Inspection on 15/07/09 for Fieldhead

This is the latest available inspection report for this service, carried out on 15th July 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

Fieldhead 26/07/06

Fieldhead 24/10/05

Fieldhead 05/05/05

Fieldhead 22/02/05

Fieldhead 30/09/04

Fieldhead 09/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOME ADULTS 18-65 Fieldhead Back Lane, Skelton Road Langthorpe Boroughbridge North Yorkshire YO51 9BZ Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 15th July 2009 9:15 Fieldhead DS0000007874.V376526.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. Fieldhead DS0000007874.V376526.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 Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fieldhead Address Back Lane, Skelton Road Langthorpe Boroughbridge North Yorkshire YO51 9BZ 01423 325052 F/P01423 325052 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) www.st-annes.org.uk St Anne’s Community Services Mr Kerin Roy Tomkinson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 5 Service Users with Learning Disability some of whom may also have a Physical Disability. 2nd July 2007 Date of last inspection Brief Description of the Service: Fieldhead is a care home registered by St Annes Community Services to provide personal care and accommodation for up to five younger adults with learning disabilities, some of whom may have physical disabilities. The home is a detached, two-storey house that is situated in its own grounds that are set back from a main road in Langthorpe, which is close to Boroughbridge. Local community amenities and facilities, including shops and pubs, are within walking distance for those with good mobility. Other than that, transport would be required. Each of the five bedrooms is for single accommodation, two of which have ensuite facilities. These are situated on the ground and the first floor, the latter of which are accessed via a staircase. There are well-maintained garden areas to the rear and side of the house along with an area for parking. The standard fee charged by the home is £1,114 per week. Toiletries, hairdressing, cigarettes, holidays and activities outside of the home are not included in the fees. This information was provided on 21 July 2009, after the inspection. Fieldhead DS0000007874.V376526.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 Care Quality Commission (CQC) inspects care homes to make sure the home is operating for the benefit and well being of the people who live there. More information about the inspection process can be found on our website www.cqc.org.uk We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations- but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The last key inspection was carried out in July 2007. Before this visit we reviewed the information we had about the home to help us decide what we should do during our inspection. Surveys were sent out to one person who lives at the home, staff and health and social care professionals before the inspection. The person who lives at the home was helped by two staff to complete the survey. We also received surveys from eight staff. Comments from the surveys have been included in the report. People who live at the home could only give us limited information as to whether they are satisfied with the service they receive or if their needs are being met. At the inspection we spoke to two people who live at the home with assistance from a member of staff and we joined everyone for lunch. One inspector was at the home for one day from 9:15am to 2:30pm. We spoke to two staff and the registered manager. We looked around the home, and looked at care plans, risk assessments, daily records and staff records. We spent a total of 5¼ hours at the home. Feedback was given to the registered manager at the end of the visit. What the service does well: People are supported to make decisions and receive care that meets their individual needs. Staff gave us good examples when people have been supported to make choices. For example new menus that are based on people’s preferences have just been introduced. Staff had talked to people, used pictures of food and their knowledge of people’s likes and dislikes. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 6 Staff surveys and discussions with staff told us people’s needs are met and the home is good at making sure people received individualised care. We were told, ‘the home cares for people well’ and ‘caters for the individual’s needs, likes and dislikes’. Daily records showed that peoples needs are being met. Individual records showed us people’s health and personal care needs are met, and staff are vigilant and look for changes in peoples well-being. We joined everyone for a meal at lunchtime. People who live at the home and staff sat together. The mealtime was very relaxed and there was a good atmosphere and interaction between everyone. People who live at the home enjoyed the meal which was home-made soup and crusty bread. People who live at the home are supported by a competent staff team. A good recruitment process is in place and staff receive the right training to help them understand and meet the needs of people living at the home. Good systems are in place for monitoring the quality of the home. The manager and staff carry out different safety checks. The area manager visits at least monthly and carries out checks to make sure the home is running smoothly. 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. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 7 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. Fieldhead DS0000007874.V376526.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 Fieldhead DS0000007874.V376526.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): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are properly assessed before they move into the home and they are assured their needs will be met. EVIDENCE: Since our last key inspection in July 2007 nobody has moved into the home. At the last key inspection we made a judgement that people using the service experience a good outcome in this area and they know what to expect from the service and can be confident that their needs will be met. In the Annual Quality Assurance Assessment (AQAA) the registered manager told us if they were planning an admission they ‘would work with the prospective individual, their care manager, family, friends and advocates etc’. We have not received any information since our last inspection to show the outcome would be different. Fieldhead DS0000007874.V376526.