Inspection on 12/05/09 for Hazelgrove & Martingrove

This is the latest available inspection report for this service, carried out on 12th May 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

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.

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Extracts from inspection reports are licensed from CQC, this page was updated on 07/08/2009.

Key inspection report CARE HOME ADULTS 18-65 Hazelgrove & Martingrove Hazelgrove & Martingrove 34/36 Lymington Road New Milton Hampshire BH25 6PY Lead Inspector Pat Trim Unannounced Inspection 12th May 2009 10:30 Hazelgrove & Martingrove DS0000073286.V375181.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. Hazelgrove & Martingrove DS0000073286.V375181.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 Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelgrove & Martingrove Address Hazelgrove & Martingrove 34/36 Lymington Road New Milton Hampshire BH25 6PY 01425 611901 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) You Trust Mr Michael Gordon Butterworth Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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). 2. The maximum number of service users to be accommodated is 15. Date of last inspection New Service Brief Description of the Service: Hazelgrove and Martingrove are two separate houses, registered as one service. The houses are next to each other with a shared garden. The service provides care and support to 15 people who have a learning disability. The service has recently been taken over by the You Trust, formerly known as the Southern Focus Trust. Accommodation is provided in 15 single bedrooms, some of which have en suite bathrooms. There are 2 lounges and a dining room in Hazelgrove and a lounge and dining room in Martingrove. The homes have a large garden at the rear of the property and are situated on a main road between Lymington and New Milton. Local transport is easily accessible and New Milton is close by. The fees for the service are currently from £586.04 to £873.18 per week. Hazelgrove & Martingrove DS0000073286.V375181.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 people who use this service experience good quality outcomes. We used lots of information from different places to write this report. We looked to see if anyone had written to us to tell us they were not happy with Hazelgrove and Martingrove. No one had. We also looked at anything the home might have told us about what has happened since the You Trust took over. We used some of the information the registered manager gave us about the home in a form called the Annual Quality Assurance Assessment (AQAA). This is something the home has to fill out every year to tell us what they are doing to make sure people are helped to do the things they want to and get the care they need. We also asked people who use the service to fill out a form to tell us what they think of the service. Four people filled them out for us. We also sent three forms to other people who sometimes work with people who live at Hazelgrove. Four staff who work at Hazelgrove also filled out forms to tell us what it is like to work there. One of our inspectors visited the home and stayed for five and a half hours. While she was there she spent time talking to people who live there to ask them what it what like living at Hazelgrove and Martingrove. There was also an opportunity to talk to some of the staff and to look at some of the bedrooms, lounges, dining rooms, kitchens and bathrooms to see that people lived in a clean, comfortable and safe place. Three people were case tracked. This means following what happened to people from when they wanted to move into the home and looking at what has been written down about them. We also looked at some of the records Hazelgrove has to keep to make sure they were being kept up to date. What the service does well: Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 6 The people who now run the home want the people who live there to be able to say how they want to live their lives. Staff are helping them write down what they want to do and how staff can help them do it. People who live in Hazelgrove are encouraged to do as much for themselves as they can and as they want to. People who live there said: I like cooking for myself. I often do this. I go to Weightwatchers every week, because I want to lose some weight. Staff help me eat healthily. I like going for walks and I do this on my own. I can catch the bus to town to go shopping. We have day trips, nice food and parties. I am treated well. We go out, we go out in the town and in the minibus. The home has a house meeting every month so people can say what they want to happen. They are choosing their holidays at the moment and everyone was looking forward to going away for a few days. They go in small groups as people like to do different things. One person was looking forward to dancing every evening as this was a favourite activity of theirss. Hazelgrove provides a homely environment with a relaxed atmosphere. People who live there enjoy a comfortable and friendly relationship with staff. The home has been repainted recently and the people who live there have been involved in choosing new furniture. People said: I chose my new bedroom carpet and I am very proud of it. We chose the new furniture and it is very nice. There is a staff team that have worked at the home for a long time. They know the people who live there really well. They felt they were given good training to help them do their job. What has improved since the last inspection? What they could do better: We think the The You Trust knows what it wants to do to make things even better for the people who live in Hazelgrove and Martingrove. One of these things will be to have a flat where people can try living on their own to see if they like it. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 7 They also want to have more staff so people can go out more easily at evenings and weekends. 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. Hazelgrove & Martingrove DS0000073286.V375181.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 Hazelgrove & Martingrove DS0000073286.V375181.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): 3. 