Inspection on 17/12/09 for Kelvin Grove

This is the latest available inspection report for this service, carried out on 17th December 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kelvin Grove 07/03/07

Kelvin Grove 20/02/06

Kelvin Grove 30/08/05

Kelvin Grove 11/01/05

Kelvin Grove 03/08/04

Kelvin Grove 18/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Key inspection report CARE HOME ADULTS 18-65 Kelvin Grove 18 Rothsay Road Bedford Bedfordshire MK40 3PN Lead Inspector Sally Snelson Key Unannounced Inspection 17th December 2009 10:45 Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Kelvin Grove Address 18 Rothsay Road Bedford Bedfordshire MK40 3PN 01234 217287 01234 217287 kelvingrove@together-uk.org www.together-uk.org Together Working for Wellbeing NBHA Chilterns Joanne Forrest Care Home 12 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) Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2009 Brief Description of the Service: Kelvin Grove is a large detached property on a road leading down to the river within walking distance of Bedford town centre and a range of local amenities. The home is managed by Working Together for Well-being and New Leaf Housing Association is responsible for the building. The home provides residential care for 12 people with mental health needs. All the bedrooms are single and meet the space requirement. There are communal lounge, dining, kitchen and laundry areas on the ground floor. The home has a good-sized rear garden and limited parking at the front with metered parking close by. The fee for this home is from £510.00 per week. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgments made within the main body of the report include information from this visit. The inspection was a key inspection, was unannounced and took place from 10:45hrs on 17th December 2009. The managers post is currently vacant. The previous manager had recently been promoted and this report still refers to her as the manager. The new manager Emma Edwards supported the inspection from 1.30pm when she started a late shift. During the inspection the care of two people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. We also looked at recruitment, training health and safety documentation, medication records and food planning as well as touring the building. Any comments received about the home, plus all the information gathered on the day was used to form a judgment about the service. The manager and the service manager (the previous registered manager) had completed an AQAA in advance. We would like to thank all those involved in the inspection for their input and support Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 6 What the service does well: What has improved since the last inspection? The staff had worked with the residents about areas of the home that should be used for smoking and ensured people were aware of the consequences to both their health and safety. All care plans were current and had been review. Staff also identified risks and there were management strategies for the risks although the people using the service were encouraged to be independent and to make informed decisions. The policies and procedures for the safe administration and recording of controlled drugs had been improved. Areas of the home had been decorated and there was a maintenance plan that detailed when other work such as the kitchen and windows, were to be implemented. Records showed that extras staff had covered night duty during a period of challenge. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 7 The staff team, including those used from an agency on a regular basis had received safeguarding and medication training. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 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 Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 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): 1,2,4 The service understood the importance of ensuring that the needs of a prospective resident could be met at Kelvin Grove, and that he/she would ‘fitin’ with the other residents. 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. EVIDENCE: The service had a user-friendly Statement of Purpose and Service Users Guide that was up-to-date and was kept under review. During the inspection we looked at the care file of a resident who had moved into the home since the last inspection. The service had received information from his care manager as part of the application process. This information had been used to make an initial decision about the possibility of admission. He had then been invited to make short visits to the home and further assessment by staff and resident had influenced the final decision. The first month of his stay had been described as a ‘trial period’. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 10 The staff team ability to meet the needs of the residents will be discussed within the staffing section of the report. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 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. Care plans were reviewed six monthly and additionally when significant change took place. People who use the service told us that they were actively encouraged be involved in the development of their plan and to attend reviews where their contribution would be valued. 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. EVIDENCE: The care needs of two residents were tracked in detail. This involved reading their care files, observing the care and support that was provided and talking to them and the staff on duty about the support provided. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 12 Care files had been completed in detail and reviewed at least six monthly to keep the information current. We were told, and residents confirmed that they had been involved in the care planning process. However there was nothing in the documentation to support this, such as a resident’s signature or a statement of involvement. A good attempt had been made to write the support plans in a person centred style, and after discussion with the manager and the service manager we were aware that training was being developed to build upon this style and also alter the way that risks were identified and managed. The manager and the service manager confirmed that the company was aware that the care documents needed altering and were in the process of introducing a mental health recovery plan which would be person centered and focus on moving the resident forward. This was planned to start the first week in January and the manager was committed to it, and believed it would be more user-friendly. Each resident was allocated a key worker whose role was to continually assess their needs and met with them to discuss their support plans and how the care and support was delivered. The staff team encouraged residents to make choices and take acceptable risks. The documentation to support risks showed that in the first instance people living at the home were encouraged to be as independent as possible. For example all residents were considered for self medication and the associated risks considered. We saw that some people were assessed to completely administer their own medications whereas others could administer on a daily basis. Sometimes, because of the nature of the medication or the changing needs of the resident, assessments were altered a number of times and people moved from self medicating daily to weekly or vice versa, because of their changing needs. In these situations the paperwork could become confusing as each assessment generated new paperwork and often details were duplicated. We discussed with the manager the problem of balancing the need for care files to include sufficient information and also be user friendly for staff, particularly agency staff, who would need to refer to the plans to support any aspect of care delivery. For example some of the plans duplicated the same information but in a different way; often more than once. