Care Home: Stanningley Road

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What the care home does well What has improved since the last inspection? People who live at the home now have a detailed contract showing what it costs for them to live at the home. Care plans now have more information in them on people`s likes, dislikes and interests. This means that staff can give more individualised support. Handwritten entries on the medication administration record sheets (MAR) are now signed by two people. This is safe practice and reduces the risk of errors being made. Staff have received mental health awareness training. This means they are better equipped to meet people`s needs. Soap dispensers have been fitted in hand washing areas to make sure of good hygiene with hand washing. Some areas of the home have been re-decorated. What the care home could do better: Staff must be made aware of their responsibility to report any suspicions or allegations of abuse properly. This will make sure that people are protected. Staffing levels should be kept under review to make sure people`s needs are being fully met, especially their leisure and recreational needs.Consideration should be given to the introduction of satisfaction questionnaires. These should be distributed to people who live at the home, their relatives or friends and any other professionals the home is involved with. This will make sure that people are asked for their views on any improvements that could be made to the service. CARE HOME ADULTS 18-65 Stanningley Road 59 Stanningley Road Armley Leeds West Yorkshire LS12 3NW Lead Inspector Dawn Navesey Key Unannounced Inspection 31st July 2008 09:30 Stanningley Road DS0000001508.V367350.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 Stanningley Road DS0000001508.V367350.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. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanningley Road Address 59 Stanningley Road Armley Leeds West Yorkshire LS12 3NW 0113 2311237 F/P 0113 2311237 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) TACT UK Ltd Mrs Lynn Christine Shenton Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Stanningley Road DS0000001508.V367350.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 category: Learning disability - Code LD The maximum number of service users who can be accommodated is: 7 19th December 2006 2. Date of last inspection Brief Description of the Service: Stanningley Road is a care home registered to provide care and accommodation for up to seven people who have a learning disability. Nursing care is not provided but the local healthcare team offers good support to the people living there and staff. The home is a large detached property located in a residential area close to the Armley area of Leeds. It is within walking distance of the local supermarkets, banks, shops, pubs, cafes and a post office. People use these facilities on a regular basis. The home has a car that is used for appointments, activities and college. Public transport links to the city centre are easily accessed. The house is set back from the road with boundary walls making the garden areas safe. Access to the home is from a quiet road behind the house. There are three floors with bedrooms being situated on all of them. The top floor has been converted into a flat for one person. The current charges at the home range from £914.22 to £816.81 per week. Additional charges are made for toiletries, magazines, newspapers, activities and transport. Stanningley Road DS0000001508.V367350.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. The Commission for Social Care Inspection (CSCI) inspects services at a frequency determined by how the service has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk This unannounced visit was carried out by one inspector who was at the home from 9:30am until 3:15pm on 31 July 2008. The purpose of the inspection was to make sure the home was providing a good standard of care for the people who use the service. Before the inspection, evidence about the home was reviewed. This included looking at any reported incidents, accidents or complaints. This information was used to plan the visit. The manager of the home completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information. We looked at a number of documents during the visit and visited areas of the home used by the people who live there. We spent a good proportion of time talking with the people at the home, staff and the manager. Comments made to us during the day appear in the body of the report. Survey forms were sent to people living at the home. Information from those returned is reflected in this report. Feedback at the end of the visit was given to the manager. What the service does well: People who live at the home said they were happy with the service. Comments included: • • I am always happy here, happy all the time. It’s a nice place to live. One person nodded and smiled when asked if they enjoyed living at the home. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 6 Staff also showed a good understanding of person centred care. They said it was important to respect people and treat them as individuals. We observed staff being very respectful in their interactions with people. People were very relaxed with staff and were pleased to see staff when they arrived. People were chatting, laughing and joking, and enjoying the company of staff. There was a good atmosphere. People said they liked the staff and that staff were kind. People who live at the home spoke highly of the quality of the food and choices available. Comments include: • • • It’s very good. I enjoy it. Good cooks. People’s health and personal care needs are well met. Staff had good knowledge of people’s personal support needs. Good records are kept of health appointments and their outcomes. Staff make sure that people are given support to attend appointments to meet their health needs. What has improved since the last inspection? What they could do better: Staff must be made aware of their responsibility to report any suspicions or allegations of abuse properly. This will make sure that people are protected. Staffing levels should be kept under review to make sure people’s needs are being fully met, especially their leisure and recreational needs. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 7 Consideration should be given to the introduction of satisfaction questionnaires. These should be distributed to people who live at the home, their relatives or friends and any other professionals the home is involved with. This will make sure that people are asked for their views on any improvements that could be made to the service. 