Inspection on 08/09/09 for Coachmans Drive (51)

This is the latest available inspection report for this service, carried out on 8th September 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

Coachmans Drive (51) 19/11/07

Coachmans Drive (51) 24/10/06

Coachmans Drive (51) 04/02/06

Coachmans Drive (51) 26/11/05

Coachmans Drive (51) 18/02/05

Coachmans Drive (51) 04/08/04

Coachmans Drive (51) 02/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Coachmans Drive (51) 51 Coachmans Drive West Derby Liverpool Merseyside L12 0HX Lead Inspector Daniel Hamilton Key Unannounced Inspection 8th September 2009 09:30 Coachmans Drive (51) DS0000025241.V377088.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. Coachmans Drive (51) DS0000025241.V377088.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 Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coachmans Drive (51) Address 51 Coachmans Drive West Derby Liverpool Merseyside L12 0HX 0151 228 2295 0151 228 2295 croxteth.park@unitedresponse.org.uk www.unitedresponse.org.uk United Response Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Barbara Moore Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 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 the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 2 Date of last inspection 12th August 2008 Brief Description of the Service: 51 Coachmans Drive is a two bed-roomed bungalow that is situated in the Croxteth Park area of Liverpool. The service is provided by United Response and is registered to provide personal care and support to two adults with a learning disability. There is one registered manager and a team of staff that support the people who live in 51 and 53 Coachmans Drive. Both 51 and 53 Coachmans Drive are identical in layout and adjacent to each other. Each property has a large lounge, dining area, kitchen and a small spare room. The spare room in 51 Coachmans Drive is used as an office. Likewise, the spare room in 53 Coachmans Drive is used as a staff ‘sleep-in’ area. There are gardens to each of the properties. The property is decorated and furnished to a good standard and provides a homely environment that is domestic in character. Care Home Fees range from £1,482.17 to £1,710.50 (plus additional top-up fees) per week. Coachmans Drive (51) DS0000025241.V377088.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. This unannounced inspection took place over one day and lasted approximately 8 hours. Two people were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Registered Manager, Service Manager, four senior support workers and two relatives were spoken with during the visit. Likewise, one of the two people living in the home was encouraged to participate in the inspection process using their preferred methods of communication. (The other service user was on holiday at the time of the visit). Survey forms were also distributed prior to the inspection, in order to obtain additional views and feedback about the service provided and reference was made to an Annual Quality Assurance Assessment (AQAA) which was completed by the Registered Manager before the inspection. The AQAA is a self-assessment tool that focuses on how well outcomes are being met for people using the service and contains numerical information about the service. All the key standards were assessed and action taken in response to the previous requirements and recommendations from the last key inspection in August 2008 was reviewed. What the service does well: 51 Coachman’s Drive is a small home, which works on the principles of ordinary community living. The home offers a small and homely environment, which presents as being welcoming and friendly. Information on the service had been developed in the form of a ‘Guide for People we Support’ and a range of care planning documentation had been produced, to ensure staff understood how to provide person centred care in response to individual needs. The people using the service were supported to remain as independent as possible and to take responsible risks as part of their lifestyle. Staff continued to support service users to access and participate in a range of communitybased activities and to maintain relationships with their families and friends. Staff were observed to communicate and engage with the people using the service throughout the day and were seen to treat people with respect and dignity. Staff demonstrated knowledge and understanding of the needs and Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 6 preferences of the people they supported and the service users appeared relaxed and comfortable in their home environment. What has improved since the last inspection? What they could do better: Copies of care management reviews should be obtained to provide evidence that the needs of the people using the service are kept under review periodically. The content of personal files should be reviewed, to ensure information is not duplicated. Medication Administration Records should identify the name of the service user and the amount of medication received, to provide a clear audit trail for all medication. Excessive stocks of medication should be returned to the pharmacist, to ensure best practice. A complaint log should be established and available for inspection to provide information on any complaints received. Action should be taken to address the maintenance and refurbishment issues identified during the visit. This will help to ensure that service users live in a homely, comfortable and safe environment. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 7 The training and development needs of staff should be kept under close review to ensure staff complete refresher and ongoing training periodically. 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. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. 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. Policies and procedures are in place to ensure the needs of prospective service users are assessed prior to moving into the home. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) and examination of records confirmed that a ‘Guide for People we Support’ had been produced in a standard format by the Registered Provider (United Response), as noted at the previous inspection. The manager reported that she was working in partnership with the ‘Inclusion Team’ to develop the document into a format more suitable for the needs of people with a learning disability, as recommended at the last visit. Copies of original contracts had been archived and stored at the Registered Provider’s head office in Putney. The original contracts had been replaced with ‘Individual Charters / Contracts’ to ensure the people using the service or their representatives were aware of their rights and obligations. Examination of the Annual Quality Assurance Assessment (AQAA) for the service and previous inspection records confirmed that United Response Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 10 (Registered Provider) had developed policies and procedures in relation to referral and assessment. No new service users had moved into 51 Coachmans Drive since the last visit and records showed that the two people living in the home had been in residence for a number of years. As identified in previous inspections, the original assessments for the two people living in the home had been archived. The manager reported that the needs of the people using the service had been reviewed by health and / or social service care managers however only one person using the service had a copy of a recent review on file. The manager was requested to obtain copies of all reviews to provide evidence that the needs of the people using the service are kept under review periodically. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. People using the service are supported to have as much choice and control over their lives as possible, in order to promote independence and wellbeing. EVIDENCE: The Annual Quality Assurance Assessment for 51 Coachmans Drive detailed that the Registered Provider (United Response) had policies and procedures in place covering ‘Individual Planning and Review’ and the value base of the service. The personal files of two people using the service were viewed during the visit. Each file contained a range of documentation including Support and Essential Lifestyle Plans (ELP), which had been developed in partnership with the people using the service and their representatives. Plans viewed provided key information on each individual’s needs, preferences, support requirements, likes and dislikes, preferred routines etc and had been reviewed periodically. It was noted that one person using the service was in need of a person centred Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 12 review and the manager agreed to address this. Other supporting documentation was available for staff to reference including; communication profiles, support guidelines, listen to me workbooks, medical profiles, intimate and personal support assessments and a range of personcentred risk assessments. The majority of documents had been kept under review however some information was brief and had also been duplicated within other documentation. Examples were discussed with the manager who agreed to address and review these issues. The people living at 51 Coachmans Drive have complex communication and support needs. Therefore, the opportunity for service users to make decisions and their needs known relies to some extent on the staff team understanding and responding to their non-verbal communications. Staff were observed to effectively communicate and engage with the people using the service during the inspection process and were seen to treat service users with dignity and respect. Likewise, the people using the service were observed to be relaxed and comfortable in their home environment and responded positively to staff interaction by smiling, touching, gestures and / or responsive sounds. Discussion with the manager and staff confirmed the people living in the home were encouraged to take appropriate risks associated with the normal aspects of daily life and staff were available at all times to offer support. The people using the service were encouraged to actively participate in their local communities and a range of risk assessments had been completed for each service user in order to identify and control environmental, health and safety and person-centred risks. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Meals, activities and routines are flexible and varied to enable service users to follow their preferred lifestyle. EVIDENCE: Since the last inspection, a new document entitled ‘Things to consider in the future’ had been developed by the service, which outlined individual actions, goals and ideas for the future. The people using the service also had an activities programme as previously noted. Discussion with staff, direct observation and examination of records confirmed the people using the service continued to receive help and support to participate in a range of individualised person-centred leisure and recreational activities e.g. voluntary work, swimming, gym membership, bowling, pictures, hairdressing and personal shopping etc. One of the service users was also a Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 14 supporter of Everton Football Club and continued to attend home games at Goodison Park. At the time of the visit one of the people using the service was on holiday in Aberdeen. The other service user had been supported on a ‘Centre Parcs’ and a ‘Haven’ caravan site holiday earlier in the year. Examination of records and discussion with staff and relatives confirmed the people using the service continued to have regular contact and visits with family. Service users were observed to participate in shopping for household products and food. At the time of the visit the service had a £120.00 weekly allowance for food (shared between the two houses). Records viewed highlighted that menus were planned on a weekly basis and records of individual meal choices were recorded in diaries to provide information on each person’s dietary intake. Staff were observed to provide the people using the service with appropriate assistance with eating and drinking and guidance had been obtained from speech and language therapists as and when necessary. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The principles of respect, dignity and privacy are put into practice so people using the service can be confident they will be well cared for. EVIDENCE: The people living at 51 Coachmans Drive required intensive support with all aspects of personal care and support. A range of guidance had been produced to provide direction for support staff as previously noted and staff were observed to offer support to service users in a person-centred and dignified manner. Each person using the service had a ‘Health Action Plan’ which provided a summary record of health appointments for each service user. Health care appointments provided evidence that the people using the service had attended routine appointments with chiropodists, dentists, general practitioners, district nurses, opticians and other health care professionals when required. The Annual Quality Assurance Assessment for the service detailed that staff had access to a policy on the control, storage, disposal, recording and Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 16 administration of medicines. A copy of the corporate medication policy was stored in the “Getting it Right” quality manual and brief local procedures had also been developed for staff to reference. None of the people using the service self-administered medication at the time of the visit. The manager reported that staff responsible for the administration of medication had completed both in-house and external medication training. A basic medication assessment had also been developed to assess the competence of staff responsible for medication however this required further work to ensure the assessment was fit for purpose. Medication was dispensed by a local pharmacist. An identification system had been established to help minimise administration errors and record of staff authorised to administer medication, together with sample signatures was available for reference as previously noted. Medication Administration Records (MAR) and medication stocks were viewed during the inspection. Overall, MAR sheets viewed had generally been completed to a satisfactory standard however the following issues were noted. Firstly, one MAR did not contain the name of a service user and the auditing system did not provide a clear audit trail for individual medication received. Stock levels for some medication was also excessive. Examples were discussed with the manager during the visit. No controlled drugs were on the premises at the time of the visit. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Systems have been developed to listen and respond to complaints and to safeguard and protect service users from abuse. EVIDENCE: The Annual Quality Assurance (AQAA) for 51 Coachmans Drive confirmed procedures were in place for ‘concerns and complaints’. Previous inspection records detail that the complaints procedure had also been developed in a pictorial format that was suitable for the needs of people with a learning disability and confirmed service users and / or their relatives had received a copy of the complaints procedure. Copies of the procedure had also been placed in service user’s file for reference. The (AQAA) for the Service detailed that no complaints had been received since the last service. At the time of the visit the complaint log for the service could not be located therefore this information could not be verified. The Registered Provider (United Response) had developed an Adult Protection and Prevention of Abuse and a Whistle-blowing policy and a copy of the Liverpool Inter Agency Vulnerable Adult Protection Procedures was available for staff to reference. The manager and staff spoken with during the visit demonstrated a sound awareness of their duty of care to safeguard the welfare of the people using the service and training records viewed confirmed the majority of the staff team had completed training in abuse awareness. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some parts of the bungalow remain in need of repair, maintenance and / or refurbishment in order to provide the people living in the home with a safe, clean and comfortable environment. EVIDENCE: 51 Coachmans Drive is a two-bedroom bungalow that is adjacent to its sister home, which is an identical property. The bungalow had a spacious lounge and dining area. Laundry facilities were domestic in character and situated in the kitchen where service users could use them. The kitchen had a worktop available, which was at a level that enabled the people using the service to assist from their wheelchairs. The premises had one adapted bathroom for use by the people living in the home and staff. The bathroom was equipped with a raised bath with tracking system and a shower and a changing table with overhead hoist. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 19 The home did not have an alarm call system installed. Previous records detail that staff placed individual monitors in service users bedrooms to alert staff in the event of a service user(s) experiencing difficulties. Records were also available to confirm that a night support worker also undertook regular recorded checks. Both service user had their own bedrooms which were pleasantly decorated, furnished and had been personalised with assistance from staff. Contractors were hired for the gardens and to maintain the home and environment as and when required. Jobs in need of attention and / or hazards were recorded in a health and safety maintenance file and records confirmed that a range of weekly, monthly, six monthly and annual health and safety checks were completed. On the day of the visit the home was generally clean and tidy however some parts of the home were in need of attention, maintenance and / or refurbishment. For example, the carpet in the lounge and hallway was stained / stretched and some walls, doors and skirting were in need of repainting. Similar issues were noted at the last inspection. The AQAA detailed that since the last visit the ‘living’ areas had been redecorated. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 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 arrangements, recruitment practice and training opportunities ensure that people are cared for and supported effectively. EVIDENCE: 51 and 53 Coachmans Drive had been allocated a combined team of 12 permanent staff (including the registered manager) to provide direct care and support to two people who lived in each property. At the time of the visit there was a vacancy for one part-time employee. Discussion with the manager and staff and examination of staffing rotas confirmed the staff team consisted of one Registered Manager; two senior waking night staff and nine senior support staff. Staffing levels during the day varied dependent upon the needs and routines of the people using the service and during the night, one staff member undertook sleep-in duties (based in 53 Coachmans Drive) and another undertook waking night duties covering both 51 and 53 Coachmans Drive. The Annual Quality Assurance Assessment for the service detailed