Inspection on 03/08/09 for 85 Heath Road

This is the latest available inspection report for this service, carried out on 3rd August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

85 Heath Road 09/08/07

85 Heath Road 09/08/06

85 Heath Road 13/12/05

85 Heath Road 05/08/05

85 Heath Road 13/01/05

85 Heath Road 14/09/04

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

Key inspection report CARE HOME ADULTS 18-65 85 Heath Road Barming Maidstone Kent ME16 9LD Lead Inspector Robert Pettiford Key Unannounced Inspection 3rd August 2009 8:55 85 Heath Road DS0000023800.V376929.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. 85 Heath Road DS0000023800.V376929.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 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 85 Heath Road Address Barming Maidstone Kent ME16 9LD 01622 729946 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) heathrd@mcch.org.uk www.mcch.co.uk MCCH Society Ltd Ms Karen Gowers Care Home 3 Category(ies) of Learning disability (0) registration, with number of places 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 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 3. Date of last inspection 8th August 2008 Brief Description of the Service: 85 Heath Road is one of a group of small care homes managed by MCCH Society Ltd. The home provides care through encouraging independent living and support for a maximum of three residents with a Learning Disability. The home does not currently provide 24 - hour care or night time sleep-in cover. The home’s care staff work on a roster basis to cover identified key care times. The home currently has 99.9 direct care hours over 7 days per week. The residents in the home are required to be semi independent and can access activities within the local community and day services in the area. 85 Heath Road is situated in Barming, with good local amenities near by. It is on a main bus route to Maidstone town centre. The house has two bedrooms, a communal bathroom/toilet and small office/staff room on the first floor. The third bedroom with en-suite facilities is on the ground floor, alongside the lounge, kitchen/dining area. The home has car parking to the side of the property (but further car parking is available on the main road) there is a ramped pathway entrance to the front door and a garden to the rear of the property. The current weekly fees are according to assessment. Additional charges may be made for personal items such as clothes; toiletries and magazines; leisure and social activities (e.g. pub, cinema) Information on the Home’s services and reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. 85 Heath Road DS0000023800.V376929.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 this service experience good quality outcomes. The inspection took place at 8:55AM on 3rd August 2009 We agreed and explained the inspection process with the registered manager who was present for part of the inspection and a senior member of staff. The focus of the inspection was to assess the home in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process. This was to support us to explore any issues of concern and verify practise and service provision. The home had completed an annual quality assurance assessment questionnaire (AQAA). This provided us with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements 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. Further information can be found on the Commissions website with regards to information on KLORAs and AQAAs. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, rotas, and training records. In addition an environmental tour took place. We identified a sample of residents for case tracking (a review of the level of care and support needed, and if it is being provided in a way that treats them with respect and dignity). 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 6 What the service does well: 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. 85 Heath Road DS0000023800.V376929.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 85 Heath Road DS0000023800.V376929.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): People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that their needs will be properly assessed prior to moving to the home. However these need to be kept under review. EVIDENCE: The standard relating to the assessment of residents prior to them moving into the home was met from the previous inspection. No evidence or intelligence would suggest that the process does not continue to meet with the required standard. Records showed at the previous inspection that residents have an assessment, which identifies their individual needs prior to or on admission to the home. This is then reflected into the care plans and these are developed in agreement with the individual where possible. We however identified a resident whose increased mobility needs, specifically with regard to the level of staffing were not in our opinion being met on evidence gathered during the inspection process. Previous information held by the Commission showed the Statement of Purpose states the ethos of the home is to support residents with their needs, but says residents living in the 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 9 home are required to be semi independent. However on evidence viewed through the care tracking of several residents and discussions with staff this was not the case for all residents. During the inspection a fire alarm test was made. We directly observed in the presence of one staff member a resident who had difficulty opening the front door. Residents spoken with by the Commission during the course of the inspection also expressed a wish to have additional staffing. Accident records also show residents have had falls in the past. The level of staffing at present does not currently provide 24 - hour care or night time sleep-in cover. The home’s care staff work on a roster basis to cover identified key care times. The home does have a sophisticated alarm monitoring system supported by an independent company with staff back up. However in the view of the Commission on evidence gathered at and leading up to the inspection the current staffing arrangements put residents at potential risk and are in need of review. The home is therefore required to review the resident’s needs to ensure that arrangements have been made for appropriate support. The home is requested to specifically look at mobility and risk assessments and include care management within the review process where possible. A requirement has been made to this effect. The assessment process as shown in the AQAA recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. 85 Heath Road DS0000023800.V376929.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): People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from having clear individual plans that are comprehensive, identify their needs and are specific to the individual resident. EVIDENCE: The key principles of the home for delivering a quality service are based on the belief that residents should be able to take control of their lives. The staff of the home are strongly committed to supporting all residents to make informed decisions and understand the range of options which are available to them. Evidence of this was gathered through taking to the residents, staff, manager and information contained in the AQAA. As previously mention the Commission has requested that resident’s needs are re assessed to ensure that the current staffing levels meet their needs. 