works hard to make sure people are offered choice and given opportunities to make decisions. People who live at the home completed surveys with the help of staff. Surveys were positive about the care they receive. The manager works closely with staff to make sure people’s needs are met in they way they want. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? Each person now has a statement of terms and conditions, with a record of the current range of fees. To make sure people have access to information about their placement. People now have an up-to-date care/service plan that identifies their social, personal and healthcare needs. To make sure their needs are being met. All identified risk has been assessed and a system is in place for them to be reviewed and a plan of care is in place to show how risk will be managed, to make sure people are safe. The transport arrangements have been reviewed to make sure charges to people are recorded, equitable and value for money. There is ongoing discussion with people and their relatives and advocates about the viability of the bus. Each person now has a health care plan that is appropriate for their individual need, to make their healthcare needs are properly met. All staff have safe handling of medication training as part of their induction training and safe handling of medication is regularly discussed at team meetings, to make sure people receive the right amount of medication. A complaints record log is now in place to record the number and nature of complaints so that this can be properly monitored. Most staff have had training on safeguarding adults to make sure they understand the policies and procedures on adult protection. Most of the maintenance issues raised at the last inspection have been addressed. There is now a training plan in place to make sure that staff complete training that will equip them with the knowledge and skills in safe working practice. The acting manager has made application to be registered and has started the registered managers award. To make sure the home has a person who is responsible for the day to day running and is accountable to the Commission. The home is now notifying us of any event that affects the health or well being of any person living at the home. There is now a system in place where staff are responsible for withdrawing money from bank accounts, more than one staff member can sign to withdraw cash to make sure people can access money when it is required. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 7 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. St Alban`s Cottage DS0000001496.V370653.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 St Alban`s Cottage DS0000001496.V370653.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 & 5. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home provides people and their carers with comprehensive information for them to be able make a choice if the home can meet their needs. A thorough admission process is carried out to make sure the home can meet the needs of people who move into the service. EVIDENCE: Since the last inspection the home has reviewed the statement of purpose and service user guide, giving people good information about what and how the service is provided. However, because of staff changes some of the staff information needs updating. The home’s written information is not in format such as Makaton signs or symbols, which is a format that would enable people to understand what is written. All four surveys that were completed showed that people had received enough information about the home before they moved in. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 10 People now have a contract of tenancy and care. However, because most people have complex needs and could not sign their contract these were either signed by staff or just left blank. People’s relatives or advocates should sign these contracts on people’s behalf. We were told in the AQAA that people moving into the home are assessed before admission. There have been no new admission since the last inspection. We were told that people’s needs are also being re-assessed as the organisation has developed the new documentation for person centred care. This means that each person is involved in making decisions about how their care and support is given in a way that they prefer. We found evidence of this in the three people’s care files we looked at. St Alban`s Cottage DS0000001496.V370653.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 & 9 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Individual needs are met by the implementation of clear and detailed support plans and risk assessments, which have involved people’s relatives. People have a say in the day to day running of the home and are encouraged and supported to make choices. EVIDENCE: Progress has been made with the standard of people’s care plans and risk assessments. Those seen gave clear, detailed action on how people’s needs are met. Much of the information is person centred. It gives some good information on likes and dislikes and preferences with care and support. More information is now included on people’s social and recreational needs. The plans are reviewed regularly and any changes made are well documented. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 12 Any risks identified for people are properly assessed with an action plan put in place to manage the risk. These are also evaluated and reviewed regularly to meet people’s changing needs. Staff said that they are using the detailed assessment information to put together people’s care plan, so that people get the care and support identified. We saw information about how people wanted to be cared for and about any special equipment used, as well as advice from the physiotherapist on how to position people when they are in bed. The manager said staff have had training on person centred care and support planning. Staff told us and we saw that people are supported to plan their activities on a daily basis. Weekly activities are diarised in advance. Staff spoke about the training they had received and said they felt the whole team was working together to develop people’s plans and involving relatives and advocates. We saw that staff had good knowledge about the people they cared for. They were able to describe the care they give and talk in detail about how people like to be supported during their daily routines. They showed a good awareness of the support plans and risk assessments. People were offered choices throughout the day, for example, what to do, where to go, what to eat, or if they wanted the radio or the television on, whether to spend time in the lounge or in their own room. Staff respected people’s choices and responded well to what they wanted. Due to the complex needs of people living in the home it is difficult to hold meetings with them. We were told that that during one to one with people they are asked if they are happy with things such as food and activities. People who can verbally communicate were given time for them to communicate their wishes. People who do not use verbal communication are observed from their body language and facial expressions in response to questions. St Alban`s Cottage DS0000001496.V370653.