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. A thorough assessment process enables the registered manager to be sure only people whose needs the service can meet are offered a placement. EVIDENCE: No one has moved into the home since the You Trust took over running the service. Feedback from four people currently living in the home showed they felt they had been involved in choosing to move in. The AQAA recorded that The You Trust has its own assessment tool, which was comprehensive and assessed all aspects of people’s personal, health, mental health and daily living needs. The registered manager said everyone currently living in the home has had a new assessment of need completed to make sure information is up to date. Three of the people currently living in the home were case tracked. Each of these had a new assessment, which they had been involved in completing. The assessment identified what areas of their care they could do independently Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 10 as well as those aspects they needed help with. For example, some people managed their personal care independently or did not need support with using public transport. Where help was needed, the assessment clearly identified whether people needed physical support or prompting. The assessments included comments by the people who used the service and, where appropriate, had been signed by them to evidence their involvement. Hazelgrove & Martingrove DS0000073286.V375181.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 and 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 who use the service are able to be involved in planning their care and identifying what they want to be able to do for themselves. Risk assessments are used to enable people who use the service to do the things they want to whilst minimising the risk of injury. Any limitations imposed on people who use the service are done so in their best interests and the reasons for them explained to the person involved. EVIDENCE: The registered manager said a review of care plans is being undertaken to make sure they reflect the needs identified in the new assessments. Everyone who is able to has been encouraged to write their own short term care plan with aims and objectives for the next six months. Key workers are giving support where it is needed. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 12 The care plans for the three people being case tracked were viewed. Each person had identified what they wanted to achieve over the next six months and more detailed care plans gave staff guidance on how this could be achieved. The registered manager has reviewed the risk assessments in place when the organisation took over to make sure they were relevant and up to date. He said he plans to use risk assessment pro-actively to enable people to achieve their objectives. For example, it is used to enable people to use the kitchen safely and cook meals of their choosing. The need for any limitations is recorded in the needs assessment, together with the reason for it and that the limitation has been explained to the person it relates to. Only one of the three people case tracked had any limitation imposed on them. This was at the request of the person it related to and was to help them manage their money safely. The registered manager stated that any limitation would need to be clearly identified as in the persons best interests; agreed as necessary by all involved health care professionals, and explained in detail to the person it related to. Hazelgrove & Martingrove DS0000073286.V375181.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 and 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 who use the service are able to take part in a wide range of activities, employment and education, that they enjoy. Staff support them to maintain contact with family and friends and to enjoy relationships. EVIDENCE: People who use the service felt they were usually able to make choices about all aspects of their life. People are being encouraged and supported to identify what they want to achieve as short- term goals and existing care plans are being reviewed to ensure they show how people are to be helped to achieve these goals. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 14 A wide range of activities was offered that included accessing the local community. Some people worked locally, in shops, care homes and playgroups. Some people attended a day centre, whilst others went to classes for drama and computer studies. Local clubs included slimming clubs, the gym and social clubs. People said they were also able to join in daily activities in the home, such as planning, shopping for and preparing meals, helping with housework and doing their own laundry. Care plans recorded where this was an objective. People are supported with hobbies such as knitting and drawing and staff saw spending time with people who use the service socially as a large part of their role. Martingrove is a separate building from Hazelgrove and people who live here are able to look after themselves with minimal support from staff. In the morning two people were cooking their dinner here and said how much they enjoyed being able to look after themselves. The registered manager is currently reviewing staffing levels. He hopes to increase the number of staff employed to provide more flexibility and to support more outside activities during the evenings and at weekends. Important relationships are recorded in the assessment. People said how important to them maintaining links with their families was and many people go back to their families at weekends. Long-term friendships have developed between people who use the service and the registered manager showed they were supported if they wished the friendships to develop further. The service had information about the local advocacy scheme and the registered manager said advocates would be involved to support both people explore the implications of relationships. People who use the service were busy planning holidays for the year. Some people were going to the Isle of Wight for a short break at the weekend and were very excited about it. One person was looking forward to dancing every night. A trip to Jersey was also being planned. Main meals are served at lunchtime, but are also kept for people who are out then to have in the evening. On the day of the visit the main meal was chicken curry or ham and cheese salad. People confirmed they had been able to choose what they had and could always have something else. They also confirmed they are involved in planning the weeks menus. People who were trying to follow a healthy eating plan confirmed staff helped them by providing healthy choices. Hazelgrove & Martingrove DS0000073286.V375181.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 and 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. People who use the service receive help with personal care in the way they like it. They are able to see health care specialists when they need to, which makes sure they receive the health care they need. People who use the service are supported to manage their own medication where this is something they wish to do through a risk framework. EVIDENCE: The majority of people who use the service require minimal assistance with personal care. Some people like to be reminded they need to wash or change their clothes and this is documented in their care plans. Some people have identified in their short-term care plans that they wish to become more independent in managing their personal care and new care plans are being completed that clearly identified what help staff needed to give. For example, one person was able to bathe or shower independently and only needed staff to help putting on skin cream. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 16 Some people who use the service felt staff listened to what they said and did what they asked, but others felt they sometimes did not listen. Comments received from a care professional showed she thought the service treated people with respect. A parent commented that The staff are kind and caring and enable her to reach her full potential. The AQAA recorded that the service wishes to develop individual health care plans, but this has not happened yet. The registered manager explained the service wants to support people who use the service to manage their own health care needs as much as possible. The plan for one person showed how he was being supported to achieve this. The assessment identified what health care needs people have and records showed they received the health care they needed. For example, if someone needs regular eye checks, these are arranged. Records showed that people who use the service are able to regularly see dentists, chiropodists and doctors. Mental health needs are assessed and support plans put in place to help people manage them. Staff have guidance on how to use distraction techniques to help people manage their behaviour. The registered manager stated that restraint is not used for anyone currently living in the home. Feedback from a health care professional indicated the service works well with other agencies, stating the service seeks advice/information from GP or our team when necessary. A care professional also commented the service communicates well with other agencies. Staff also felt When needed specialist agencies are involved to ensure the wishes and needs of residents are met. Information given by the registered manager also demonstrated the service consults health care professionals for advice and support. The AQAA recorded the service wished to support people to manage their own medication, where this was identified as an objective. This is identified in the assessment. The registered manager said five of the people living in the home manage their own medication. Risk assessment is used to make sure this is done safely. People have secure storage in their rooms and show staff they are taking the medication regularly. Staff are responsible for administering everyone elses medication. The majority of this is provided in a monitored dosage system and kept in a secure cupboard. The amounts received are checked on receipt to make sure they are correct. Only staff who have received training are permitted to give out medication and the staff responsible at the time of the visit confirmed they had received training. The administration records were viewed and found to have been completed correctly. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 17 The registered manager stated that no one currently using the service had medication to manage their behaviour that was prescribed as when required, so no specific care plan was needed for guidance on how and when to use it. The AQAA recorded that no controlled medication was being kept in the home and the registered manager confirmed this. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 18 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 and 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 use the service have the information they need to be able to make complaints and be confident their concerns will be listened to. Staff have the training and guidance they need to minimise the risk of harm to people who use the service. EVIDENCE: Feedback from surveys completed by people who use the service and from speaking to people during the visit demonstrated they knew how to make complaints and were confident the management of the service would listen and take action. The AQAA recorded four complaints had been made since the organisation took over. These had been recorded in the complaints log, together with the action taken and the outcome. The complainant in each case had been informed of the outcome of the investigation in writing. All four complaints had been upheld and the complainants satisfied with the outcome. The commission had received no complaints about the service. The registered manager explained he encouraged people to bring their concerns to him as he felt this was one way the organisation could get feedback about how the service was running. People who use the service said they also raised issues at monthly house meetings. One recent concern was that signage, used to show whether the bathroom was in use, had been removed by the new providers as it was felt institutional to have this on the Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 19 doors. However, staff explained this signage had been put there at the express wish of people who use the service who did not like to lock the door. The registered manager said the decision would be discussed and reviewed at the next house meeting to make sure the views of the people who use the service were listened to and acted on. Staff felt they had the training and guidance they needed to enable them to identify and report any possible abuse. The registered manager said a refresher session about safeguarding was being arranged for all staff at the next team meeting. Three staff spoken with were able to show they knew the action they would need to take if an allegation of abuse was reported to them. The registered manager had recently demonstrated his ability to work with other agencies to minimise the risk of abuse and to use the safeguarding procedure Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 20 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 and 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 who use the service are able to live in a clean, comfortable environment that meets their needs. There are systems in place to minimise the risk of infection. EVIDENCE: The AQAA recorded that the home is undergoing an extensive renovation programme. This has included redecorating both houses, fitting new carpets and buying new furniture. People who use the service have been involved in choosing the new fixtures and fittings. Some people said they went out to choose the furniture. Another person had been involved in choosing his new carpet and he was very pleased with the result. The AQAA recorded that two people who previously shared a room have been supported to choose to have their own rooms. Changes to the environment Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 21 have been made to enable everyone to have a single room. En suite bathrooms have been added to two bedrooms. The organisation also plans to convert part of Hazelgrove to provide a two bedroom flat. This will be used to provide people who use the service, who are considering moving to more independent living, an opportunity to try living in a different environment. The flat will provide a stepping stone between residential care and independent living and the registered manager said it was envisaged people would stay there for a short period of about six months. People who use the service who wish to, are supported to join in household tasks such as cleaning and doing their own laundry. The service also employs a cleaner, to make sure heavy duty cleaning is regularly carried out. Feedback from four surveys showed people who use the service thought the home was kept fresh and clean and there were no unpleasant odours at the time of the visit. The laundry has recently been fitted out with two new washing machines and tumble dryers. The majority of staff have had infection control training and have a supply of protective clothing in case they need it. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 22 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 and 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 use the service are supported by well trained staff, in sufficient numbers to meet their needs. EVIDENCE: The registered manager explained he wishes to increase current staffing levels to provide more flexibility. This will enable people to do more activities during evenings and at weekends. At present, three staff are on duty from 8 a.m. till 7 p.m. and two staff from 7 p.m. till 12 a.m. These two staff then sleep in to provide night cover. There is an on call system in place to provide support. In order to increase day staff time, night support is being reviewed. The registered manager confirmed this process is in the early stages and will take time. A change in night cover will only be implemented after a thorough Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 23 risk assessment has been completed and if the outcome shows the risk to people who use the service is not significant and there are clearly demonstrable benefits to people who use the service. The registered manager said that no new staff had been employed since he had been in post, but the service was advertising for a team leader and another full time member of staff to enable the increase in staff support already discussed. Staff previously employed felt their recruitment had been thorough and fair. The registered manager said the organisations human resources department completed all recruitment checks. Interviews would be held at the home and two people who use the service would be involved in this. Applicants would also be invited to visit the home for a meal so other people who use the service could meet them. Feedback from four staff surveys and three staff spoken to at the visit showed they thought they received a good induction. The organisation has its own induction programme, which any new staff will be expected to complete. The induction programme is completed over several months and includes mandatory training as well as completing a workbook to demonstrate competency. The AQAA recorded that five staff have completed a National Vocational Qualification (NVQ) 2. The registered manager said future employees would be expected to complete a Learning Disability Qualification (LDQ) as it was felt this met the needs of people who use the service better. Current staff will have the opportunity to also complete this qualification. The registered manager said a review of current training has been completed and a training matrix completed to enable him to monitor staff training needs. Staff felt their training enabled them to meet the needs of people who use the service, comprising mandatory training such as food hygiene and first aid, as well as service specific training such as Dealing with difficult people. The registered manager said all staff had recently attended a company awareness day to learn about the philosophy of the You Trust and staff confirmed this. Hazelgrove & Martingrove DS0000073286.V375181.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 and 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 service is run in the best interests of the people who use the service. There are opportunities for people who use the service to express their views about it and their wishes form part of the development plan. There are systems in place to monitor the environment and minimise the risk of accidents to people who use the service. EVIDENCE: The registered manager has over 10 years experience in working in care settings and has previous experience of being a registered manager. He has completed a registered managers award and is also a qualified assessor. Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 25 People who use the service said they found him easy to talk to and were seen throughout the day visiting his office to tell him what they were doing or to ask his advice. At lunchtime he had a meal with everyone, which gave another opportunity for people to speak with him informally. Staff said they also found him approachable and felt they had been able to raise issues with him. Feedback from four staff surveys showed they had regular supervision where they could discuss practice issues and personal development. People who use the service thought they had lots of chances to talk about the care and support they received. They had recently had their needs reviewed with their key worker and had been able to talk about what they wanted to do during this process. They also had monthly house meetings. Minutes, in large print, were taken at these meetings so everyone had the chance to see what was discussed. Recent suggestions had included providing the staff rota in pictorial format so everyone knew who was working each day. This is being done. The last meeting had also asked for holiday ideas and these were being booked. The AQAA recorded the organisation had a system for enabling people to give feedback about the service they received. The registered manager said these were available in pictorial format so everyone could use them. They would be sent out later in the year. As stated in the previous section of this report, staff are expected to complete mandatory training such as health and safety, food hygiene and first aid. Training records showed staff had this training and the opportunity to attend regular refresher sessions. The AQAA included data about the servicing of equipment. A random selection of documents evidenced these dates were correct and established there are systems in place to make sure equipment is maintained to a safe standard. Hazelgrove & Martingrove DS0000073286.V375181.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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 27 Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hazelgrove & Martingrove DS0000073286.V375181.R01.S.doc Version 5.2 Page 28 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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