Inspection on 28/08/09 for 14-15 St James Road

This is the latest available inspection report for this service, carried out on 28th August 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

14-15 St James Road 05/03/08

14-15 St James Road 23/05/06

14-15 St James Road 27/09/05

14-15 St James Road 25/04/05

14-15 St James Road 22/11/04

14-15 St James Road 15/07/04

14-15 St James Road 16/03/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 15/02/2010.

Key inspection report CARE HOME ADULTS 18-65 14-15 St James Road 14-15 St James Road Exeter Devon EX4 6PY Lead Inspector Graham Thomas Key Unannounced Inspection 28th August 2009 08:40 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14-15 St James Road Address 14-15 St James Road Exeter Devon EX4 6PY 01392 670160 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) Mrs Deborah Veronica Phillips Mr Warwick Nicholas Phillips Manager post vacant Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must obtain NVQ 4 in Care or Registration as a 1st level Nurse with the Nursing and Midwifery Council by 1st December 2006 3rd September 2008 Date of last inspection Brief Description of the Service: 14-15 St. James Road is registered to provide care for up to 17 people, both men and women who have or have had a mental illness and who are between the ages of 18 and 65. The Home comprises two adjoining semi-detached houses, which have access to each other at second floor level. To the rear of one is a small garden and to the rear of the other is a patio. One house has a roof garden accessible from the first floor. Each house has its own kitchen and living rooms. The Home is situated in a residential area close to the city centre and some rooms overlook the Exeter City Football Club ground. The Home’s Statement of Purpose says that at the Home therapeutic care is delivered…to enhance personal esteem and confidence and ‘to help service users to achieve or regain individual life skills required to attain or return to a more fulfilling lifestyle. Currently, weekly fees of between £405 and £512 are charged. Copies of the inspection report are available from the office. 14-15 St James Road DS0000021830.V377367.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. Before we visited the home we reviewed information received about it since our last visit. This included, for example, the Annual Quality Assurance Assessment (AQAA) completed and returned to us before the visit. We also checked whether we had received any complaints and any incidents about which the home had notified us. We visited the home and spent approximately seven hours there and looked around the premises inside and outside. During our visit we spoke with people living in the home, the staff and the manager. We also spoke with a visiting specialist social worker We examined a number of records including care plans, staff records and other records about the running of the home. After our visit, Mr Phillips sent us some information we had requested. What the service does well: People thinking of moving into the home have the opportunity to spend time there before moving in. The home makes sure it can meet their needs before offering them a permanent place. People living in the home, are supported to make decisions about their lives. Staff are helped to support people by a good system of care planning and recording. Improvements in record keeping mean that people can be assured that they will receive support to pursue their individual goals and that these will be understood by staff. People living at St James Road are well supported to follow individual lifestyles according to their own needs and preferences. They can feel confident that their health and personal care needs will be well met. Staff will listen to people’s concerns and act upon them. They also know what to do if they suspect or witness any abuse. Staff are clear about people’s needs and the support they require. They receive the training they need to understand and support people. The home’s environment and facilities are being improved to make them more comfortable and safe for people who live there 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 6 The new manager is working with Mr and Mrs Phillips to make life better for people living in the home. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. 14-15 St James Road DS0000021830.V377367.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 14-15 St James Road DS0000021830.V377367.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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 this service. People thinking of moving into the home can feel confident that the home’s assessment and admission procedures will ensure that their needs will be met. EVIDENCE: In the Annual Quality Assurance Assessment completed and returned to us before our visit, the service told us that people who are considering a place at 14-15 St James Road “…are referred to us by local brokers through e-mail correspondence. Some Care Managers also discuss perspective new service users who they would like to place with us. Then we arrange a meeting between the prospective service user, care manager and manager of House to show the prospective service user the fabric of the home and the people who live here. All prospective service users will be given an up to date Statement of Purpose and the Home’s Brochure which will contain a detailed schedule of what the Home offers, the costs of the fees and a code of conduct. They will also be given a copy of the Home’s latest report, a Service user’s contract, shown a designated room which will be theirs if they decide to come and stay. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 9 All new service users will be given a full assessment undertaken by the Care Manager, or independent advocate which will demonstrate the individual aspirations and future development of the prospective new service user. There will also be a full risk assessment for the new service user”……………”If the service user after consideration Is happy to perhaps consider coming here then the person will be invited around for dinner one evening and introduced to the other service users and staff. If things go well then another visit will be arranged perhaps to come and stay for a day. If over a period of time the prospective service user is happy to come to 14 St James Road on permanent basis then this will be arranged. Initially the new person may only come on trial period and is always made aware of this.” We spoke with a visiting Care Manager who told us that the person he was supporting was visited in at their previous placement and that the admission process had been gradual as described. He also told us that the person had received enough information about the home before they moved in. In the plan of another person who had moved into the home recently, we saw that information had been gathered about the person to check if their needs could be met. This included a questionnaire completed by the person’s care manager and a risk assessment. The home had also completed its own admission checklist. 