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, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People who use the service are supported to make choices about their lifestyle and to develop their life skills. Appropriate activities are arranged and a good, healthy and varied diet is offered. EVIDENCE: People are involved in various activities each week. This includes day centres, shopping, trips, and visits to the pub and for meals, visiting friends and family. Staff organise in house activities for people, like getting involve with meal preparation. Each person’s response to the activity is documented in their daily log. We were told in the AQAA that what the home does well is: • Accessing local community, matching interests with opportunities. • Support people to maintain relationships with family and friends outside St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 14 • • • • of St Albans. People are involved in menu planning, 2 weekly supermarket shopping with fruit and vegetables being bought locally on a more regular basis to support local businesses and increase community participation. People are involved in planning, choosing and preparing meals. The home involves Speech and Language and Dietetic services to provide advice and support. The keyworker system ensures that people work with a member of staff to co-ordinate and move forward their life plans and goals. People are supported to go on hoildays and to visit relatives. People are also given the opportunity to spend time on their own in their room. Four surveys from people who live at the home said usually they are involved in making decisions about what they do each day. We saw records displayed in the kitchen of people’s likes and dislikes and copies of menu plan. Menus appear to be well balanced and nutritious. 3 monthly. However, some had not been done for some time since We were told that meals are discussed with people on a daily basis, so that people get the food they want to eat, A record of the food eaten is is kept on people’s individual daily log. Meals are offered at times and places to suit individuals. We saw in one person’s care file a record of all food served to him. The manager said this was done when there was a concern about that person dietery needs. Some people had a record in their support plan to have their weight done and of food for lunch on offer. People are offered snacks and drinks throughout recorded 2007. The manager said this was an issue as they depend on people being weighed at day centres because the home does not have any weighing scales. This needs to be reviewed as the home should have equipment to weigh people so that any change in weight can be quickly identified and the appropriate action taken. It was clear that staff make sure there is a variety the day. One person was enjoying a cup of tea he requested from staff. Staff who are very good at cooking are able to give people a much more imaginative meal, it would appear that people enjoyed it. On the day of the St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 15 inspection people were going to have curry for tea, which was made by one of the staff on duty. St Alban`s Cottage DS0000001496.V370653.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): People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Personal and health care support is provided in a way that meets people’s needs. There is a good system in place for safe management of medication. EVIDENCE: Staff support people with their personal care needs in private and with dignity. Written information in People’s support plans showed that they are also able to chose the gender of staff delivering their personal care. Any specialist equipment needed is provided to enable people and support staff in moving and handling. GPs and other health care professionals make visits and a record is kept on each person’s file. There is detailed information in support plans on how personal care and health related tasks are to be carried out to makes sure that people’s needs are fully met and at a time that suits them. Staff have good knowledge of their likes, dislikes and preferences. We were told that any specialist training needs that arise would be addressed through the organisation’s training department. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 17 Medication reviews take place regularly with GPs. All people are registered with a dentist and chiropody input has been sourced locally. A good relationship has been developed with the district nursing team and the occuptaional therapist and physiotherapist to ensure a multi disciplinary approach to health is taken. Medication ordering has been reviewed, a new procedure has been devised and shared with all team members and the medication ordering cycle has been diarised. We found that staff were clear of the procedures to follow when adminstering and ordering medication. Staff told us that they had received training on safe handling of medication as part of their induction training. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect people from abuse. EVIDENCE: The home has a complaints procedure displayed in the entrance hall of the home. This is also in the Statement of Purpose and Service User Guide. It is an easy read complaints procedure, making it more accessible. Since the last inspection one person has been supported to make a complaint about the care they were receiving. We saw a log of the outcome showing how the complaint was followed up. We were told that people’s keyworker took time to explain the complaint procedure to them. All four people indicated in their survey that they knew who to speak to if they were unhappy and all but one said they knew how to make a complain. We were told in the AQAA that what the service does well is: • Clear procedures. • Training provided to all staff, abuse awareness as part of induction • Clear audit trail to support finance policies and procedures and people are involved in handling their own money when going shopping. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 19 Good records are kept of people’s finances and their monies are kept safe. Handovers of the monies takes place at each shift change and the manager regularly checks the finance records and receipts. Most staff have had adult protection training to make sure they know what to do if abuse is suspected or reported. They also have access to the organisation’s adult protection procedures. We spoke with staff and they all knew about the procedures and what action to take. However, one staff spoken to was not clear of the whistle blowing procedure and what to do. People are protected by the use of body maps to document any bruises, scratches or marks they may have and are not able to say how they happened. This is good practice to monitor for any signs of possible abuse. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home offers a homely, and safe environment for people and it provides appropriate specialist equipment to enable people. EVIDENCE: We were told in the AQAA that people were involved in the replacement of living room furniture and personalising their bedrooms, people had chosen all their furniture. Quarterly meetings are held with the housing association to make sure maintenance is kept up to date. We saw that the communal areas were showing signs of wear and tear and needed redecorating, despite this, there was a very homely feel. We saw some areas that require attention. The bathroom floor covering is badly stained, there is no blind at the bathroom windows to ensure privacy and there was no soap provided in any of the bathrooms. One of the radiator guards is very rusty and this was identified at the last inspection. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 21 The electrical extractor fans through out the building need cleaning. People’s bedrooms are well maintained and show their individual interests and personality. Ceiling tracking is in place in the bathroom and two people’s bedrooms. Clinical waste is properly managed and staff wear protective clothing when attending to people’s personal care needs. Staff have received training in infection control and were able to say what infection control measures are in place. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff are competent and well supervised to meet people’s needs. People are protected by the home’s recruitment procedures. EVIDENCE: There are usually three staff on the morning shift and three staff on the afternoon shift. At night there is one waking and one sleep in member of staff in the home. The manager is part of the emergency on call arrangement for all homes and services in the area. Staff said they felt there is enough staff and they never feel rushed. The manager said the combination of full time and part time workers provides flexibility for staffing levels. Recruitment is properly managed. Interviews are held, references and CRB (Criminal Record Bureau) and POVA (Protection of Vulnerable Adult) first St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 23 checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Three staff files seen showed that all the appropriate checks had been carried out before staff started work with people. We were told that people living in the home are involved in the recruitment of staff. All applicants are invited to the home to spend some time with people living in the home, to observe their interaction with people. We were told in the AQAA that the home provides: • Good staffing levels, best use of resources through rota management. Supervisions is divided between the service manager and two senior support workers to ensure they happen in line with CSCI requirements and United Response standards. • NVQ training and a comprehensive induction training and refresher training for staff. One staff member has taken on the responsibility for co-ordinating training needs and liaising with United Response area office. • Common Induction Standards integrated into induction. There is an annual training plan for staff training, which include ongoing updates for such as moving and handling. Staff training is mostly up to date. Records are kept of staff training and when their updates are due. The manager assesses this every month to make sure training doesn’t get missed. Staff said the manager supports them and their training needs are discussed at their supervision and Annual Appraisal. Some staff still need adult protection training. Not all staff have an NVQ (National Vocational Qualification) in care at level 2 or above. Plans are in place for some of the staff team to undertake an NVQ. . All staff said they felt they had a good team and the manager was very supportive. Staff said they felt communication and teamwork within the home were great. The home has its own relief staff and permanent staff are willing to work additional hours. There is regular monthly staff supervision and annual appraisals. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is well managed. This means that the interests of people are seen as important to the manager and staff and are safeguarded at all times EVIDENCE: The home has a new manager who has started the RMA (Registered Manager Award). She offers good leadership to the staff and has good systems in place to make sure people are supported and cared for properly. She is currently waiting for a date for an interview with us to become the registered manager. The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to people and staff about the home. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 25 A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation carries out an annual service review, as part of its quality assurance programme. This also includes service users, relatives and staff. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Maintenance records are well kept. Environmental risk assessments are completed and reviewed. Health and safety training is well maintained. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. The manager now has a system in place where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. The home has a comprehensive range of policies and procedures in place to ensure health and safety. The manager makes sure staff are familiar with these. St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 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 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 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 3 3 X St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 St Alban`s Cottage DS0000001496.V370653.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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