Inspection on 29/09/09 for 15 Pentire Crescent

This is the latest available inspection report for this service, carried out on 29th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Pentire Crescent 05/09/06

15 Pentire Crescent 06/02/06

15 Pentire Crescent 20/09/05

15 Pentire Crescent 13/01/05

15 Pentire Crescent 22/07/04

15 Pentire Crescent 27/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

Key inspection report CARE HOME ADULTS 18-65 15 Pentire Crescent East Pentire Newquay Cornwall TR7 1PU Lead Inspector Ian Wright Key Unannounced Inspection 29th September 2009 09:30 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 15 Pentire Crescent Address East Pentire Newquay Cornwall TR7 1PU 01326 371000 01326 371099 mail@dcact.org 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) Spectrum Vacant (Application for registration submitted) Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users that can be accommodated is 3. Date of last inspection 2nd September 2008 Brief Description of the Service: 15 Pentire Crescent provides care and accommodation for three people on the autistic spectrum. It is run by Spectrum, an organisation that provides specialist care to people on the autistic spectrum. The home is situated in East Pentire, which is near Newquay. The house is a detached, two-storey building, with a large garden. People who use the service are provided with their own bedrooms, one of which has an ensuite bathroom. There are two additional bathrooms. All the bedrooms are on the ground floor of the house. The home has an office and a separate sleeping in room for staff. There is a domestic-style kitchen with open plan dining room a conservatory and a separate laundry/store room downstairs. There is also a workshop that people who use the service are able to make use of. On the first floor of the building there is a large, comfortable lounge, with TV, video, music centre and a computer with internet access. The home does not specifically provide accommodation for people with physical or sensory disabilities, but could readily adapted to meet special needs, if required. Fees range from £1211 to £1513 per week at the time of this inspection in September 2009. There are additional charges for personal items such as toiletries, newspapers and magazines, according to the information provided at the time of the inspection. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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 key inspection took place in four hours in one day. All the key standards were inspected. The methodology used for this inspection was: (1) To case track two people using the service. This included inspecting their records. (2) Discussing care practices with staff and management. (3) Discussing with people using their service their experiences of life at the home. (3) Inspecting records and the care environment. (4) Carrying out a postal survey of people who use the service, staff and professionals who work with the service. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? Previous requirements set at the last inspection have been met; for example there is evidence that training is available to staff, fire precautions seem satisfactory and the Commission is being notified of any incidents required by law. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 6 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. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 1, 2, 5 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. Information provided to people who use the service (e.g. regarding services offered) is good. For example all people who use the service (and /or their representatives) receive a statement of terms and conditions of residency or contract when they move in. This ensures people are aware of their rights and responsibilities. Pre admission assessment procedures are satisfactory and ensure the registered persons check they can meet the persons needs before admission is arranged. EVIDENCE: We inspected a copy of the homes statement of purpose and service user guide. These contain satisfactory information about the service. The registered provider has a satisfactory assessment procedure. For example prospective clients and their families visit the home before admission is arranged. Senior staff visit the person to meet them as part of the assessment process. The person concerned also visits the home as part of the assessment process. There have been no admissions to the service since the last inspection. According to surveys we received people using the service said they 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 9 were asked if they wanted to move into the home before this was arranged. People said they were given enough information about the home before they moved in so they could decide if it was the right place to move to. We were able to inspect contracts / statements of terms and conditions of residency for people using the service. Information inspected was satisfactory. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 6, 7, 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. Satisfactory care planning procedures are in place. There are satisfactory opportunities for people to participate in making choices and be involved in decision making. Staff enable people using the service to take an appropriate level of risk so they can pursue as independent a lifestyle as possible. These measures ensure the needs of people who use the service are met and they are given the opportunity to make choices how they lead their lives. EVIDENCE: A care plan was contained in the file for each person we case tracked. Care plans are accessible to staff. There is a review process in operation, and people who use the service (and / or their representatives) are invited to meetings which occur. From discussion and observation, people who use the service are involved in making decisions about their lives, and how the home is run. Where 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 11 restrictions are in place, these are recorded. Restrictions in place appear appropriate considering peoples needs. According to surveys we received, people using the service said they could either ‘always’ or ‘sometimes’ make decisions about how they spend their time during the day. Suitable risk taking seems to take place to enable people using the service to live as independently as possible. The home has its own transport, which enables people to participate in community activities. Suitable risk assessments are kept on file, and reviewed as necessary. People living in the home either manage their own monies and/ or receive assistance from staff. Suitable systems for their management (where appropriate) are in place. Management have appropriate systems to ensure records are checked. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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: 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. The registered persons ensure people living in the home can live a lifestyle which meets their needs and wishes. EVIDENCE: People using the service have the opportunity to pursue a range of activities. Some people have work placements. There are opportunities to go to the leisure centre e.g. on the day of the inspection one person was going to the gym. Other opportunities include attending college, massage, going to the pub, clubs etc. One person makes furniture using the garage which has been converted into a workshop. Other social and shopping trips are organised according to the wishes and needs of individuals. There is evidence from daily records that people participate in a suitable range of activities. People have opportunity to visit friends and relatives and these people also visit the home. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 13 Routines in the home seem appropriate according to individual needs. There was a relaxed and friendly atmosphere in the home throughout the time of the inspection. One person said the home was ‘ a relaxed and fun place to live’. The home has a menu with a suitable range of meals available, and people are involved in making choices of meals they want. Records also show people appear to have a varied and nutritious diet. One survey response said the food budget should now be increased as it had remained about the same for a number of years. We were unable to discuss this with the respondent, although we felt food supplies in the home, and menu choices available seemed satisfactory. According to surveys we received people using the service said they could either ‘always’ or ‘sometimes’ choose what they wanted to do during the day, evening and weekend. We received on comment that one person would like to go out more in the evenings e.g. one person would like to go to night clubs more often. Staff and management should do their best to accommodate this person’s wish. According to the surveys we received food was seen to be to a good standard. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 18, 19, 20 People using the service experience generally good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal and healthcare needs of people living in the home are satisfactorily promoted and met. EVIDENCE: We observed people using the service receiving suitable care and support from staff. Support was carried out in a professional, but relaxed and friendly manner. Documentation regarding how care tasks are completed is satisfactorily documented in care plans. Staff responding to our survey said they were either ‘Always’ or ‘’Usually’ given up to date information about the needs of the people they supported. People living in the home appear to have their personal hygiene needs met. All people using the service looked well cared for on the day of the inspection. Care and support is suitably tailored according to individual needs. For example some people have very low level care needs, and therefore the staff 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 15 team work with these people to enable them to live as independently as possible. However, one person answering our survey did say they should receive ‘more help with some things’- however no specific examples were given regarding what they wanted more assistance with. Respondents to our survey, who live in the home, said either staff ‘always’ or ‘sometimes’ treat them well. Respondents to our survey said carers ‘sometimes’ or ‘never’ listen and act on what they say. Where people answered ‘sometimes’ or ‘never’ rather than ‘always’ in the survey, no specific reasons were given so it would be wise for management to explore these issues further for example through advocacy or resident meetings. However we did not see any signs of bad practice, and staff were observed as being helpful and supportive to the people living in the home. Records show people living in the service have suitable access to health care professionals such as GPs, dentists, opticians etc. Records document medical input. We received one response from someone involved in the commissioning of the service (social services). This respondent was very positive about the service and said the service provided an ‘excellent standard of support..(and the service always ) listens to ideas from parents / social workers’. We inspected the medication system. The medication policy seems satisfactory. Medication is stored appropriately in a medication cupboard. Medication is administered via a monitored dosage system supplied by a local pharmacist. There are satisfactory records regarding administration of medication. There is a record in staff files that staff have received appropriate training regarding handling medication. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 22, 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. The registered persons have satisfactory complaints and adult safeguarding procedures. This should help to ensure any concerns, complaints and safeguarding allegations are investigated appropriately. EVIDENCE: Copies of the complaints and adult safeguarding procedures were inspected and are satisfactory. There have been no concerns, complaints or safeguarding concerns raised to the commission about this service. We would advise the registered provider to include information regarding access to the social services complaints procedure within their procedure and /or within individual service user guides. People who are funded by local authorities have a right to use this procedure if they are funded by social services, and subsequently they should be made aware of this. The registered providers adult safeguarding procedure is satisfactory. Care staff said they would inform the manager if they suspected any abuse had occurred. Training regarding safeguarding is delivered to care staff as part of their induction. Staff who we spoke to, said they had no concerns regarding the attitudes of other staff or care practices in the home. According to surveys we received people using the service, and staff, said they knew how to make a complaint. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 17 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 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. 15, Pentire Cresent provides a suitable facility for the people living there. EVIDENCE: The building was inspected. Three people are accommodated at the home. The home is a spacious ‘chalet’ style bungalow. There is a kitchen, and laundry. There are three single bedrooms. The communal areas consist of a large lounge / dining area. On the first floor there is another communal lounge which is used by people living in the home. Decorations and fixtures and fittings are all to a good standard. Bathrooms and toilets are to a good standard in regard to cleanliness and the quality of fixtures and fittings. We have been told thermostatic valves are fitted to all bath and shower facilities. The home was clean, warm and light enough on the day of the inspection. The kitchen was clean. There are some concerns about 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 19 the work surface in the kitchen. There are some gaps in the surface which make it not easily cleanable. This either needs to be repaired or replaced to minimise any infection control risks. One respondent to our survey said the management of maintenance issues should be improved, but its ongoing effectiveness may need to be monitored if this is not already occuring. We however understand that Spectrum have reorganised this service. Laundry facilities are satisfactory. The outside of the building and the gardens were maintained to a satisfactory standard. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 32, 33, 34, 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. Staffing levels appear satisfactory to meet the needs of people currently accommodated at the home. Recruitment checks are to a good standard. Some minor improvement is required to training provision. People using the service can subsequently be assured they will be supported by staff who are suitably recruited, vetted and trained. EVIDENCE: On the day of the inspection there were satisfactory numbers of staff on duty. For example there was two staff on duty in the morning, and one person in the afternoon and evening. One resident was away, one person is very independent and the other person using the service had one to one support. Staffing levels are therefore deemed satisfactory to meet people’s needs accommodated at the home. Respondents to the staff survey said staffing levels ‘usually’ or ‘always’ satisfactory. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 21 Personnel records were inspected for the staff on duty for the day of the inspection. These were satisfactory. Staff employed had two references, a Protection of Vulnerable Adults First check (POVA First) , a Criminal Records Bureau check (CRB) , a completed application form and evidence of identification. It would be helpful if a scanned copy of the POVA First check is stored with other personnel records on the Spectrum records system. This will help us validate this check has been completed before the member of staff has commenced employment. Respondents to the staff survey said Spectrum carried out appropriate recruitment checks before they commenced employment. We inspected training records for the same sample group of staff. By law staff require the following training: • • • Regular fire training in accordance with the requirements of the fire authority. There must always be at least one first aider on duty (at appointed person level) All staff must have manual handling training and should have regular updates of this (e.g. annually). If people living in the home do not require moving and handling assistance- staff should have basic training lifting inanimate objects as is required by law. All staff must have basic training in infection control. Staff who handle food receive food hygiene training. All staff must have an induction and there needs to be a record of this. Awareness training regarding the needs of people accommodated. • • • • The delivery of training is generally satisfactory. The registered provider offers staff a comprehensive staff induction which covers the majority of the elements required by law. Staff subsequently attend follow up training which covers the areas more comprehensively. However, some of the staff files inspected show that some of the staff still need to attend the follow up training. For example one person needs basic manual handling training (there is no moving and handling support for people living in the home) and two people need to have food hygiene training. There are opportunities for staff to obtain a National Vocational Qualification in care. When staff have received an NVQ 2 there is the opportunity to obtain an NVQ 3 in care if this is deemed by management as appropriate. Respondents to the staff survey said induction, training and supervision arrangements are satisfactory or very good. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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): 37, 39, 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. The manager and the staff team are effective in ensuring the service is managed to a generally good standard. Some improvement is required to health and safety procedures for example there needs to be an up to date gas certificate and hard wire test certificate. This will give more assurance that people live in a safe environment. EVIDENCE: The registered provider is Spectrum, a registered charity supporting people with autism / aspergers syndrome. The manager of the home is Ms Kate Fennessy. Ms Fennessy is currently not registered as the manager with CQC, although an application for registration has been submitted and Ms Fennessy is waiting for CQC to interview her. The home seemed well organised, and staff 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 23 we spoke to were positive about Ms Fennessy’s management skills. Respondents to the staff survey were universal in praise for the service’s commitment to catering for the needs of people who use the service such as enabling a good quality of life, facilitating a person centred service and listening to staff and the concerns of people who use the service. There is a satisfactory quality assurance system in place. For example we were shown copies of surveys completed. The manager has to complete a monthly management report to evidence the service meets organisational standards, and senior management visit the service on a monthly basis. An annual development plan is in place. From this inspection, National Minimum Standards seem generally met; although some improvement to the quality assurance system needs to occur to ensure staff receive required training, and health and safety precautions are improved. It is important the registered provider develops a quality assurance policy and procedure, and this is available for inspection. The manager has completed the Annual Quality Assurance Assessment (AQAA). This is an annual return required by the Commission. We have received some notifications, required by the commission (e.g. regarding untoward incidents) which are required according to the Care Home Regulations 2001. Policies and procedures in the home are dated May 2003. It is important there is evidence these are being regularly reviewed and updated when required. The registered provider has a health and safety policy. There is a fire risk assessment dated January 2009. Testing of fire extinguishers and the fire system appear to have been completed appropriately by external contractors (January 2009). Internal checks on the fire system appear to have been completed appropriately by staff (e.g. emergency call points and emergency lighting). Health and safety risk assessments have been completed. However, we did not view any risk assessment or routine testing records regarding the prevention of legionella. If this is not occurring this needs to be organised. The Health and Safety Executive publish a useful document regarding this matter via their website. Suitable records regarding accidents and incidents are kept. Portable electrical appliances have been tested and appear satisfactory. The electrical hardwire circuit was tested, however the results deemed the circuit unsatisfactory. Remedial action needs to take place, and evidence of its completion needs to be available for inspection. Gas appliances also need to be retested. This expired in January 2009. An up to date certificate of insurance is displayed. 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 24 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 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 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 Score 3 3 3 3 3 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 39 40 41 42 43 3 X 2 X X 2 X 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 Requirement Timescale for action 01/05/10 2. YA39 24 Staff must receive training required by law and according to the needs of people living in the home. This will ensure that people living in the home can be assured staff are trained according to legal standards. 01/12/09 The registered persons must ensure: 1. There is a quality assurance policy in place. 2. Quality assurance systems are improved for example so standards required by regulation are met. (E.g. in regard to health and safety, training etc.) Improvement in this area will help to ensure there is an effective system to ensure continuous improvement. The registered persons need to ensure satisfactory health and safety precautions are in place. For example: 1. Ensure suitable testing occurs on the electrical hardwire circuit (as DS0000028263.V377845.R01.S.doc 2. YA42 13 01/01/10 15 Pentire Crescent Version 5.3 Page 27 necessary) 2. Gas appliances need to be tested annually and an up to date gas certificate needs to be available for inspection. 3. There is a policy and satisfactory procedure regarding the prevention of Legionnaires’ disease. This will help to ensure people living in the home reside in a safe environment. 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 YA22 Good Practice Recommendations Ensure there is reference to the Social Services Complaints procedure, in the homes complaints procedure, and /or service user guide, as people funded by local authorities have a right to use this if they have a concern or a complaint. Review staffing arrangements to enable one person to go to night clubs and other evening activities more frequently. 2. YA14 15 Pentire Crescent DS0000028263.V377845.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission South West 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). 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