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): 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 are supported to make decisions and receive care that meets their individual needs. EVIDENCE: The survey from the person who lives at the home told us they are treated well and are happy living at Fieldhead. Staff surveys and discussions with staff told us people’s needs are met and the home is good at making sure people received individualised care. These are some examples of what staff told us the home does well: • • Gives people full support to fulfil their needs and ensure that they have (where possible) what they require. Tries to give people a say whenever possible. DS0000007874.V376526.R01.S.doc Version 5.2 Page 11 Fieldhead • • The home cares for people well. Caters for the individual’s needs, likes and dislikes. In the AQAA the registered manager said, “‘Each month all the clients are encouraged to take part in a clients meeting, which is held at a level and pace which suits them. This allows the clients to express choice in where they live and what they personally wish for.’ We looked at house meeting minutes that showed us staff and people at the home regularly discuss topics that relate to the home. They have recently talked about holidays, menus and decoration. In the AQAA the registered manager also told us, “All our clients are asked on a daily basis on what choice they want, for example what to wear, what they would like to eat or they may ask where to go such as shopping.” Staff told us people are given choice and encouraged to make decisions where possible. Care records had guidance about offering choice to people. For example one person’s care plan said staff should get the different cereals out then the person can point to the one they want. One staff discussed how the home had recently introduced new menus that were based on the preferences of the people who live at the home. They said they had talked to people, used pictures of food and staff knowledge of people’s likes and dislikes. Staff thought the new menus were very popular. We looked at two people’s care records, which had good information about how people’s needs should be met. Each person has a personal profile with specific guidance for support and good information about routines. They cover important areas of care such as personal care, mobility and communication. One person’s information said they can finish putting on garments such as trousers if staff start the process. Staff confirmed they do this. We observed the care people were receiving during our inspection, which matched what was recorded in the care plan. One person’s care plan said they had specialist equipment to help them eat meals and they received this support at lunch time. One care file had a ‘person centred plan’ dated November 2008. This identifies what is important to the person and how everyone can help the person achieve what is important. Most action points were being followed to help the person achieve what is important but we did not see evidence that every action point was being followed. The plan identified that the person should have support to write to a relative but this did not appear to have been done. It was identified that the person should have opportunities to develop skills in the kitchen and be Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 12 encouraged to do laundry but there was no evidence that these had been followed up. The manager agreed to look at these areas. The manager said St Anne’s is setting up a group so everyone can complete a person centred plan if they wish and they hope to have this in place by the end of this year. We looked at risk assessments, which identified potential risks and the action that is required to minimise the risk. Staff record information about people and what they have been doing. The records show how peoples needs are being met. Six staff surveys told us they are always given up to date information about the needs of the people they support; two staff said they are usually given enough information. Fieldhead DS0000007874.V376526.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. People have an enjoyable and varied lifestyle. People do not get enough opportunities to take part in daily tasks around the home so some elements of independence are not promoted. EVIDENCE: In the AQAA the registered manager gave us good examples of how the home supports people to maintain personal and family relationships wherever possible. Staff said the home is good at supporting people to have regular contact with their relatives. Care records contained good information about family and friends, and other people who are important to them. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 14 Staff surveys told us people who live at the home have a good lifestyle. In the surveys we received the following comments; • • • Service users receive good balanced meals Service users go out to activities, days out, holidays etc We Promote independence and get service users to try new things In the AQAA the registered manager identified that their plans to improve the service included organising more social activities. We talked to the manager and staff about this. They told us people who live at the home go out on a frequent basis and do different things but felt this had been slightly restricted recently because they have been low on staffing numbers. We have covered this in more detail in the staffing section of the report. We asked staff and the manager about daily living skills. They told us people who live at the home have limited involvement in tasks around the home, and in the main staff are responsible for cleaning the house, laundry and cooking the meals. One person’s plan said they should have opportunities to develop skills in the kitchen and be encouraged to do laundry. We did not see any evidence that this was being followed. The manager said one person goes in the kitchen and helps with the washing up but three people do not generally go in the kitchen because there are associated risks. We looked at one person’s file but it did not contain a risk assessment for accessing the kitchen. The laundry room is a small area and is not easy to access. The manager agreed to look at how people could be more involved in daily living around the home. We joined everyone for a meal at lunchtime. People who live at the home and staff sat together. The mealtime was very relaxed and there was a good atmosphere and interaction between everyone. People who live at the home enjoyed the meal which was home-made soup and crusty bread. We looked at the menus, which are varied and nutritious. Staff said the meals are good quality and meal times seen as a very important part of the day. Fieldhead DS0000007874.V376526.