14-15 St James Road DS0000021830.V377367.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 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 this service. People can feel confident that they will be supported to make decisions about their lives. Improvements in record keeping mean that people can be assured that they will receive support to pursue their individual goals and that these will be understood by staff. EVIDENCE: We looked at three people’s individual care plans. We saw that the plans had been based on the assessments made before people moved into the home. Each plan contained information about people’s personal histories, their needs and preferences. This included information about people’s social activities, physical and psychological health and personal support needs. For example, in one person’s plan we saw that the person had digestive problems. In the plan we saw detailed observation records concerning eating, drinking and toileting 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 11 and correspondence concerning an appointment with a continence specialist. The plans we examined had been regularly reviewed. Individual plans contained risk assessments. Areas covered by these assessments included medication, smoking and diet, physical health, the influence of others and the environment and practical issues. Details of potentially challenging behaviour were contained within the risk assessments. We discussed the challenges posed by one person with a visiting care manager and the home’s staff. From this we learned that the home had worked cooperatively to find a solution that would support the person and minimise the disruption to others living in the home. The plans we examined were signed by the person where possible. Staff had signed to say that they had read the plans. In our discussions with staff they demonstrated a clear understanding of the needs of people living in the home. A key worker system is in operation. This means that people using the service have specific individuals with whom to consult and discuss any issues about their support and care. Since we last visited the home, Number 15 has been allocated to the accommodation of people requiring less support who may be resident for a shorter period. During our visit, we saw people in both houses pursuing their chosen routines. In addition, people’s plans described their participation in daily household chores. People arose at a time of their choosing and moved around the home as they pleased. One person told us about regular visits they made to their family in the locality and how they had been supported to maintain this contact. This was reflected in the person’s individual plan. 14-15 St James Road DS0000021830.V377367.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): This is what people staying in this care home experience: Standards 12, 13, 15, 16 and 17 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 this service. People living at St James Road are well supported to follow individual lifestyles according to their own needs and preferences. EVIDENCE: People’s individual plans showed details of their personal interests and goals. In the home’s entrance hall we saw photographs of people enjoying a trip to Dartmoor and a recent barbeque party. We also saw notices concerning regular activities such as swimming. Information was also available about the use of a local leisure card. People living in the home confirmed that they used these cards and that they have bus passes and use local transport. Staff told us about their support for people to attend badminton, snooker and swimming. In people’s plans we also saw evidence of individual activity and attendance at groups such as “Springboard”. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 13 One person living in the home told us that they chose not to participate in organised activities and that this choice was respected. The home’s records showed how people were involved in the home’s routines such as cleaning and laundry Individual records contained detailed personal histories, including details of family contact. People living in the home told us about arrangements for them to keep in touch with friends and family. This included, for example, visits to family members and telephone calls. A pay phone is available in the home. Our discussions with people’s key workers showed that they had good knowledge of people’s social needs and preferences and the individual support people needed. People living in the home have a key to the front door. The home’s policy requires people staying out after 10:00pm to inform staff. One person had individual arrangements for medication in order that they could attend a late social activity. We saw that staff were respectful of people’s privacy by knocking on people’s bedroom doors before entering. However, individual rooms are not fitted with locks and people told us that this facility had not been offered. We saw that the home has a weekly menu though individuals told us that this was flexible enough to accommodate their individual needs and preferences. The service told us in the questionnaire they completed that people were encouraged and supported to cook for themselves. During our visit we saw people in the kitchen being supported to choose and prepare food for themselves and others. Staff told us about regular cooking classes that take place in the home twice a week. These were originally designed for people living at number 15 who require less individual support. However, they have proved to be popular and are also attended by some people from number 14. People’s plans we looked at showed how they were being encouraged and supported to make healthy dietary choices and this was confirmed by one person with whom we spoke. We saw in another person’s plan that nutritional monitoring had been followed in accordance with their specific health needs. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 this service. People can feel confident that their health and personal care needs will be well met. EVIDENCE: During our visit we noted that people were dressed in individual styles according to their own preference. In people’s individual plans we saw that there were risk assessments and individual plans concerning physical and mental health detailing the support people required. In the files we saw that one person had been assessed by a Speech and Language Therapist and was waiting to see a continence specialist. We also saw evidence of routine appointments for eye tests and chiropody. Records showed that one person’s nutrition was being closely monitored by staff. We also saw evidence of regular mental health reviews. Our discussions with people’s key workers demonstrated that individual health needs were understood by staff. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 15 We saw that the home has policies and procedures in relation to the administration of medicines. A “monitored dosage” system is in use in which most tablets are dispensed by the pharmacy in prepared blister packs. We found that medicines were securely stored in the home’s office. People administering their own medicines had secure storage facilities in their room for this purpose. Each person had a “declaration of wishes” in their plan regarding who would be administering medicines. Those who were selfmedicating had been risk assessed. Training records showed that staff administering medicines had received appropriate training. Good practice was noted in accounting for medicines. For example, staff who administered medicines had provided sample signatures. Individual medicine administration records contained a photograph of the person to ensure correct identification and reduce errors. Where there had been changes in an individual’s medication, two staff had signed to confirm the new prescription. Information was available for staff about each medicine. Although no controlled drugs were in use, there was separate, secure storage for such medicines and a controlled drugs register. Staff with whom we spoke were aware of correct procedure regarding controlled drugs and records of previous use suggested that this was being followed. We saw evidence of regular auditing of the medication system. The sample of records we examined was correct, up to date and in good order One person who does not routinely self medicate had separate arrangements for late return to the home. This involved medicines being left in the person’s secure cabinet by staff for the person to take on their return. A check was then being made in the morning to ensure the person had taken the medicine and confirmation made on the administration record. Whilst recognising the need to promote the person’s developing independence, we considered that the audit trail provided by this system was not sufficiently robust. We therefore recommend that this should be treated as self-medication by the home and that self-medication procedures should be applied to this specific activity. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 this service. People living at St James Road can feel confident that staff will listen to any concerns and act upon them. They also know what to do if they suspect or witness any abuse. EVIDENCE: People with whom we spoke said that they felt confident that staff would listen to and act upon their concerns and complaints. The home’s complaints policy was prominently displayed in the entrance hall. There was also a box for suggestions and in the hallway together with sealable envelopes so that people might remain anonymous if they wished. A system was in place for recording complaints and any actions taken. The manager told us that there had been no complaints since our last inspection visit. Our own records showed that we have received no complaints about the home during this time. Staff have folders with details of safeguarding procedures and information about safeguarding adults from abuse. Staff also told us that this was discussed at staff meetings and that they had completed questionnaires on the subject. Our discussions with staff demonstrated that they knew what action to take if they suspected or witnessed abuse. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 17 The care plans we examined contained information about people’s potentially challenging behaviour and how staff should respond to this. When we spoke with staff they were aware of individual behaviour that might be challenging and how they would respond to this. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 this service. People living at St James Road are benefiting from ongoing improvements in the home. The home’s environment and facilities are being improved to make them more comfortable and safe for people who live there. EVIDENCE: The two houses are furnished and decorated in a homely, domestic style. During our tour of the premises we noted that there were no offensive odours and that the home was sufficiently clean. We saw that there was a cleaning rota and that people living in the home were encouraged to join in this activity with staff. There were specific notes for staff on the daily cleaning routine. We also noted that, in accordance with a previous requirement, animals are now not permitted in the kitchen areas. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 19 Since our last visit to the home, a substantial investment has been made in the property. We also saw evidence of ongoing upgrading and improvement. High quality wooden flooring has been laid in both houses, a new kitchen has been fitted in number 15 and a new bathroom. Furniture in both lounges has been replaced. We also saw evidence of recent decoration. The manager told us that there were further plans to replace the stair carpet. Recent work on the new floor had resulted in internal fire doors not closing properly. Similarly, the painting of the rear fire exit door had left it difficult to open. Immediate requirements were made to address these issues. Mr Phillips has since confirmed that the necessary work has been completed. At the time of our visit the home’s laundry facilities were being upgraded to include professional standard washing and drying machines. The Manager showed us a contract to confirm that these would soon be installed. A system of soluble red bags was used for heavily soiled laundry. The flooring in the laundry are was not impermeable and consisted of plain floor boards. An impermeable floor is important in the control of infection. Risk assessments were seen relating to environmental risks. We also saw evidence of ongoing maintenance and testing. For example, test labels on fire equipment and portable electrical appliances indicated up to date tests. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 this service. People are well supported by staff who are clear about people’s needs and the support they need. Staff receive the training they need to understand and support people. EVIDENCE: People with whom we spoke during our visit told us that staff were “good” and “supportive”. We observed staff talking with people living in the home. The conversations were generally relaxed, supportive, respectful and goodhumoured. A key worker system was in operation in which individual staff hold particular responsibilities for individuals living in the home. All staff sign that they are aware of the contents of individual plans. At the beginning of our visit we attended a staff handover meeting in which staff demonstrated their awareness of people’s need and how they would be met. This discussion provided important information for staff at the beginning of their shift and instructions from the manager for which staff would be 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 21 accountable. For this reason we recommend that notes should be kept of handover meetings. The staff rota showed that two staff are on duty at all times. In addition, the manager is on duty between 9:00am and 6:00pm. The manager told us that Mr and Mrs Phillips also spend time in the home. At the time of our visit, people’s individual needs were being met and staff had time to talk with people. We looked at the files of recently recruited staff and saw that there was a robust recruitment procedure in place. This included a formal application procedure, requests for references and criminal records checks. We noted that staff recruited from abroad had also provided translations of key documents as part of their recruitment. Staff confirmed that they had received induction training when they started work in the home. This was confirmed in records in individual staff files. The induction however did not follow the nationally recognised “Skills for Care” framework. As a nationally recognised framework this provides a sound basis of good practice and is therefore recommended. We saw certificates to confirm that staff had attended other training relevant to their work. This included, for example, Mental Health, Mental Health and Recovery Awareness Days. There was also evidence of training in health and safety topics. We saw that there was an ongoing programme of training for National Vocational Qualifications. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 this service. People living in the home are benefiting from the improvements that are being brought about under the supervision of its new manager. EVIDENCE: Since our last visit to the home, the previous manager has left. A new manager has been appointed who has yet to register with the Commission. The new manager holds a Doctorate from a foreign university. She is currently undertaking a National Vocational Qualification at level 4 in leadership and management in social care. She has also attended various short courses relevant to her work. In discussion, the new manager displayed a clear understanding of her role and values appropriate to supporting people with 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 23 mental health needs. Since her appointment she has, with the support of the Registered Providers, overseen a number of improvements in the environment, recording practice and staff training. Systems were seen for monitoring the quality of the service. In the hallway, a box is provided for suggestions with sealable envelopes provided. We saw evidence that questionnaires were being sent to people using the service, their families and visiting professionals. Systems for handling people’s money had been improved since our last visit. We saw that there were individual protocols in people’s files. Cash held for people living in the home was securely stored. We examined two examples. Records of income and expenditure were kept together with receipts. The amounts recorded corresponded with the amount of cash held in each example. Health and safety issues were examined during our visit. Evidence of an ongoing staff training programme was seen in health and safety topics such as fire safety and first aid. We saw that environmental hazards had been risk assessed. We also found that routine checks and maintenance were being carried out in respect of, for example, fire extinguishers and portable electrical appliances. During this visit we saw that the garden areas were clear of hazardous equipment. We also noted that hazardous substances were locked away when not in use. We noted that infection control had been improved since our last visit by a more systematic cleaning regime. We also saw that staff were, for example, wearing aprons and gloves for routine cleaning tasks. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 36 X 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 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 25 14-15 St James Road DS0000021830.V377367.R01.S.doc 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The home’s self administration procedure for medicines should be applied in instances where people administer their own medication at night. This is to provide a clear audit trail of accountability for these medicines 2. YA16 People’s individual rooms should be fitted with locks and a key offered to the room’s occupant. These locks should be capable of being locked from the inside and from the outside by staff in an emergency. This facility should be offered to all people living in the home unless otherwise indicated by risk assessment. This is to offer privacy to people and security for their possessions. 3. YA30 The Laundry Floor should be made impermeable. DS0000021830.V377367.R01.S.doc Version 5.2 Page 26 14-15 St James Road This is to prevent the spread of infection in the home. 4. YA31 Notes should be kept of all handover meetings. This is to ensure clear lines of accountability for work undertaken in the home. 5. YA35 The nationally recognised “Skills for Care” framework should be used for induction training. This is to ensure that staff are trained in line with nationally recognised standards and current good practice. 14-15 St James Road DS0000021830.V377367.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission South West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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