Care Home: Wings

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What the care home does well Prospective people who use this service can expect to have their needs assessed before they move in and will ensure the service can meet their needs. People were provided with a contract and agreements were established. The home enables residents to maintain an appropriate lifestyle with individual opportunities and support. All the feedback from residents and the expert by experience were positive about this. The expert by experience reported: `Residents use public transport with support and the two company cars. All residents have DVD players, TV`s and music systems in their rooms. Residents have had friends over for drinks and visits after prior arrangement with staff. Residents all get free time to themselves.`Residents were aware of how to complain and felt that they were listened to. The expert by experience went on to say `Residents have regular meeting to discuss any issues or grumbles they may have but these are not at any planned intervals`. Wings was a clean and comfortable home, very spacious with large enclosed grounds. The lounge, kitchen and laundry were nicely decorated and well equipped. What has improved since the last inspection? There had been progress made since the last visit to the home. All but 1 of the previous 9 requirements and 5 out of the 7 recommendations have been actioned. There had been a change in the resident group and as a result the residents said the atmosphere was more positive. Access to all parts of the home, such as the laundry and kitchen were freely available to use at all times. A new rise and fall bed had been obtained for one resident based upon an occupational therapy assessment. This will ensure that the needs of the individual are met and they are no longer at risk from previous equipment. Policy documents were freely available to staff and the complaints documentation had been revised to direct people to the correct area of our organisation. The quality assurance systems at the home now take account of the views of people who use the service and documentation was seen to support this. What the care home could do better: There are 2 areas that the home needs to develop. The first is that residents are placed at risk because staff are not adequately trained to meet their needs. Secondly, the premises must be suitable for all who use the home. The Statement of Purpose says the home is suitable for people who use wheelchairs and one person currently uses a wheelchair, but there are rooms within the home that are not accessible to them. The expert by experience wrote: `a path needs to be laid across the lawn to the fire meeting point to make it accessible for the one wheelchair user`. The home needs to be accessible for people in wheelchairs. And a way forward is to have this assessed by an occupational therapist. CARE HOME ADULTS 18-65 Wings 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP Lead Inspector Claire Hutton Unannounced Inspection 23rd January 2008 10:45 Wings DS0000063585.V359570.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 Wings DS0000063585.V359570.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. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wings Address 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP 01638 583934 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) manager.wings@traccare.co.uk Compass Care Limited Vacant Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within the category of MD, Mental Disorder excluding Learning Disability or Dementia, may be admitted into the home unless that person also falls within the category LD, Learning Disability is Dual Disability. 1st February 2007 Date of last inspection Brief Description of the Service: Wings is registered as a Care Home for 6 younger people with learning disability and mental health needs, and offers placements to individuals with challenging behaviour. The home is situated on a private road in Beck Row, near to Mildenhall air base. The location is semi-rural and the home’s two vehicles enable residents to access local facilities. Parking is available at the front of the building. The bungalow offers six individual bedrooms, a living room and a dining room. The Managers office is situated at the front of the home. The fenced garden is mainly grass, but has a patio area and vegetable/flower patch maintained by people living in the home. Wings is owned and run by Compass Care. Compass Care is owned by Tracs Ltd. The home has a statement of purpose providing information about the facilities and services provided. The service user guide is in the process of being updated to provide additional information to prospective residents, including the most recent inspection report by the Commission for Social Care Inspection (CSCI). The basic fee is £1800.00 per week. Wings DS0000063585.V359570.