Care Home: Wheathill Road, 19

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What the care home does well The home enables and facilitates mental health residents to develop sufficient skills to move on to more independent accommodation in a supportive environment. The service provides residents with a supported home like environment in which they can develop sufficient skills for more independent living . The home has retained a fairly stable staff team which provides residents with consistency. Recruitment checks are conducted through the Head Office and ensures that staff are thoroughly checked prior to employment. Training is wellprovided for including mandatory topics as well as those relating to mental health issues. As the home is part of a group, good support networks are in place as well as on call advice. What has improved since the last inspection? Assessment information and pre admission procedures had improved and this provides residents with ample opportunities to sample the service prior to admission. The staff`s knowledge of adult protection and whistle blowing had improved which provides residents with greater safety. The new Manager has settled into her role having been in post for nine months. She has identified and acted upon some of the previous shortfalls in the service, for example the need for more active rehabilitation. She has acted upon this and this has had a positive effect in the home and for resident`s lives. The staff team appeared to be working more actively with residents and evidence of improved rehabilitation was noted. CARE HOME ADULTS 18-65 Wheathill Road, 19 19 Wheathill Road Penge London SE20 7XQ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 22nd July 2008 09:15 Wheathill Road, 19 DS0000006907.V368000.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 Wheathill Road, 19 DS0000006907.V368000.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. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wheathill Road, 19 Address 19 Wheathill Road Penge London SE20 7XQ 020 8659 7425 F/P 020 8659 7425 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) Community Options Limited Manager post vacant Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for service user category MD(E) for named service user only. 16th November 2007 Date of last inspection Brief Description of the Service: The home is a large house located in a residential area of Penge. The facility is part of the Community Options group, which operates the home, whilst Hyde Housing owns the building. This partnership is the basis for the operation of all Community Options facilities. The home is for five residents who have long-term mental health problems. All residents in this home are on Enhanced Care Programme Approach (CPA). The main purpose of the home is rehabilitation into the community, with residents developing the skills for more independent living. Residents are encouraged and supported to be independent in all activities of daily living. In addition integration into the local community and accessing local services including health provision, is promoted. The home has its own staff team with a Manager and Deputy Manager heading it up. Senior management and personnel are provided through the head office of Community Options. On call support and advice are also available through the company seven days a week 24 hours a day. The fees are £ 323.61 weekly. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection was conducted over a one-day period. The Manager facilitated the inspection. Periods of observation were undertaken in the communal areas. Prior to the inspection the Manager had completed the AQAA and forwarded this to the CSCI. This contained good information relating to the service. Four comment cards were provided during the inspection, including two for relatives who attend the home frequently. During the visit the inspector met with several residents and observed staff interaction and engagement with residents. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans, complaints records, as well as health and safety records. At a separate visit to Head Office, a sample of staff personnel files were inspected for evidence of recruitment procedures. Feedback was provided to the Manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: The home enables and facilitates mental health residents to develop sufficient skills to move on to more independent accommodation in a supportive environment. The service provides residents with a supported home like environment in which they can develop sufficient skills for more independent living . The home has retained a fairly stable staff team which provides residents with consistency. Recruitment checks are conducted through the Head Office and ensures that staff are thoroughly checked prior to employment. Training is well Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 6 provided for including mandatory topics as well as those relating to mental health issues. As the home is part of a group, good support networks are in place as well as on call advice. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using 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 pre-admissions procedures provide residents with a range of information, including visits to the service, to assist their decision making process, and enable them to establish whether the service is right for them. Staff are provided with comprehensive information on which they can base an initial care plan and address resident’s needs. EVIDENCE: At the time of the site visit the home had one vacancy. Two prospective residents were being assessed for their suitability for admission to Wheathill Road. All residents are under Care Programme Approach (CPA), which is a system of aftercare for resident living in the community. The system requires regular reviews and follow up by the multi disciplinary team and named personal to co-ordinate their care package. This is to ensure residents with presenting mental health problems are supported and have early interventions should a relapse occur. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 9 Since the last site visit there have been no new admissions and on previous inspections all residents’ files have been inspected. The admission process was discussed with the Manager who had implemented new procedures. The following information is not based on documentary evidence; it is that of the verbal information received from the Manager. All prospective residents would be assessed twice by two individual employees of Community Options one of whom would be the Home Manager. A written report would be produced as a result of this assessment. One of these reports was viewed and the content was to a good standard, outlining all of the activities of daily living in respect of the resident’s abilities and limitations. Once the assessment has been conducted and there is a possibility of admission, trial visiting including overnight stays are organised. These can vary in number and the time spent in the home as the resident requires. Consideration would be given to the current client group in respect of gender and dependency. The residents would be provided with the brochure Statement of Purpose and Service User Guide. Families and advocates are invited to visit, as they want. Records of trial visits would be retained. The admission would be planned for the weekday and weekends avoided due to the lack of support services available. All multidisciplinary information would be sought including the Care Programme Approach (CPA) assessment and care plan documentation. A trail period of three weeks is incorporated into the acceptance of placement. Residents are issues with a licence agreement and contract. Those seen were signed by the residents and a nominated person from Community Options. Wheathill Road, 19 DS0000006907.V368000.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): 6,7and 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The information in care plans enables the staff to plan and deliver the care. Although care plans are limited in the associated presentations and behaviour of the resident’s actual mental health condition, hence staff would not have the information to address those issues. Without comprehensive information inconsistencies in care and approach can occur, which may negatively impact on resident’s health. Risk assessments were in place to address all activities of daily living. EVIDENCE: The care plans are in the process of being further revised and developed. The care plans seen were well laid out and information easy to access. The care plan documentation had improved since the last inspection with more comprehensive interventions detailed, from which staff can deliver the care. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 11 The documentation of care and support are split in to two distinctive sections one headed “care plan”, which details those interventions, which are staff led, whilst the “support plan” is resident led. This is a confusing system although staff working with it seemed to understand it. The first care plan inspected detailed in the care section, issues around dietary needs, meal preparation, activities of daily living and financial support. The support plan included support around medications, finances, leisure and social. In both sections there was little on the actual presentation of the mental health problems. Mental health issues can present themselves in many different ways. Staff need to have the information on which to deliver consistent care to address mental health issues, and these must be fully recorded. Without details of the mental health conditions and how it presents itself for that resident, it would be difficult for staff to detect any change or possible signs of relapse. Included in the care plan package, was an overview of risks with individual supporting risk assessments. These were sufficient in content to address community living and the activities associated with that. The care package in the home works in conjunction with the CPA care plan and are updated in line with CPA reviews. The daily events records were well completed with a lot of detail on the resident. Please see requirement 1. Wheathill Road, 19 DS0000006907.V368000.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 and 16. People using 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. Residents are supported and enabled them to be involved with the local community by accessing services and leisure facilities. Visiting is open and residents are encouraged to promote social networks. Residents are supported with the preparation of meals of their choice where healthy eating is promoted. EVIDENCE: During the site visit the residents were engaged in a number of activities including those outside of the home. Most residents attend the local MIND, which provides support seven days a week. The centre offers a range of activities for residents including a Sunday lunch which residents seem to enjoy. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 13 One resident is attending college and has done a number of training courses that they enjoy. They are also due to attend a work placement organised through Horizon Housing. One resident was attending a gardening club. This resident is also getting involved with the home’s garden planting vegetables. It was evident that activities had improved. Residents were seen to engage with many everyday tasks, which on previous inspections had not been observed. Motivation of resident is a difficult area for mental heath residents; however staff must continue to promote activities of daily living, in order to enhance the resident’s ability to achieve their maximum potential. Each resident has storage and fridge space for their food purchases. Residents are supported to shop and cook for themselves. As part of the improvement in rehabilitation activities, a dinner party is planned where by each resident can bring a guest. Residents, with