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. Stanningley Road DS0000001508.V367350.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 Stanningley Road DS0000001508.V367350.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): 2 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home will meet their needs following assessment. EVIDENCE: People who live at the home said they were happy with the service. Comments included: • • I am always happy here, happy all the time. It’s a nice place to live. One person nodded and smiled when asked if they enjoyed living at the home. In the AQAA, the manager said, ‘All prospective residents have to fulfil the homes criteria for admission. The people who live in the home are consulted.’ and ‘New residents are also offered a test drive. This includes a visit to join the group for dinner, an overnight stay and a weekend stay. Before a decision is made the other people in the home are asked their opinion of the suitability of Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 10 the person. A full assessment of needs plus care plans and risk assessments are produced.’ Records we looked at showed that people had detailed assessments carried out by the manager of the home, before they moved in. These had also been reviewed as people’s needs changed. In the AQAA, the manager also said that in the next 12 months, ‘All individuals are to have comprehensive person centred planning assessment done by specifically trained TACT staff.’ This is to see if people are happy living at the service or if they would wish to move on. We also looked at contracts that had been drawn up between the home and the people living there. These have been produced in an easy read format and now show all costs to people. This includes contributions to petrol for the house vehicle. Stanningley Road DS0000001508.V367350.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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are encouraged to make decisions about their lives and are involved in planning their care and support. EVIDENCE: We looked at care plan and risk assessment records for some people who live at the home. Most of the plans seen gave some clear and detailed instruction on how the needs of people who use the service are to be met. They had good information about how people should be supported with personal care, and their health needs. There were some minor shortfalls with the care plans and risk assessments. Terms such as ‘monitor, ‘needs support’ and ‘needs assistance’ do not tell staff how much support a person needs and could lead Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 12 to needs being overlooked. However, staff were familiar with what was written in people’s care plans and could talk confidently about the support they give. Some risks had been identified for people but were not supported by a risk management plan. For example, a person who was identified as being at risk when cooking in the kitchen had no management plans for this. Staff were however, aware of the risks and how they were to be minimised. The manager said she would review this and make sure plans were put in place. Staff also showed a good understanding of person centred care. They said it was important to respect people and treat them as individuals. We observed staff being very respectful in their interactions with people. One person said, “It is good for people’s confidence to be more independent. We support them rather than do things for them”. Care plans and risk management plans have been reviewed regularly. Staff said they did this with people who live at the home. Some plans had been signed to say they had been discussed in this way. It would be good practice to make sure this happens more to show how people or their families have been involved in drawing up the plans. In the AQAA, the manager said they had made improvements to the service. One example given was, ‘Two individuals have become more independent and now go out shopping regularly independent of staff. This has been achieved by careful care planning and risk assessing.’ They are also planning for one person to start using a local shop independently. This person said they were looking forward to doing this. People said they had regular meetings in the home to discuss activities, the menus, staff issues and anything that was bothering them. We saw minutes of these meetings that showed people had been able to voice their opinions. It was clear that people could choose how to spend their time and make decisions about their lives. Stanningley Road DS0000001508.V367350.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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are able to make some choices about their lifestyle. Overall, social, educational, cultural and recreational activities meet most people’s expectations. They also benefit from a good, healthy and varied diet. EVIDENCE: People said they had enough to do at the home. In the AQAA, the manager said, ‘Individual lifestyles are planned with the person and documented in their individual plans. Opportunities to be involved in all the daily running of the home are offered to people to enhance their life skills and confidence.’ Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 14 Activity on offer to people includes, attending a local church, walks in the park, shopping, day trips out, watching TV, listening to music, sitting in the garden, karaoke, board games, baking and going to local cafes. People’s different needs are met. Staff said they try to offer activity based on people’s likes, dislikes, interests and background. Several holidays have been arranged this year. They include camping in Scotland, Austria, Blackpool and Brighton. People who live at the home are known in the local community and have made friends with people. One person told us they enjoy their church service “very much”. Another told us they were a ‘regular’ at the café. People are also given the chance to enjoy their own company if this is what they prefer. One person said, “I find it easier to watch television on my own”. They also said they enjoyed going to the pub for “A pint”. People are given good support to keep in touch with family and friends. One person is supported to write letters. Another is taken regularly to their family home. One person is supported to take holidays with a staff member at their family’s home. This is a good way for them to keep in touch. Staff said that they try to make sure that everyone gets out at least once per day. They said that recent staffing levels have affected their ability to do this though. There has been staff sickness and vacancies at the home. The manager said they try to cover these shifts but are not always successful. Menus are developed in the home from meetings with people who use the service. There is a good choice and plenty of variety. People who live at the home spoke highly of the quality of the food and choices available. Comments include: • • • It’s very good. I enjoy it. Good cooks. Staff said they would always provide an alternative if people didn’t like what was on the menu. In the AQAA, the manager said, ‘All staff members have had training in Nutrition and health.’ Staff talked confidently about how they support people with healthy eating while making sure people get what they like. Stanningley Road DS0000001508.V367350.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 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s general healthcare needs are well met and based upon their individual needs. EVIDENCE: Staff had good knowledge of people’s personal support needs. Staff were thoughtful, polite and respectful of people’s dignity when attending to any personal care needs. People looked well dressed and groomed and said they had the support they needed. Staff gave good examples of how they encourage people to be independent but still make sure people’s dignity is maintained. People who use the service said they like to be “smart”. Good records are kept of health appointments and their outcomes. Staff make sure that people are given support to attend appointments to meet their health needs. Where people’s needs have changed due to health issues, care plans have been updated. The manager has developed an assessment and plan Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 16 regarding people’s health to make sure their needs are being fully met and nothing is missed. This is reviewed every year for everyone. People are referred to health professionals when needed. There were good records of how and when this had been done for people. People are encouraged to use community facilities in the local area. For example, the optician. Staff work well with other health professionals in order to give a consistent service. A community nurse has worked with the team to develop medication management plans for someone who needs ‘as and when required’ medication. Guidelines for anxiety management have also been developed with a health professional. Staff have received training on meeting the specific health needs of people who live at the home. Courses have included, mental health awareness training, epilepsy and meeting nutritional needs. Staff were very positive about this training. One said, “It has been very beneficial, really good training”. In the AQAA, the manager said, ‘Where possible people are given the responsibility to administer their own medication. All staff have received up to date training in medication.’ We looked at the medication systems and records. The home uses a monitored dosage pre-packed system for medication. There are good ordering and checking systems in place. We checked some medication administration records (MAR) sheets. These were found to be in good order. Staff said they did not administer medication unless they had been trained to do so. The manager of the home has also been trained to deliver safe handling of medicines training to the staff. Stanningley Road DS0000001508.V367350.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 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall people are protected. People are confident that they will be listened to and that action will be taken when necessary. EVIDENCE: The home has an easy read complaints procedure. This is kept on display in the home. Making complaints and raising concerns is also discussed at house meetings to keep it fresh in people’s minds. We asked people what they would do if they were not happy about something. One person said, “Talk to staff, tell them what’s up”. They then went on to give an example of the sort of thing they might bring up. This showed they had a good understanding of raising concerns. We looked at home’s complaints book. complaints made. There have not been any recent Most staff have received training in safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. Some staff were fully aware of their responsibilities to report concerns or suspicions of abuse. However some staff said they would confront the person who they suspected was carrying out abuse before they would report it. This is not safe practice and could lead to people being put at risk. The Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 18 manager said staff were not trained to do this and their safeguarding policy clearly states staff must report any suspicions or allegations. She said she would re-inforce the whistle-blowing and safeguarding policy and procedure to all staff. There have been a number of safeguarding incidents at the home since our last inspection. These have been managed properly. Strategy meetings have been held and protection plans have been put in place for people. Staff said they had been given good support in managing and working around these issues. Support has also been gained from outside agencies such as care managers, the police and health professionals. People are given good support to manage their own money. There are good systems in place to make sure money is kept safe. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 19 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 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The environment is homely, comfortable and safe for people who live at the home. EVIDENCE: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was clean, tidy and homely. People who live at the home were proud of their bedrooms and were pleased to show us round. Bedrooms were very personal, and consideration had been given to the décor and furnishings to make sure it reflects the preferences and personalities of the people who live there. Each room had photographs, pictures and personal items. People said staff give them support to keep their rooms clean and tidy. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 20 The furnishings, carpets, and furniture were good quality and the home was decorated to a good standard. The manager has recently requested a new kitchen to be fitted. She said this has been approved and will be done this year. The kitchen was clean and proper procedures were, in the main, being followed to promote safe food hygiene practices. The manager was advised that open food items stored in the fridge should be labelled with the date of opening to make sure they are being kept and stored as the manufacturers instructions state. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who live at the home. Staff have received training in infection control as part of their induction and were able to say what infection control measures are in place. Hand washing and hand drying facilities were available in all areas of the home. Liquid soap or paper towels were available. This ensures good hygiene practice. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 21 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 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is, in the main, enough staff. They are trained and competent to meet the needs of the people who use the service. People are protected by the home’s recruitment procedures. EVIDENCE: We saw good interaction between people who live at the home and staff. People were very relaxed with staff and were pleased to see staff when they arrived. People were chatting, laughing and joking, and enjoying the company of staff. There was a good atmosphere. People said they liked the staff and that staff were kind. The home generally has a low turnover of staff and many staff have worked at the home for a number of years. Staff had good knowledge of the people who live at the home and were able to provide information about individual likes and dislikes. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 22 There are usually three staff on duty on the morning shift and four staff on the afternoon shift. Staff said they have recently been short staffed due to sickness and vacancies. The rota showed that sometimes staff numbers went down to only two staff on certain shifts. Staff said they could still meet people’s needs with these staffing numbers but it meant that activities were cancelled. Some people who live at the home need 1-1 staff attention at times or there are times when two staff must be in the home to make health and safety needs are met. Staffing levels should be kept under review to make sure people’s needs are being fully met. We looked at the recruitment process for three people working at the home. The files had all the relevant information to confirm these recruitment processes were properly managed. This included application forms, interview notes, references and CRB (criminal records bureau) checks. In the AQAA, the manager said, ‘When recruiting new staff we take into consideration the needs of the residents. Specific interests and skills are matched to the resident’s interests. Staff are recruited who demonstrate a good degree of knowledge or common sense that is relevant to do their job.’ In the AQAA, the manager also said, ‘All new staff members have to complete in-house induction, Tact induction and Skills for Care qualification plus all statutory training and tact values training.’ Records showed that staff’s training was up to date. The manager has good records on staff’s training and can easily see when updates are due. Staff spoke highly of the training they receive from the organisation. The majority of staff have completed an NVQ (National Vocational Qualification) in level 2 or above. Other staff are also working towards this. Some staff are also trained to be facilitators of person centred planning. This has given them the skills to work with people to identify their future hopes, dreams and aspirations. Staff meetings are held every month and additional meetings are held to talk about care issues. Staff also said they received regular supervision and had opportunities for personal development. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 23 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, 38, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed. The interests of people who use the service are seen as important to the manager and staff and are safeguarded and respected. EVIDENCE: In the AQAA, the manager said she thought the service does well by saying, ‘We encourage and value all residents’ contributions towards the running of the home. All staff are constantly reminded that they are guests in the home. We have a clear commitment to give equal opportunities to everyone. We carefully listen to all the people we support and respond effectively.’ Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 24 The home has an experienced manager who has successfully completed the registered managers award. She works alongside staff to make sure of good practice. All staff said she was supportive and a good leader. Staff said, “She always listens and tries to solve problems” and “She is a great manager, she works well with us”. The manager said she has good support within the organisation and that her training needs are well met. The organisation’s area manager, visits on a on a monthly basis to carry out monitoring visits. This involves talking to people who live at the home and to staff. A report of these visits is made showing details of any action to be taken to improve the service. The manager was not aware of any quality assurance feedback questionnaires being sent out by the organisation. It is recommended that consideration is given to the introduction of these to people who live at the home, their relatives or friends and any other professionals the home is involved with, asking for their views on any improvements that could be made. Arrangements are in place to make sure of safe working practices. The home has a comprehensive range of health and safety policies and procedures in place. Staff are given opportunity to read and become familiar with these during their induction. Health and safety checks are carried out around the home and fire records are maintained. In the AQAA, the manager confirmed that all health and safety checks are up to date. Accident or incident reports are completed. The manager analyses these to identify any patterns or trends and to look at ways of avoiding future accidents. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 3 2 X X 3 X Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 Requirement Staff must be made aware of their responsibility to report any suspicions or allegations of abuse properly. This will make sure that people are protected. Timescale for action 30/09/08 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 YA33 YA39 Good Practice Recommendations Staffing levels should be kept under review to make sure people’s needs are being fully met. Consideration should be given to the introduction of satisfaction questionnaires. These should be distributed to people who live at the home, their relatives or friends and any other professionals the home is involved with. This will make sure that people are asked for their views on any improvements that could be made to the service. Stanningley Road DS0000001508.V367350.R01.S.doc Version 5.2 Page 27 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 Stanningley Road DS0000001508.V367350.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. 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