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 the service experience good quality outcomes. This was an unannounced key inspection that focused upon the core standards relating to Adults (18 – 65). It took place on a weekday lasting seven hours. The inspection team had additional members. This was an expert by experience and his supporter. David Rushbrook (Expert by Experience) and his supporter came from ‘Barking and Dagenham centre for Independent Living Consortium’. As a service user David Rushbrook has an expert opinion on what it is like to receive services for people who have a learning disability. His comments are included throughout this report where he is referred to as an ‘Expert by Experience’. The inspection process included visiting all areas of the home, discussions with staff and residents, observations of staff and resident interaction, and the examination of a number of documents including residents’ care plans and associated documents, medication records, the staff rota, records relating to health and safety and records relating to staff recruitment. The report has been written using accumulated evidence gathered before and during the inspection. The Commission had received an Annual Quality Assurance Assessment (AQAA) completed by the manager before the inspection. This completed document is a self-assessment. Two completed surveys were received back from the three residents currently at the home. Two staff were interviewed in private during the visit to Wings. A new manager has been appointed to Wings and we await an application to register this person. What the service does well: Prospective people who use this service can expect to have their needs assessed before they move in and will ensure the service can meet their needs. People were provided with a contract and agreements were established. The home enables residents to maintain an appropriate lifestyle with individual opportunities and support. All the feedback from residents and the expert by experience were positive about this. The expert by experience reported: ‘Residents use public transport with support and the two company cars. All residents have DVD players, TV’s and music systems in their rooms. Residents have had friends over for drinks and visits after prior arrangement with staff. Residents all get free time to themselves.’ Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 6 Residents were aware of how to complain and felt that they were listened to. The expert by experience went on to say ‘Residents have regular meeting to discuss any issues or grumbles they may have but these are not at any planned intervals’. Wings was a clean and comfortable home, very spacious with large enclosed grounds. The lounge, kitchen and laundry were nicely decorated and well equipped. What has improved since the last inspection? What they could do better: There are 2 areas that the home needs to develop. The first is that residents are placed at risk because staff are not adequately trained to meet their needs. Secondly, the premises must be suitable for all who use the home. The Statement of Purpose says the home is suitable for people who use wheelchairs and one person currently uses a wheelchair, but there are rooms within the home that are not accessible to them. The expert by experience wrote: ‘a path needs to be laid across the lawn to the fire meeting point to make it accessible for the one wheelchair user’. The home needs to be accessible for people in wheelchairs. And a way forward is to have this assessed by an occupational therapist. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 7 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. Wings DS0000063585.V359570.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 Wings DS0000063585.V359570.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, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people were assessed, which ensured the service could meet their needs. People were provided with a contract and therefore agreements were established. EVIDENCE: The home had a Statement of Purpose and a Service Users Guide. The manager had these documents out and was in the process of updating these when we visited. The plan was to update both but to make the Service Users Guide more accessible by using a picture form of communication with words to make it easier for people with a disability to understand. The Statement of Purpose sets out the admission criteria for the home. A new resident was in the process of being assessed. An assessment was said to have been completed and was to be made available to the new manager. The existing residents had been consulted and knew of the prospective resident and had met them on a resent visit. The manager was keen to ensure that the prospective resident was compatible with the current residents and that the home and could meet the needs. Existing contacts were seen to be in place and were signed. These contracts also set out a trial period of 13 weeks to ensure the placement is the right choice for all concerned. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 10 The self-assessment states ‘Service User Guide & Statement of Purpose contain all details required. Assessment process is extremely detailed and assesses all needs. It includes all relevant parties in liaison with the client. A care plan is developed prior to admission from this assessment and then reviewed and updated regularly’. Wings DS0000063585.V359570.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff had access to up to date information so that they could support people appropriately. EVIDENCE: Two care plans were examined. These were well set out and had relevant up to date information clearly communicated. There were personal pen pictures on each individual, an independent life skills assessment had been recently completed and objectives and needs were set out. Examples of these included budgeting own money, doing laundry and ironing and maintaining a healthy diet. To support these objectives there were risk assessments in place. Examples included kitchen access, support needed in the community and access to things that may lead to self-harm. All the risk assessments had been reviewed in the last 3 months. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 12 Throughout the day residents were seen to make decisions about the time they got up, what they did for the day and what meals they ate that day. All these decisions were respected and supported by the staff on duty. The two surveys completed by residents said that staff always treated them well and that staff always listened and acted on what the resident said. Staff spoken with were clear how they would promote independence by doing activities like cooking/making drinks with residents and not for residents. They also said that shopping purchases were for the residents to decide and therefore how they spent their money was up to the residents. The expert by experience said ‘Residents chose what to wear and all go shopping for new clothes. Staff advise residents of their rights, although one resident said they would like this in writing supported with picture text for other residents. One resident goes to bed at 7pm, to watch TV and listen to music rather than going to evening clubs, this is her choice. Residents have gone on day trips to Great Yarmouth and the American adventure’. Wings DS0000063585.V359570.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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate opportunities for leisure and personal development were offered and met the needs of the resident group. People enjoyed a varied diet. EVIDENCE: There were currently three residents at this home and each person had a different plan in place for their ‘leisure, education and meaningful activities’. This was the title of an element of the care plan. One resident was seen going out for the day in one of the homes vehicles. They were accompanied by 2 staff and planned to go to a near by town to do shopping as it was market day. Their plan for the rest of the week included attending a pottery class, swimming, attending a day centre one day and having an aromotherapist visit them at home on another day. Another resident attended a day centre 4 days a week and had the 5th day at home and liked to do DIY jobs around the home and in the grounds. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 14 On the day the resident in question was painting shelves for another resident. This resident also liked to go to the local gateway club and enjoyed speedway and dog racing. The third resident had been offered a shopping trip that day but chose to stay at home as they had not got much sleep the night before. This resident spoke of attending bingo locally. The resident group are getting on well together and this year are planning a holiday together to Great Yarmouth. Relationships with family were seen to be supported. One resident is supported to write to a relative and this was documented. Another resident visits family for a weekend once a month and staff were aware of this. Staff spoken with were aware of how they would promote privacy and dignity for individuals and spoke of knocking and waiting for a response before entering a bedroom and aware of ensuring confidentiality when speaking with residents. The expert by experience reported: ‘Residents use public transport with support and the two company cars. All residents have DVD players, TV’s and music systems in their rooms. Residents have had friends over for drinks and visits after prior arrangement with staff. Residents all get free time to themselves.’ In relation to meals and meal times residents have helped develop the menu in place. A recent addition to the menu was faggots as one resident wanted to try them. The menu had a 2nd option available on each main meal of the day. On the night of faggots, chicken stir-fry was the 2nd option. Healthy eating is encouraged. Food stocks were good and included plenty of fruit and vegetables. Breakfast was cereal and toast. Lunch was a sandwich, jacket potato or soup and a roll. On the day one residents made their own sandwich for lunch. The expert by experience reported: ‘Residents get to choose the monthly menu of food and assist with the weekly shopping where they can choose items. Fresh fruit and vegetables are available at all times as is juice. The home has a water dispenser which residents all use. We looked at the menu’s including the healthy options which are available at all times, which we felt was very good.’ Wings DS0000063585.V359570.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported in a manner suited to their personal preference. Medication practices were sufficiently effective to protect people. EVIDENCE: In each of the 2 care plans examined there was a section for staff to follow entitled personal care needs. This gave the level of support required and the preferred type of personal support required. Staff spoken with were aware of who preferred showers and not a bath and how much guidance was needed. Staff were quite clear that they would be guided by the choices of the resident. The expert by experience reported: ‘Male and female staff members work with residents apart from matters around personal care. If help is not required from staff, residents are allowed to do things for themselves. A resident can choose what time to get up and go to bed, the house encourages residents to go to bed by 11.00pm but this is not enforced if they want to stay up later to watch TV for example. Residents can choose when and how often they wash or shower. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 16 The residents feel safe and know the doors are locked at night, as is the side gate. The residents know they should ask strangers for ID and then contact a staff member before admitting to the home’. The previous day a resident had attended the dentist and they spoke of this. On the day of the visit a different resident had requested to see the GP and was taken by staff in the vehicle provided by the home to attend their appointment. The daily statements written by staff stated the amount of support given with any activity (such as attending appointments) and also the general well being of an individual including their mood. Care plans set out how an individuals mental health needs would be met with specific individual plans around managing personality disorders and self-harm. The manager stated that she was keen to access further training for staff relating to issues of self-harm. The self-assessment stated: ‘Care plans contain detail of how client should be supported. We have a detailed policy on support with personal care. Plans contain general & specific health care needs/ action plans are in plans for clients with LD. All medical appointments are documented. We have robust procedures in place for all aspects of medication’. The medication system was examined. Medication was kept secure. There was a procedure available for staff to follow. A simple audit of one person’s medication showed that the correct medication was in stock and that person received the correct medication at the time specified. The medication records were in order. Staff confirmed they had received both medication and first aid training. Wings DS0000063585.V359570.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected and their views listened to. EVIDENCE: The home had a complaints procedure in place and this was part of the information given to the residents. In the 2 surveys returned the residents were aware of how to complain and staff spoken with confirmed that the residents were aware, but if they were not they would give them the telephone number of senior managers within the organisation and they could call them using their cell phones. A log of complaints was in place and showed the concerns and what had been done to resolve matters. The self-assessment tells us ‘Complaints are analysed monthly and collated yearly to establish any patterns for future prevention’. In relation to safeguarding the home has the local agreed procedure in place and has had cause to use this since our last visit to the home. Those matters have now been resolved and appropriately recorded. Staff were spoken with and one member of staff had received training in safeguarding, but one had not. The manager confirmed that she was looking at ensuring all staff had received this training. Residents’ finances were examined. There are appropriate records kept to show who and how residents’ money is used. The expert by experience reported: ‘All residents have chip and pin cards which they use to withdraw their money from the post office when required. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 18 One resident withdraws their money and it is looked after by staff but this is their choice. This person can access their money at anytime. Residents get to choose what to spend their money on including clothes, china dolls, music, DVD’s toiletries etc’. Wings DS0000063585.V359570.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, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wings provides a clean and comfortable place to live. But is not fully accessible to people in a wheelchair. EVIDENCE: During this visit all the inspection team were able to tour the home and the grounds. The home was comfortable and clean throughout. The lounge, kitchen and laundry were nicely decorated and well equipped. The expert by experience thought ‘the premises were decorated to an acceptable standard and the bedrooms had many personal items including pictures, ornaments and electrical equipment. All the bedrooms were very personal to each resident. Whilst visiting the kitchen the expert by experience felt the dishwasher handle should be replaced as it is broken and sharp to touch’. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 20 Wings was found to be very spacious with large enclosed grounds all of which were accessible, but not all of it for people in wheelchairs. The expert by experience reported: ‘One person felt residents could use all the home, though the cupboards in the kitchen need to be re-arranged and a path laid across the lawn to the fire meeting point to make it accessible for the one wheelchair user’. The manager spoke of converting a room near the lounge and kitchen into a dining room. This room and the office were not accessible to a person in a wheelchair. The Statement of Purpose said that the home was suitable for people who use wheelchairs. A discussion was held with the manager and she agreed that a way forward would be to have the whole home assessed by an occupational therapist to ensure all areas were appropriately accessible. An occupational therapist had visited and assessed an individual for a specialist bed and this had been obtained. The manger spoke of improvements planned for Wings and this included making the entrance to the home more noticeable and attractive. There were also plans for the garden and developing raised beds. Wings DS0000063585.V359570.