Inspection on 13/08/09 for 53 Churchfields

This is the latest available inspection report for this service, carried out on 13th 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

53 Churchfields 19/03/07

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 24/11/2009.

Key inspection report CARE HOME ADULTS 18-65 53 Churchfields Headley Down Bordon Hampshire GU35 8PE Lead Inspector Damian Griffiths Key Unannounced Inspection 13th August 2009 10:20a 53 Churchfields DS0000068500.V377772.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. 53 Churchfields DS0000068500.V377772.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 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 53 Churchfields Address Headley Down Bordon Hampshire GU35 8PE 01428 713308 F/P 01428 713308 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) Omega Elifar Ltd Miss Kelly-Marie Rippon Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) The maximum number of service users to be accommodated is 4 Date of last inspection 13th August 2007 Brief Description of the Service: 53 Churchfields is registered to provide care and accommodation to four people who have learning disabilities. Each service user has a single bedroom and shares the use a bathroom and shower room. One of the bedrooms has an ensuite shower room. Service users share the use of a lounge / dining room, kitchen and conservatory. There is an enclosed garden to the rear of the home that service users are able to access. The home is located in a residential area of Headley. 53 Churchfields DS0000068500.V377772.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 this service experience good quality comes. We agreed and explained the inspection process with the registered manager who was present throughout the inspection. Information included in this report was gathered from talking to the service users and staff on duty. Care Quality Commission (CQC) survey forms were completed by one service user who required the help of care staff, a relative visiting the home, three surveys were completed by health and social care practitioners and three surveys were completed by care staff at the home. We looked around all the communal areas of the home and documentation and records were read. Time was spent reading, reviewing care plans and records kept within the home. This included documentation including; pre-admission assessments, risk assessments, duty rota, training and recruitment records. We observed the way service users and care workers communicated and this also formed part of the information gathering process of this report. The home had completed an Annual Quality Assurance Assessment (AQAA) a self assessment report. It provided us with information relating to; what the home considers it does well, what it could do better, what has improved within the last 12 months and planned improvements. The AQAA had been completed on time by the registered manager and contained useful information about the home. The judgments have been made using the Key Lines of Regulatory Assessment (KLORA) which are guidelines that enable the commission to be able to make an informed decision about outcome areas. What the service does well: Individual care plans listing activities chosen by service users helped to promote independence and personal development and service users were able to make their own decisions about how they lived their life. Social and healthcare practitioners all agreed that the home respected the service users privacy and dignity. Service users benefited from being able to live fulfilling lifestyles, both within the home and in the wider community, they were supported and able to experience activities that enriched their lives and maintained contacts with families and friends. They were supported to plan their own meals so that they enjoyed a balanced and healthy diet. The service user completing the CQC survey confirmed that they could do what they wanted during the day, evenings and weekends. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 6 A relative completing the CQC survey confirmed that; we are very pleased with the positive support Johnny (not real name) receives despite his very complex needs. Commenting in the section of the survey, what does the home do well, care staff said; Organising service users holidays, they are always fun. Regular trips away with families and friends were supported and the home was organising a trip to Blackpool. The homes provided support to the service users to access healthcare practitioners and provided useful information that helped make sure their needs would be met. Social and healthcare practitioners confirmed that the homes care staff had the right skills and experience to support service users social and healthcare needs and confirmed that the home supported the service users with the administration of their medication correctly. The home environment had been purpose built to suit the service users who exercised their choice in furniture and decoration. 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. 53 Churchfields DS0000068500.V377772.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 53 Churchfields DS0000068500.V377772.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): 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. Clear information was provided to service users and their representatives and each person had an assessment of their care needs before moving into the home to make sure they could be met. EVIDENCE: The home’s Statement of Purpose was available to service users, their relatives and people involved with the home. There had been no new service users to the home for some years. We looked at previous pre-admission assessments that had been completed for two of the most recent service users to the home. Each person had received a preadmission assessment that detailed all aspects of their care needs. They had been able to visit and spend time with other service users prior to moving into the home. Three CQC surveys completed by social and healthcare practitioners agreed that the homes assessment arrangements ensured that accurate information was gathered and that the right services were planned for the service users. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 9 The service user completing the CQC survey agreed that the; carers listened and acted on what they said. 53 Churchfields DS0000068500.V377772.