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 11 The home and its staff are committed to supporting the residents. This was evidenced through the care plans which detailed the areas of support that the resident needed and how this support is provided by the staff. There were guidelines in respect to routines and behaviour. The member of staff confirmed that these are reviewed with the residents on a regular basis and the families are supported to be involved. The plan focuses on current needs, development of skills. This follows the principles of person centred planning. Staff have the necessary training and skills to support and encourage the individual to be fully involved. Resident’s rights to make decisions are respected and the care plans reflected their ability to make an informed judgment. Care plans included risk assessments. All areas of risk were identified in the documentation viewed. However it was recommended that these were re drafted as some were originally written in 2006. Reviews were evidenced but based on old original risk assessment. Where there are limitations on choice or facilities, it is in the persons best interest. The resident understands and agrees the limitations where possible. 85 Heath Road DS0000023800.V376929.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: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that they are offered a range of opportunities for personal development and feel part of the wider community. Residents engage in a good level of activities which are appropriate to their needs and capabilities. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. EVIDENCE: 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 13 Residents are enabled to participate and contribute to meeting their own self care needs and day to day chores around the house. Discussion with residents and staff confirmed that the level of activities were of a good level and that they enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home. We joined residents at 8:55am while they were getting ready for the day ahead. Residents were observed participating and interacting with staff. Residents have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining and building on personal collections and specific recreational activities. The service actively encourages and provides imaginative and varied opportunities for Residents to develop and maintain social, emotional, communication and independent living. However limited options are available for one to one activities without forward planning. The home was recommended to review its staffing levels to aide more flexibility and one to one support. The staff have a strong ethos and focuses on involving Residents in all areas of their life, and actively promotes the rights of individuals to make informed choices. The AQAA showed that residents are encouraged to use all aspects of their home according to their ability and wishes - these include laundry, cooking and cleaning. Residents are encouraged to pursue activities, hobbies and interests both inside and outside of the home. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. Residents were consulted with regard to whom they saw and when and were under no compulsion to accept visitors should they not wish to do so. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents activities and schedules. Residents are able to choose where to eat, and also have facility to make drinks, meals and snacks for themselves and others with staff support should they wish. Residents on evidence seen have had been involved in planning and choosing what to eat. 85 Heath Road DS0000023800.V376929.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): People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel supported by the level of help given and that their healthcare needs are addressed. Residents can feel confident that their wellbeing will be protected by the homes policy and procedures with regard to the handling and administration of medication. EVIDENCE: The care plans fully documented the personal support required for individual Residents within 85, Heath Road. They reflected their choices and preferences and staff were observed offering guidance where needed. Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different Residents daily routines. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. It is recognised that the delivery of personal care is highly individual and must be 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 15 flexible, consistent and reliable. Attention is given to ensuring privacy and dignity when delivering any support with personal care. The care plans also fully documented all physical and emotional health care needs... Within the care plans records of health care provided by G.P, chiropodist, dentist, and opticians was evident. Residents physical and emotional health is monitored on a daily basis. Through their daily records and these correspond with support assessments held in the care plans. This system ensures that all Residents receive continuity of care and supports potential complications and problems at an early stage. It is evident through records that the emotional health support is of a high priority to this home and the staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. Evidence to support the judgements made within this section have been obtained within the AQAA and discussions with the residents and staff. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of PRN/As Required Medication. The medication was seen to be stored appropriately and administered in accordance to current guidance. The manager confirmed that all staff who dispenses medication has received appropriate training. 85 Heath Road DS0000023800.V376929.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): People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know that their concerns and complaints are taken seriously and are protected from the risks of abuse. EVIDENCE: A copy of the complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. The complaints procedure is highly visible within the service and is more readily available in different formats. The procedure however needed updating as it referred to the Care Quality Commissions previous legacy organisation. No complaints have been received by the Commission or adult abuse (safeguarding) alerts made since the last inspection. The homes Policy for the Protection of Residents and staff Whistle blowing procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training is provided adult protection. The home promotes an open culture where Residents feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding protection are in place. 