staff assistance will be preparing the meal. Each resident has a weekly activity planer designed around their rehabilitation needs and social activities. This identifies where and when they should be attending certain activities. The residents and staff were due to attend a planned walk and picnic to Greenwich Park the day after the inspection. Visiting is open and residents are encouraged to retain contact with friends and families. Residents are supported to go on overnight leave, which one resident does frequently. The residents have decided on a number of days out including a trip to Hornimans museum and a day trip to Brighton. No meals were observed during the site visit. The following information was included in the AQAA: “There is a good amount of literature in the project that supports good nutrition and healthy living. All service users are supported on a individual basis to shop and cook varied and enjoyable meals that may reflect their own culture or dietary preference and again that maximises their independence. Through an individual keyworking system that is based on the concept of recovery and that is person centered service users have the chance to explore appropriate acitivites that reflect their individualism. We encourage service users to build good networks of support that may involve their family, friends or others in the community this includes training, voluntering and working. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 14 Work with local agencies for service users to access support and training which enables them to partake in a transitional employment scheme and employment opportunites”. Residents participate in excersise groups. Social gatherings and forums are held through Community Options. There is a resident’s newsletter which is produced by a resident of a Community Option facility. Wheathill Road, 19 DS0000006907.V368000.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 using 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. Health care is provided through the local community which promotes rehabilitation and engagement with services. Medications are safely managed by staff that are trained and proficient to do so. EVIDENCE: The home employs a mix of male and female staff so that gender issues can be addressed. This is important in this home as one resident requires assistance with personal hygiene and others require prompting and support. All health care is addressed through the local community provision. Residents are supported to access these services to promote independence whist it serves to assist integration into the community. Within the care plans there is sheet for primary care interventions, which provided details on the date and a short summary of the visit. In the event that residents attend local services independently less information may be obtained or known about such visits, Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 16 hence there is a strong reliance on the residents to communicate effectively with staff. Information including records relating to CPA reviews and instructions arising out of these were available. The following information was obtained from a member of the multidisciplinary team : “I have experienced situations whereby clients where not brought for some of their out patient appointments (OPA), or CPA’s because either it was not written in the communication/diary or there wasnt enough staff on duty to bring them for reviews. However, this has improved over time. I believe clients needs are met. Staff are helpful and communicates if there are concerns re mental or physical state of clients in Wheathill Road. They follow up actions and instructions which need to be addressed as a result of reviews. The present Manager is also very proactive and have the interest of the clients at Wheathill Road at heart. Clients feel they receive good service”. The age range of the current resident population is between 52 years and 73 years of age. As the residents in this home are nearing old age they must ensure that they are fully able to continue to meet their needs. This is particularly true as the home has no lift facility. The medication storage, records and supplies were inspected. At the time of the site visit there were no persons requiring eye drops or controlled drugs. Residents are supported to become self medicating as part of their rehabilitation. One resident is at stage one of the self-administration process. At this stage the resident dispenses their medication from the package under supervision and takes it in the presence of the staff. Risk assessments are in place for each stage of the procedure to ensure that residents are capable and competent when they are at a level of fully self-medicating. Spot checks are carried out to ensure medication is being taken when residents are fully self-medicating. Those medications to be administered “ as required”, had full instructions on maximum dose, duration and reason for administration. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 17 Those medications received into the home were recorded, as were those, which were returned pharmacy. The pharmacist signs the records of returned medications. The medications were stored safely and no overstocking evident. The Manager had downloaded the latest advice on the CSCI web site regarding secondary dispensing. Information specific to the medications in use were in the file. Medication charts were completed with the allergies recorded and a photograph of the resident. All staff except the Manager had undergone recent training on administration of medications. Staff who administer medications are subject to annual proficiency tests. These are conducted by a Manager, who is part of Community Options although external to the actual home. Wheathill Road, 19 DS0000006907.V368000.