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): 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. Individual care plans listing activities chosen by service users helped to promote independence and personal development and service users were able to make their own decisions about how they live their life. EVIDENCE: Detailed care plans entitled, My Plan of Support had been drawn up from the initial pre-admission assessments of care. Service users and their representatives had been included in the planning and reviewing of the care plans. We looked at surveys in more detail and they were written in the service users own words, with pictures and photos. It covered a variety of different things that were important to the individual, such as, a daily routine, what they needed reminding about, when they needed encouragement and things they needed support with. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 11 Care plans showed how service users made decisions about their lives. They showed what had been agreed to keep them safe. They showed respect for the persons right to dignity and understanding, for example, using the bath, risk of epileptic seizure, if the water was too hot, risk of flooding, the risk of using a clothes iron and the risk of burns or going out alone. Other things that might be a risk to their safety were recorded in a risk assessment and there were guidelines in place for staff to follow. These had been reviewed and updated as things changed. Social and healthcare practitioners all agreed that the home respected the service users privacy and dignity. 53 Churchfields DS0000068500.V377772.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. Service users benefited from being enabled to live fulfilling lifestyles and to maintain contact with families and friends. They were supported to plan their own meals so that they enjoyed a balanced and healthy diet. EVIDENCE: The homes AQAA stated in the section titled, our plans for improvement in the next 12 months; continue to promote participation in the community. Support service users to research educational activities with consideration to personal preferences. Continue to support service users to maintain contact with family and friends. Continue to promote service users rights independence, choice and freedom of movement. Activities had been timetabled to ensure that service users and care staff were appropriately prepared before beginning any activity. The service user 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 13 completing the CQC survey confirmed that they could do what they wanted during the day, evenings and weekends. The home had its own transport and could visit the local community without difficulty. Service users were observed taking part in a variety of activities throughout the course of the inspection. This included visiting the local shops to buy favourite items, visiting the local leisure centre to go swimming and other service user focussed activities. The activities observed had been identified in the service users care plans and risk assessments had been completed, as discussed in the previous section. Service users were observed receiving visits from parents and preparing to go away for the weekend. A relative completing the CQC survey confirmed that; we are very pleased with the positive support Johnny (not real name) receives despite his very complex needs. We were advised by a relative that there were no visiting restrictions and that the home involved them in all aspects of their daughter/sons care as necessary. Commenting in the section of the survey, what does the home do well, care staff said; Organising service users holidays, they are always fun. Regular trips away with families and friends were supported and the home was organising a trip to Blackpool. Service users were encouraged to complete daily, independent living tasks, such as; shopping, ironing, change bedding, laundry and attending the local college to develop other skills. A service user was being supported to attend a local cafe where she/he would be able to improve their confidence and money handling skills. Care staff commenting in the section of the CQC survey, what does the home do well, said; offers all service users a wide range of community-based activities. All service users are well supported to be more independent and, the activities are organised by our home and also by outside groups which gives the service users the opportunity to develop relationships/friendships outside of the home. Care staff were observed working with service users in a knowledgeable, sensitive and respectful manner. The home was relaxed and service users were observed using all parts of the building. The privacy of service users was noted in care plans and staff were seen knocking on doors and asking permission to enter service users bedrooms. All three out of the four service users at the home went out for lunch during the inspection. We observed care staff helping the service user to choose what they were going to have for dinner. A salad and a favourite hot drink were selected from a series of picture cards that the service user was familiar with. In the section of the CQC survey titled; what does the home do well, care staff had said; the home meets the needs of each of the individuals living here, is 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 14 good at organising activities and caring for its service users, cooking, good healthy meals from fresh produce. The home was planning to develop more ways of promoting service user choice, by supporting them to choose seven planned meals each. The home had access to a range of social and healthcare practitioners including dietary experts who were available to advise if needed. Social and healthcare practitioners confirmed that the home responded to the diverse needs of individual service users, including; disability, gender, age, race, ethnicity, and sexual orientation. A service user completing the CQC survey confirmed the section of the CQC survey entitled, what does the home do well, reported; cooking, all sports, gym and swimming. This confirmed the homes statement made in the AQAA and showed how the home supported service users at home and in the local community. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 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. 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. The home supports service users to access healthcare practitioners and provided useful information that helped make sure their needs would be met. The homes practice in the administration and recording of medication met the service users needs by ensuring their ongoing healthcare needs. EVIDENCE: Social and healthcare practitioners confirmed that the homes care staff have the right skills and experience to support service users social and healthcare needs and confirmed that the home supported the service users with the administration of their medication correctly. Details of service users access to a range of local and specialist healthcare practitioners were recorded including; the dentist, the GP and the local community learning disability team. Each service user had a health action plan which had recorded their particular healthcare need. The two service users care plans sampled included a mental capacity assessment. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 16 The home had developed a hospital admission information booklet that contained full details of the service users healthcare needs in the event of an emergency admission. The booklet detailed a full range of information about the individual including; name, background, known allergies and other physical disabilities, their preferred method of communication and food requirements. This provided an essential tool to ensure that the correct personal details and information could be quickly accessed. Service users required the support of care staff to administer their medication. There was evidence in place indicating that the home had supported one of the service users to take their own medication, however, due to their changing care needs this was no longer possible. We inspected the homes medication administration records (MAR) and observed care staff administering medication to the service users. We counted tablets and compared them to the MAR. Medical administration records had been completed accurately and detailed the service users prescribed medication needs. Care staff taking medication out of the home, when the service user was going out for the day, also used a MAR to record what medication had been taken. Everyday cards, detailed service users medication needs and provided protocols for medication given from time to time. These cards had been laminated to ensure they were more distinctive and included useful information, for example; I can only have 2 mg of medication, and I may sometimes become very agitated, I will shout and scream. MAR for all the most recent, trips out, had been recorded. This ensured that care staff knew exactly when to administer medication that wasnt required every day. Care staff completing CQC survey confirmed that they had received training that gave them enough knowledge about health care and medication. Personnel files inspected showed that care staff administering medication had received this training. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 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. 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. The home had good systems to deal with complaints and had responded to safeguarding alerts. Care staff were subject to continuous professional development in this area. EVIDENCE: The homes AQAA stated in the section entitled; our plans for improvement in the next 12 months; it had to promote service users knowledge of their rights regarding concerns and instigate a service user friendly, complaints procedure. The homes complaints procedure was featured in the Statement of Purpose. It had been written in symbol/picture format to assist service users and showed how to contact CQC. The details were in need of updating and we were advised by the manager that she would complete this as soon as possible. There was also a picture format of the complaints system on the notice board. There were no complaints listed in any of the CQC survey forms completed. Social and healthcare practitioners confirmed that the home, always responded appropriately if they had any concerns. Care staff confirmed that they knew what to do in the event of somebody having concerns about the home. The home was aware of the local safeguarding procedures and had made sure that all the parties involved were informed when this was necessary. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 18 The homes AQAA stated that restraining techniques had been necessary on five occasions and the home had needed to make three safeguarding referrals to the appropriate local authorities. Commenting in the section of the CQC survey, what could the service do better, a social and healthcare practitioner stated, to date, all issues and concerns have been addressed. A clear record of events, details and outcomes of the safeguarding alerts were in place for inspection. Care staff had received full training and when consulted, were aware of how to implement the safeguarding procedures when necessary. The home had a, non-abusive psychological physical intervention (NAPPI) plan in place. This gave staff clear guidance as to the type of physical restraint to use, in a non-violent and safe manner. Care plans informed staff how to respond to service users presenting challenging behaviour. The home had also begun to assess service users under the Mental Capacity Act deprivation of liberty safeguards guidelines. Service users required help and support to manage their money. We observed the homes procedures when service user returned from a planned trip out with their care worker. The home had made available a receipt book for each service user. It showed details of every transaction that had been made. We observed the key worker numbering each new receipt and recording this in the receipt book. Any money taken out was accounted for and the key worker and the service user signed the receipt book. All monies were locked in a secure place and each resident had their own wallet. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 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. 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. The home provided service users with a safe and secure environment that was responsive to their care needs. EVIDENCE: All doors to the home had been fitted with appropriate locks and coded keypads and all visitors were required to sign in to ensure the safety and security of the service users. The service user completing the CQC survey confirmed that the home was always; fresh and clean. The home was very clean, tidy and without malodour throughout. The home had been sensitively equipped to accommodate the service users care needs in the way they preferred. The lounge area provided a comfortable place to relax with comfortable furniture and a television to watch. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 20 There were few personal touches in evidence, such as, photographs and ornaments around the home. We were advised that the service users did not wish to have these items on display. There was conservatory where service users could relax and look into the garden. The homes garden situated at the rear the property was in good condition and service users were currently creating a herb garden. One service user agreed to show us their bedroom. This had been decorated in the way they preferred and reflected their personality. Service users had access to a sensory/quiet room where they could relax if they were stressed or anxious. This room had been decorated with wallpaper designed to look like a forest and there was a canopy hanging over a comfortable sofa creating a cosy place to sit. Communal bathrooms were clean and tidy and contained paper towels and liquid soap to maintain hygiene and reduce the risks of infection. Equipment at the home had been adapted specially to reduce the possibility of accidental damage and injury. Following a service users habit of leaving the bath taps running and flooding the room, it had been fitted with an easy to use water valve that allowed staff to shut off the water supply. The homes laundry facilities met the service users care needs. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 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. 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. The home ensured that care staff received training that was relevant to meeting the care needs of the service users. The recruitment procedures were robust and provided service users with safe and experienced care staff. EVIDENCE: In order to establish whether the staff skills were adequate to meet the care needs of the service users we inspected the three personnel files of staff on duty. We looked at; the duty rota, training records and recruitment documentation. The three care staff completing the CQC survey agreed that; there were always enough staff to meet the needs of service users. They agreed that the ways of sharing information about the service users, other carers and the home manager, always worked well. Care staff also confirmed that they had received training that was relevant to their role, meeting the service users care needs, receiving updates about new ways of working and being given enough knowledge about health care and 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 22 medication. Commenting in the section of the survey, what the home does well, they said; staff ratio to service users is usually very good. Its always arranged to have extra staff when going for trips/theatre to make sure everyone will be safe and supported well. The personnel files showed that care staff on duty had gained a good mix of skills to meet the needs of service users. Skills/training required included; first aid, drug administration, epilepsy awareness, communication, NAPPI, fire safety and health and safety. The homes AQAA stated; service users are supported by competent qualified staff by the companys recruitment procedures. We inspected three personnel files that contained the documents required to establish the fitness of care staff to work with service users. Documentation included; protection of vulnerable adults (PoVA) and criminal records bureau clearances (CRB), ID, job application forms and references were all in place. Documentation provided by a care agency used by the home when care staff absences/vacancies needed to be covered, had provided evidence that all the relevant checks had been completed. This showed that the home employed robust recruitment procedures in order to safeguard and support service users. The homes AQAA confirmed that care staff had been supported to gain the appropriate training to help them support service users care needs. In the section of the AQAA, entitled; what we do well: high level of staff have achieved (or working towards) NVQ level 3 and above and well-balanced staff team with regards to skills, knowledge and experience in meeting individual needs. Personnel files showed evidence that care staff had received a full three month induction programme to familiarise themselves with the homes policies, practices and basic care and protection knowledge. Mandatory training including; health and safety, infection control and food safety ensured that care staff had acquired knowledge that would ensure that the health and safety of the service users was promoted. One of the care staff completing CQC survey commented; I feel that Churchfields home is managed and run very well and always has services best interests at heart. Generally all the staff get on well and it’s a fun, good place to work. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 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. 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. Outcomes for service users were good due to the management style of the home that made sure that the quality of care was regularly reviewed and that health and safety was actively promoted. EVIDENCE: Care staff completing CQC survey all agreed, that the manager regularly, gave them enough support and met with them to discuss how they were working. The AQAA was well completed and had all the things in it that we asked for. It was helpful in the planning of our visit and the things that we tested out were confirmed as being correct. The manager had been registered with CQC for over a year and had been able to maintain good outcomes for the service users 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 24 at 53 Churchfields. This was down to the home management approach of the home that made sure that service users felt valued and respected. There was good communication between care staff and service users. This meant that service users were fully consulted and involved in the daily running of the home and the planning of their own individual lifestyles. They had regular service user meetings and staff meetings. There was ongoing quality monitoring that included monthly visits by a representative of the owning organisation. The CQC surveys completed contained very positive statements about the home for example; Social and healthcare practitioners commented: the families are always very complimentary of the immediate staff team and manager who are committed and very supportive and, the home and staff; support individual needs and work with families, well. The homes health and safety practices were observed and inspected during our visit. We checked health and safety records that included fire safety procedures, gas and electrical equipment checks, care of hazardous chemicals and care staff training. Everything was in order and had been monitored, reviewed and where necessary updated. There were no health and safety concerns following our inspection of the home. 53 Churchfields DS0000068500.V377772.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 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 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 26 53 Churchfields DS0000068500.V377772.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. Refer to Standard Good Practice Recommendations 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Southeast 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 53 Churchfields DS0000068500.V377772.R01.S.doc Version 5.3 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!