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 17 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 this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not wholly benefit from living in a well maintained environment. Residents can not feel wholly confident that they are protected by the homes infection control procedures and policies. EVIDENCE: The standard of internal decoration and fixtures and fittings are of a variable quality. The home would benefit from a degree of re decoration and refurbishment. Carpeting in high traffic areas was very dirty. Maintenance tends to be reactive rather than proactive. The kitchen floor was found to be in need of some attention with regard to re-refurbishment and cleaning. No statutory requirement has been made at this time as the Commission is confident that the provider now made aware of shortfalls in this regard will address these outstanding issues. No evidence was available of any recent 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 18 Environmental Health Officer visits from the local Council. The manager is requested to contact the Council to review the frequency of visits. The premises are not wholly kept clean as mentioned previously carpets in certain areas are in need of deep cleaning and the bath hoist was dirty. A bath slip mat was found with growing black mould on the back. A staff member was requested to address this concern as a priority. A staff member later replaced it with a new one. Mops were not colour coded and stored correctly to decrease cross contamination of bathroom and kitchen mops. The home is requested to seek advice from the infection control nurse and ensure that it follows current policies and guidance. The laundry facilities currently meet the needs of the residents living within the home. 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 19 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 this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents care, social and emotional needs are promoted by the employment of caring and suitably trained staff. However evidence within this report suggests levels of staffing are in need of review. Recruitment procedures are robust. Therefore residents can feel confident that they are protected. EVIDENCE: From discussions with staff, observations and reviewing the staff rotas Sufficient staff were on duty at the time of inspection to meet the resident’s immediate needs. However evidence within this report suggests levels of staffing are in need of review. However limited options are available for one to one activities without forward planning. The home was recommended to review its staffing levels to aide more flexibility and one to one support. 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 20 The staff training records indicated planned and undertaken training. The manager evidenced that individual and group staff training needs had been identified. A wide range of training has been identified for all staff . The staff member present showed us the induction programme which she stated complies with the recommendations of the Skills for Care Councils. The staff training records indicated planned and undertaken training in all the key areas. Core training in Infection control, Moving and Handling, Basic Life support, fire training, food hygiene, and Adult protection has been provided. Core courses are undertaken by staff to maintain current qualifications and for protection of residents. Staffing files sampled contained the relevant details as required of the Care home regulations. 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 21 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 this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in an overall well run and managed home with good outcomes overall. However lack of a robust quality assurance processes and the managers other responsibilities managing two other homes could compromise the quality of care within the home and safety of the residents. Residents can be fully confident that their views and opinions effect how the home is run and that their best interest is safeguarded by appropriate policies and procedures. However these are out of date and in need of review. EVIDENCE: 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 22 The registered manager is actively involved in the day-to-day management of the home and works with staff and residents. However her time within the home is limited due to her currently additionally managing another two homes managed by the provider. Evidence of this was gathered from talking to the member of staff assisting with the inspection and talking to a senior representative of the provider. Whilst it is accepted that outcomes for residents on evidence gathered are generally very good issues highlighted within this report and the additional responsibilities of the manager potentially put the residents at risk of harm. The Provider is required to review the management of the home to ensure that it is managed appropriately and does not compromise safety. No requirement has been made at this time as the Commission is confident that the provider will wish to review the management of the home to achieve the best outcomes for residents. Quality of care is good. However shortfalls identified within this report with regard to staffing potentially put residents at risk and limits opportunity for one to one support. The Commission recommended that staffing is reviewed. The manager is aware of the shortfalls and has indicated a willingness to work with the Commission to address these issues. Residents expressed a great deal of satisfaction of the care provided and the staff are very supported of the manager and have a positive ethos. Residents, their relatives and staff are encouraged to comment on the services the home offers and to voice any concerns they may have. The home has a limited quality assurance system. Quality monitoring systems do not currently provide management evidence that practice reflects the homes policies and procedures. It that the out of date policies and procedures evidenced and issues identified within the report has not previously been identified by management. An appointed person of the registered provider of the home does regularly visit the home and complete what is known as a Regulation 26 visit. The Regulation 26 visits requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. However improvements in the process is required. No requirement has been made at this time as the Commission is confident that any shortfalls will be addressed. The home has a full range of policies and procedures to promote and protect resident’s health and safety. However the policies sampled were out of date. Some of which were dated 2003. The manager is requested to ensure that these are updated. There is full and clearly written recording of all safety checks. Environmental risk assessments are in place. 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 23 The manager is requested to re visit the fire risk assessment and seek the advice of the fire officer to ensure as previously highlighted residents can leave the building un hindered in the event of a fire. The provider is additionally required to ensure that the Commissions concerns throughout this report are reviewed in a timely manner. 85 Heath Road DS0000023800.V376929.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 2 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 2 25 x 26 x 27 x 28 x 29 x 30 2 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 2 x LIFESTYLES Standard No Score 11 x 12 3 13 x 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 2 x x 3 x Version 5.2 Page 25 85 Heath Road DS0000023800.V376929.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. 1 Standard YA3 Regulation 14(1)(d) Requirement The registered person shall not provide accommodation to residents at the care home unless following assessment by care management and the home they can evidence that said accommodation is suitable for their needs. The home is required to review resident’s needs to ensure that arrangements have been made for appropriate support. Timescale for action 03/11/09 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 85 Heath Road DS0000023800.V376929.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission South East 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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