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. Peoples health and personal care needs are met. EVIDENCE: In the AQAA the registered manager said, Service users have access to a wide range of healthcare professionals via our local resource team, including physiotherapists, psychologists, psychiatrists, behaviour support. The registered manager said they have had more involvement where needed with the community resource team in the last twelve months. In the AQAA the manager identified that they could improve the health action plans for people who live at the home and training has been provided to staff to make this happen. Staff said the home is good at meeting peoples personal and healthcare needs. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 16 We looked at information that showed us healthcare professionals are involved in peoples care and people who live at the home regularly attend healthcare appointments. Individual records have good information about appointments and showed us that staff are vigilant and look for changes in peoples wellbeing. Three health action plans are finished and one is nearly complete. We looked at one of the finished health action plans. This was an excellent document that provided very good information about the person’s healthcare needs and the action that should be taken to make sure their health needs are met. We observed staff knocking on doors before entering people’s rooms. We talked to staff about the quality of care at the home and they gave us good examples of how they make sure they respect people’s privacy and dignity. We observed medication administration and looked at medication systems. Medication was administered appropriately and good systems are in place to make sure the right medication has been administered. The records were completed correctly. All staff who administer medication have completed medication training. Seven staff surveys said they are given training that gives then enough training about health care and medication; one survey said they had not received enough training in this area. Fieldhead DS0000007874.V376526.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. People who live at the home are safeguarded. Complaints are properly investigated but the number of complaints received are not being carefully monitored, which could result in the level and any pattern of complaint being missed. EVIDENCE: In the AQAA the registered manager told us the home has received one complaint in the last twelve months. We checked our records which showed us the home had received two complaints. At the inspection we asked to look at the home’s complaints record but the manager could not locate this. After the inspection, the manager contacted us and said he had located the complaint’s record and would use this in future to help monitor complaints. We received information from St Anne’s that showed us they have investigated complaints properly. Seven staff surveys said they know what to do if someone has concerns about the home; one person said they did not know what to do. Staff said they would report any concerns to the manager and they are confident he would deal with them promptly and appropriately. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 18 In the AQAA the manager told us, “Adult protection is regularly reinforced at staff meetings to ensure that good practice is upheld and that each person is aware of the signs and procedure of abuse.” We looked at staff meeting minutes which confirmed safeguarding adults has been discussed at staff meetings. At one meeting the manager had ‘asked for staff responses on given situations where physical abuse has been suspected’. Safeguarding guidance that must be followed and a fact sheet were displayed in the office. Staff have attended safeguarding training. Staff were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. We looked at personal allowances for two people. The money held corresponded with the financial record. Personal monies are held individually and each person has a record of transactions. Staff check these to make sure they are correct. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 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): 24 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a spacious, homely and clean environment. EVIDENCE: The survey from the person who lives at the home told us the home is clean and tidy and they like their bedroom but would like it decorating. When we looked around the home it was clean, tidy and free from any offensive odours. In the AQAA the manager told us handrails have been fitted in the more active communal areas such as the dining room and the corridor so people who have mobility needs are able to walk independently in the home more safely. The building is attractive from the outside and homely from the inside. There is sufficient indoor and outdoor space for people to be able to have time and space alone without having to go into their bedrooms. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 20 The environment is reasonably well maintained although some areas are ready for decorating. Some wallpaper looks dated and paintwork is marked. The manager explained St Anne’s are planning to move everyone into alternative accommodation, which should take place over the next year. Therefore they are not carrying out any major work at the home but would still make sure people live in a well maintained and pleasant environment. The kitchen was inspected by environmental health in June 2009. A report of the visit was seen and this shows the visit was satisfactory. The home has appropriate laundry facilities. At the last inspection we said the gas hob in the kitchen must be made safe and kept in good working order. The manager said the hob had been replaced. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 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): 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. People who live at the home are supported by a competent staff team. EVIDENCE: Staff told us people who live at the home receive a good service and the staff receive the right support to meet the needs of the people who live at the home. We received eight staff surveys and spoke to two staff, and the registered manager. Several of the surveys made reference to good team work. We received the following comments about what the service does well: • • • It’s very individual and we are good at new ideas A good mix of staff who work together well, which makes a good atmosphere Good team work DS0000007874.V376526.R01.S.doc Version 5.2 Page 22 Fieldhead • • There is a good rapport and Fieldhead is a pleasant living environment Staff are supportive of one another. In the AQAA the manager told us six staff have left in the last twelve months, which is a relatively high turnover of staff. Suggestions in staff surveys to improve the home mainly related to the number of staff working at the home. One survey stated, “We need more members of staff and staff need to stay longer.” Another survey stated, “It would be better if service users were able to go out more and do more activities. This can be addressed when there are enough staff- there’s currently not enough staff.” One staff survey said there is always enough staff to meet people’s needs; six surveys said; there are usually enough staff; one survey said there are sometimes enough staff. The home is staffed with a minimum of two staff but many shifts have three staff on duty. Over recent weeks the home has often only had two staff on duty which limits the level of activities that people can do. The manager spends Mondays, Tuesdays and Wednesdays at the home and will work directly with people and provides extra support. The manager said they have had difficulties recruiting and retaining staff although the recent high turnover was unfortunate and staff had not left because they were unhappy working at the home but had left for personal reasons. They use agency staff when required and will usually have the same agency worker will helps provide consistency. At the time of the inspection the home had two staff vacancies but people have been interviewed and recommended for both posts. Pre employment checks were being carried out. One person was completing their induction programme. This should then resolve the staffing difficulties. In the AQAA the registered manager said, “All new staff are given a full induction and are placed on the LDIA (Learning Disability Induction Award) training programme. Following completion of the LDAI staff are then encouraged to go on to the NVQ training in health and social care.” Staff told us they receive training that is relevant to their role, and helps them understand and meet the needs of people living at the home, and keeps them up to date with new ways of working. St Anne’s has a learning and development department that monitor staff training to make sure everyone has completed all the mandatory training. We spoke to one staff who has started working at the home since the last inspection. She said the induction gave her chance to get to know the people Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 23 who live at the home and the routines before she started working unsupervised. We looked at one staff file, which had written confirmation that that all the pre employment checks were carried out before the person commenced work and they had completed the first six weeks of their induction. Every staff survey told us their employed carried out checks, such as references and a criminal records check before they started work. Staff said they regularly meet with management to discuss how they are working and they regularly attend team meetings. We looked at staff meeting minutes which showed a meeting was held in January 2009, March 2009 and May 2009. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and everyone feels supported. EVIDENCE: At the last inspection we said the home would benefit from having a registered manager. A manager was registered with CQC in May 2009. We asked the staff about the management of the home. They said the management of the home was good. One staff said, “He’s a good manager and he has the people skills to go with it.” Another staff said, “He’s very approachable.” In the AQAA the manager told us the home has improved because since the last inspection they have a registered manager in post, who also has Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 25 responsibility for managing another home, and a development deputy manager who runs this home in the absence of the manager. We talked to the manager about managing two services. He said this works well and he gets good support. Staff also told us the manager was accessible and they thought the arrangements worked well. The AQAA was completed by the manager and gave us some good information about the service. It gave us examples of what they do well, how they have improved and what they want to do better. They also told us about changes they have made as a result of listening to people who use the service. The home has some good systems in place for monitoring the quality of the home. The manager and staff carry out different safety checks. The area manager visits at least monthly and carries out checks to make sure the home is running smoothly. People who live at the home attend regular meetings and are asked about the quality of the home. The minutes from the meetings showed they have recently talked about holidays, decorating and menus. St Anne’s have asked relatives and other professionals to complete surveys about the home. The results have been analysed and along with other quality monitoring information a team plan has been drawn up. In the AQAA the manager told us they have all relevant policies and procedures in place, and equipment has been tested as recommended by the manufacturer. We looked at accident and incident forms. These had detailed accounts of what had taken place and action to prevent a similar incident occurring again. No concerns around safe working practices were seen on the day of the inspection. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 26 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 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 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 27 Fieldhead DS0000007874.V376526.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA16 YA22 Good Practice Recommendations People who live at the home should get more opportunities to take part in daily tasks around the home. This will promote independence. The home should have a complaint’s record that has details of any complaints they have been received. This will help make sure complaints are monitored properly. Fieldhead DS0000007874.V376526.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@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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