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): 31, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient staff that were well recruited, but staff were not adequately trained and supervised, therefore residents are placed at risk. EVIDENCE: The roster for January and February 2008 was examined. This showed that the plan was to have at least 3 staff on duty during the day. This was achieved by using some agency staff and was sufficient staff to meet the needs of the resident group. There was 10 care staff employed at the home. Records were examined for 3 current staff and 1 staff member being recruited. Recruitment records showed that all the required checks and references were in place before someone started work at the home. Evidence of staff training was patchy. Staff may have received training but there was no evidence to support this. One staff member spoken with said they had received training in medication, safeguarding, dealing with challenging behaviour and first aid. There was a record in their file of this training, but no certificates to support this. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 22 One staff member spoken with said they had done a 2-week induction at the home, but this was not the common standards of the skills for care induction. The staff member aware they needed further training. The manager said she would audit the training staff had received and ensure that any up dates were given, but also that training based on the residents needs was given to all staff. Staff were also asked about formal supervision, 2 staff said they had not received this. The manager said she had a plan to put in place regular supervision for all staff. The self-assessment states that 2 staff hold an NVQ qualification and that Wings will ‘Achieve NVQ targets by providing more practical support’. Wings DS0000063585.V359570.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wings was well managed and residents were able to express their views. EVIDENCE: A new manager had been appointed to this service. Ms Gerrish started at the home approximately 2 weeks before our visit. She was suitably qualified and had experience in learning disability services. She holds NVQ 2, 3 and 4 in Care. In management she had the Registered Manager Award. We await the application to process her registration. There is also a further plan changed at the home that the new manager was aware of. The self-assessment said ‘Wings is a 6 bedded unit, we will be applying to de register 1 bed’. Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 24 The feedback from people at the home about the new manager was positive. Two staff spoken with about the new manager. One said ‘I’m just getting to know her, but have found her to be open and she listens. She is really nice and supportive’. Another staff member said ‘I feel supported by the manager. She is brilliant, very organised and flexible in her support’. The expert by experience wrote ‘One resident was pleased the home had a new manager and liked the manager’. The expert by experience went on to say ‘Residents have regular meeting to discuss any issues or grumbles they may have but these are not at any planned intervals’. The last minutes seen were from 25/07/07. We also looked at the other ways the service takes into account the views of people at the home. The residents were surveyed by the service in 2007 about their views. The outcomes were available at the home, but the manager who was still new needed time to familiarise herself with this feedback and the feedback obtained from external people who had also been surveyed in 2007 about the home. The manager was aware of the wider quality assurance systems in place at the home and was delivering these quality audits to staff during their monthly staff meetings. These audits were looked at and were found to use our key Lines of Regulatory Assessment and therefore the standard to be reached would meet the standards we expect of a service. Each audit checklist had a corrective action plan attached. Also available was the regulation 26 reports. These are a report that we require to be completed by the organisation and they should visit the home once a month unannounced and check the quality within the home. These had regularly been completed since our last visit. Therefore we believe that this service is monitoring the quality of service offered for the people who use it. Since the last inspection all the policies and procedures have been consolidated and have been colour coded for ease of access. One of the quality audits was on fire procedures. The equipment within the home had been serviced in November 2007. The manager explained that individual staff within the home have been delegated tasks to be responsible for, for example health and safety or infection control. In a tour of the home it was seen that health and safety matters were well managed. Chemicals were locked up and data sheets on chemicals used were available. Records of temperatures for food safety were maintained as were hot water temperatures. The expert by experience was pleased the gas storage area was securely locked. Wings DS0000063585.V359570.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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 2 36 2 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 (1) (a) Requirement Timescale for action 23/05/08 2. YA35 13 (6) 3. YA23 13 (6) The premises must be suitable for all who use the home; therefore all of the home needs to be accessible for people in wheelchairs. Residents were placed at risk 23/05/08 and therefore staff must be adequately trained to meet their needs. The registered person must 23/05/08 ensure that all staff attends training to prevent residents from suffering abuse or placed at risk of harm or abuse. (This is a repeat requirement) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations 50 of staff should achieve NVQ level 2 Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Wings DS0000063585.V359570.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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