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 and 23. People using 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. Complaints information is available for residents, staff and visitors to access. Complaints are taken seriously and responded to appropriately. Staff had a working knowledge and understanding of adult protection and whistle blowing, regular updating is required in these areas, to ensure that they are familiar with current guidance and contact points. EVIDENCE: Information on how to make a complaint is contained within the Service User Guide, Statement of Purpose and on display in the entrance hall. Within the complaints file, there was the complaints record including the complaint monitoring form. The last complaint recorded was dated as September 2006. This was discussed with the Manager, who had reviewed the records relating to complaints and was aware of the need to record all complaints regardless of how received, or how seemingly trivial they may be. The complaint information retained included an outline of the complaint, the action taken and the outcomes detailing whether these were satisfactory to the complainant or not. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 19 A new form had been developed by the Manager for the recording of “informal complaints “. When questioned on what this meant she related that this was more to do with comments made by resident not actual complaints. Staff must be clear, that any communication, which constitutes a complaint, even if it is not titled as such, is dealt with appropriately. There is a suggestion box located in the dining room for all residents, to have the opportunity to anonymously put forward any suggestions that they may have about the project or service. The following was extracted from the home’s AQAA: “We have clear Policies & Procedures in place which are reviewed regularly. Staff team are well informed and undertake appropriate training. Good communication to all parties to raise awareness and minimise risks etc. All clients are informed of the procedure from the point of when they move into the project. They are provided with a copy of both which is filed in their information folder which is kept in individuls room and there is also a copy on the client noticeboard.We also have it as a discussion point at many house meetings and agin through keyworker systems.” We spoke to the three staff that was present during the site visit. All were asked about dealing with actual or suspected abuse, they were all aware of the need to report such matters internally and possibly externally. The new contacts for reporting suspected abuse, needs to made clear to staff as they cited the pervious Adult Protection co coordinator for referral, in addition they stated that they could refer it to CSCI or the Care Managers. The same staff were asked about whistle blowing and again they had a good understanding of the term and appropriate action to be considered. Wheathill Road, 19 DS0000006907.V368000.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): 24 and 30. People using 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 maintained to a good standard, clean and hazard free. Residents have sufficient space in their bedrooms to personalise them to their own specifications. Comfortable communal areas provide space for socialising and relaxation. EVIDENCE: Communal areas were clean and tidy, residents were observed undertaking chores including hovering of the lounge areas. The kitchen is spacious and is provided with sufficient equipment so that residents can purchase and store all food items in individual allocated space, including individual areas in the fridge and freezer. The allocated smoking areas had improved with new flooring and redecoration. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 21 Bedroom one, which is currently vacant was inspected. It is in need of redecoration and cleaning to the carpet. One area, which was of concern, was a large hole in the wall with electrical cables coming out. It was unclear if this was to be further repaired. In any event this bedroom must be made safe prior to any new admission moving into it. Two other bedrooms were inspected and found to be personalised, clean and tidy. One bedroom was without a radiator guard. Risk assessments are conducted for those radiators, which are without protection. All residents are fully consulted and involved in the personalisation and decoration of their individual room to suit their individual needs and personality. The garden was tidy, and as residents are involved with gardening projects, there are plans to further develop the garden for this purpose. The external window frames are in need to repair and redecoration. This has been referred to the appropriate department and an inspection conducted in respect of the work to be done. Please see requirement 2. Wheathill Road, 19 DS0000006907.V368000.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 and 35. People using 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. Staff are subject to robust recruitment procedures which affords protection to residents. Staff are provided in sufficient numbers to met resident’s needs. Staff receive training on the mandatory topics as well as those which are related to the current resident population, this ensures that staff are competent and capable to care for residents. EVIDENCE: The home employ’s six staff including the Manager. There are two staff per shift and one sleeping in staff member during the night time period. There are currently no staff vacancies. The staff team has remained consistent for a number of years which provides stability and consistency for residents. In mental health facilities stability and consistency particularly of staff, are the foundations for residents well being. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 23 The home uses regular bank staff to cover vacancies. This was said to be at a minimum to cover staff annual leave. Each staff has a personal training plan which is developed to address areas where skills need updating. Training is also discussed in supervision. Five staff are NVQ trained. All staff have completed the mandatory updates the specified intervals. This is monitored closely by the Manager. In addition all staff have attended the Mental Capacity Act training. Other training staff stated that they had received included dual diagnosis, dealing with epilepsy and Aspergers. Training certificates confirmed these courses. Staff felt that they we well supported with training both within the company and with external training. Community Options have introduced the new “Staff Performance & Development” system to develop individual staff objectives with clear outcomes, which works in conjunction with the Company’s own objectives and the business plan. Those staff with whom we met confirmed that they received supervision from either the Manager or her Deputy. They were provided with a copy of the supervision notes and asked to sign as agreement to their content. Annual appraisals were also conducted with all staff . The staff personnel files were inspected 31 July at the Head Office. The personnel files were maintained to a good standard. The administrator retained evidence of identification checks including passports and confirmation of the employees address. Application forms, notes taken during the interview and results of tests relating to the job were all on file. Health clearance is undertaken by an external company. CRB and POVA first are conducted on all staff. Offer letters job descriptions and contracts all provided good evidence of robust recruitment procedures which provides safety to resident with whom they work. Wheathill Road, 19 DS0000006907.V368000.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 and 42. People using 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 home is managed by an experienced individual supported by her Deputy and senior personnel of Community Options. Health and safety measures provide residents with a safe home for them to live in. Quality assurance measures include the views of resident’s relative’s staff and other parties involved in the service. EVIDENCE: The Manager has been in post since November 2007. She is in the process of becoming registered under the CSCI procedures. The Manager has applied to do the RMA and has had the first introductory session. She hopes to complete Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 25 her NVQ 4 after this. The Manager stated that since she had commenced employment with Community Options she had received good support including mentorship from another senior manager within the company. She stated that they meet regularly for supervision where any issues can be discussed and this is an opportunity for problem solving In addition she felt that having a Deputy, who was well experienced in the home, had been very beneficial. The home has no lift or specialist equipment available or in use. Evidence of the annual portable electrical appliance testing and five year electrical testing were available. Water temperatures are checked weekly and the water treatment risk assessment had been conducted November 07. The fire equipment had been serviced March 08. The fire risk assessment was dated January 2008. Fire drills had been conducted three times since November 07. Staff and residents had attended these. Signatures need to be obtained as proof of attendance. Weekly fire alarm tests we recorded and emergency lighting checks undertaken. The home has a designated fire marshal. All staff have attended first aid training with most staff have done the one day course and one has completed the four day training. Health and safety audits are undertaken quarterly by two staff the records of the audit February 08 were viewed. They detailed the areas inspected and any areas, which required further attention or repair. The employer’s liability cover was current. The last report under Regulation 26 was February 08. The home is reminded that Regulation 26 visits must be undertaken monthly unannounced and a report on the findings left in the home. Residents meetings had been conducted April and May 2008 and minutes confirmed this. Staff meetings had been conducted April and June 08. Minutes are circulated to staff. Staff confirmed supervision and that they were offered a copy of the notes taken during the session. Community Options has an annual development plan for the organisation in general and a specific one for each home. Community Options had conducted their annual quality survey “ Service User Satisfaction Survey”, two months previous. The results of which will be collated Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 26 and circulated. The Manager had received verbal feedback indicating a positive response to most areas. Manager’s meetings are held for all Managers in the company. Resident’s monies are securely stored. These are checked at every shift changeover for accuracy, the home records income and expenditure where residents sign. The receipts are retained and those cross-checked with itemised expenditure confirmed they were accurate. Financial planning and budgeting is part of rehabilitation is included in every one’s care plan. Please see requirement 3. Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 27 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 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 3 x Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 Requirement The Manager must ensure that all care plans are fully reflective of the resident’s mental health needs and detail appropriate action to deal with them. Bedroom1 must be made safe and to a satisfactory standard prior to any new admission moving into it. Regulation 26 visits must be undertaken monthly unannounced and a report on the findings left in the home. Timescale for action 28/09/08 2 YA26 3 YA39 23 28/09/08 26 30/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 29 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 Wheathill Road, 19 DS0000006907.V368000.R01.S.doc Version 5.2 Page 30 - 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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