that the Registered Provider (United Response) had a policy on recruitment and Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 21 employment including redundancy. Recruitment was coordinated by the Registered Provider’s Human Resources Department as previously noted. The manager reported that no new staff had commenced employment at 51 and 53 Coachmans Drive since the last visit. Therefore, no recruitment records where checked during the visit as no issues of concern were identified with this outcome area at the last visit. The Annual Quality Assurance Assessment (AQAA) for the service detailed that 8 (72.73 ) of the 11 staff members (excluding the Registered Manager) had achieved a National Vocational Qualification at level 2 or above in Care. On the day of the visit, documentary evidence of National Vocational Qualifications could be located for only five (45.45 ) staff. The manager reported that an additional two staff had completed the award and were awaiting their certificates and three staff were working towards the qualification. Previous inspection records confirm that the Registered Provider had developed a corporate induction package, which was based upon the ‘Skills for Care’ Common Induction Standards. Since the last visit the manager had established a training record and evidence of training completed was in the process of being collected for the staff team. Discussion with staff and examination of the training matrix for the service confirmed staff had access to induction, safe working practice, national vocational qualifications, abuse, medication, equality and diversity and other training relevant to the needs of the people they supported. Records viewed revealed that some staff were in need of refresher training for some safe working practice topics and this had been highlighted on the training matrix for action. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Management and administration systems are subject to ongoing development and review to ensure the service is run in the best interest of the people using the service. EVIDENCE: At the time of the inspection Barbara Moore was registered with the Care Quality Commission as the manager of the service. Documentary evidence was available to confirm the Registered Manager had completed the level 4 National Vocational Qualification (NVQ) - Registered Manager’s Award and the manager reported that she was in the process of completing a level 4 NVQ in Care. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 23 Feedback received from staff and relatives of the people using the service confirmed the service was managed in the best interest of the people using the service and staff confirmed the manager was helpful and supportive. The Annual Quality Assurance Assessment (AQAA) for 51 Coachmans Drive detailed that an annual development plan for quality assurance was in place and confirmed monitoring systems had been established as previously noted. The manager reported that the organisation continued to utilise a comprehensive auditing / quality assurance manual entitled “Getting It Right” and evidence was available to confirm monthly and quarterly assessments were undertaken by senior staff on behalf of the Registered Provider. On the day of the visit a service manager was observed to visit the service to undertake a routine assessment and to offer support. Minutes were also available to confirm staff meetings were coordinated each month. Since the last inspection a questionnaire had been sent out to the families of all the people using the service during July 2009 to seek views on the quality of the service. No issues of concern were identified. Advice was given to the manager on how to develop the survey. Comments received from family members included; “Everything is excellent in my opinion” and “I monitor the standard of care closely and I have always found the manager and staff to be open and honest.” Information received via the Annual Quality Assurance Assessment (dataset) for the service, confirmed policies and procedures had been developed on Health and Safety. Likewise, the AQAA confirmed that equipment in the bungalow had been serviced and / or tested periodically however the last recorded date for a review or certificate for the fire alarm system was March 2000. Examination of fire records for the bungalow confirmed the fire alarm system and emergency lighting was tested on a weekly basis by staff. Service records were also available to confirm the fire extinguishers and alarm system had been serviced periodically and an engineer was observed to undertake an inspection of the fire alarm system on the day of the visit. Records confirmed that additional weekly, six monthly and annual health and safety checks were also completed as previously noted. A certificate had also been obtained to provide evidence that the electrical wiring installation was safe. Coachmans Drive (51) DS0000025241.V377088.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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 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 2 X 3 X 3 X X 3 X Version 5.2 Page 25 Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA2 YA6 YA20 YA20 YA22 YA24 Good Practice Recommendations Copies all care management reviews should be obtained to provide evidence that the needs of the people using the service are kept under review periodically. The content of personal files should be reviewed, to ensure information is not duplicated. Medication Administration Records should identify the name of the service user and the amount of medication received, to provide a clear audit trail for all medication. Excessive stocks of medication should be returned to the pharmacist, to ensure best practice. A complaint log should be established and available for inspection to provide information on any complaints received. Action should be taken to address the maintenance and refurbishment issues identified during the visit. This will help to ensure that service users live in a homely, comfortable and safe environment. The training and development needs of staff should be DS0000025241.V377088.R01.S.doc Version 5.2 Page 26 7. YA35 Coachmans Drive (51) kept under close review to ensure staff complete refresher and ongoing training periodically. Coachmans Drive (51) DS0000025241.V377088.R01.S.doc Version 5.2 Page 27 Care Quality Commission Northwest 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. 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