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 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: 11,12,13,14,15,16,17. Residents were involved in the domestic routines of the home. They took responsibility for their own room, menu planning and cooking meals according to their abilities. 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. EVIDENCE: Each residents file included a personal profile that detailed their preferences and how they wished to be supported. On the day of the inspection some residents were away from the home involved in daily activities, and others were going about their daily routines in the home as they wished. At times during the day we were aware that Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 14 relatives and friends were visiting the home and meeting with a resident in a private or communal area, according to their wishes. Three residents went out for a coffee with a staff member as part of a coffee club activity and residents and staff were looking forward to the next day when they would all go out together for a meal to celebrate Christmas. Residents told us that they could be supported financially and with staff support to have meals out and holidays. People using the service who chose to have a planned meal away from the home were given the budget allocated for that meal towards the cost. One meal a week was planned to be out of the home and any residents who wanted could attend. We were told that one of the groups that ran within the home, the art group, was run by a resident for the residents. One resident took us on a tour of the building, including his own bedroom. The communal areas of the home were clean and tidy, and it was evident that for some clients keeping their rooms tidy was not a priority. This was their choice as long as it did not present a health hazard. The resident told us that he was very happy with the home, the way it was run and the support he received. Residents were encourage to make decisions relating to menus, and help with the preparing of meals and the shopping. Menus were planned together as part of weekly residents meetings. Three of the people using the service had a budget for food and catered for themselves. They had their own kitchen in which to cook and store food. All of the residents in this home had a mental health diagnosis and were supported and encouraged to live as independently as possible. We saw that this support, in the form of telephone support, would continue for a while after a person had been helped to move towards independence. The AQAA told us that the company offered comprehensive service user led training such as, Going into employment, Learning and working together, Self knowledge and confidence, Coping skills, Risk taking, Recruitment and selection, Public speaking, presentation and peer to peer feedback. Some of the residents from this home were to be involved. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. Personal support was responsive to the varied and individual needs and preferences of the residents. The home respected and understood the rights of residents in the area of health care and medication. They worked with individuals regarding any refusal to take medication. 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. EVIDENCE: At the time of the inspection there were 12 people living together at Kelvin Grove. None of them needed assistance with care continually, but many needed prompting and intermittent support with health needs and dependencies. Some needed support with decision making and the agreed restriction of access to substances such as alcohol and tobacco. Risk Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 16 assessments were in place to ensure potential risks were minimised for all activities of daily living whether individuals were fully independent or not. Staff told us that Community Psychiatric Nurses (CPNs) were frequent visitors to the home and staff had good relationships with them, and the GPs, and consultants, involved in residents care. Staff encouraged people to regularly attend health screening and health appointments, including opticians and dentists. At the start of the inspection staff were preparing to take an anxious resident to a hospital appointment. At the last minute this had to be cancelled, but only after staff had tried to offer as much support as possible and considered alternatives. Staff correctly reported accidents and incidents and these were reviewed, for audit purposes, on a regular basis. The medication policy described how people would initially be assessed to self medicate. Some people were able to administer for a short period, for example a week or to administer certain of their medications. The medication record sheets (MAR) in the home were well completed but could appear a little messy and full as staff were using the sheets to record the exact time a medication was given, the signatures of the two staff who checked the medication, and in some incidences, where a variable dose was prescribed, the amount given. Weekly audits of remaining stock were also recorded on the MAR sheets as well as in separate books. We discussed with the manager what information needed recording and how this should be audited. Controlled drugs held in the home were now stored and administered in an appropriate way according to the guidelines of the Royal Pharmaceutical Society of Great Britain. Staff were not clearly recording the amount of any unused medication, that had been dispensed in a bottle or box, and was not returned to the pharmacy, but was carried forward to be used the next month. This failure could make it difficult to audit the medication held in the home. In the files we looked at we saw that residents had recorded their wishes for the end of their lives. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The service had robust complaints and safeguarding policies and procedures that ensured the residents were kept safe. 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. EVIDENCE: There was a complaints procedure in place that was easy for all residents to understand. The procedure outlined how a complaint was investigated and what the respondent should expect in the way of a response and in what timescale. Residents had their own copy of the complaint procedure and they were reminded about their right to complain and the whistle blowing procedure as part of key work sessions. Complaints were held in a dedicated file, which also included information as to how the complaint had been investigated and how the complainant had been responded to. Since the last inspection all staff had attended an update on the safeguarding of vulnerable adults and the manager showed a clear understanding of the process and the role of the staff team in keeping people safe. Deprivation of Liberty (DOLS) and the Mental Capacity Act (MCA) had also been incorporated Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 18 into the training programme for this home so that staff had a basic awareness of how this legislation may affect the residents. We checked the accounts for the two residents who we were case tracking. Accounts balanced correctly with funds remaining, individual residents and staff had signed for all transactions. Individuals money was not used to make purchases that should be the responsibility of the service i.e. coffee for staff accompanying a resident out for a coffee or other social event. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30. The home provided a physical environment that met the specific needs of the people who lived there. The home was comfortable and had a programme to improve the decoration, fixtures and fittings. However, there had been a slippage of timescales. 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. EVIDENCE: During this inspection we were given a complete tour of the communal areas of the home by one of the residents. The tour included a visit to one bedroom. Some areas of the home had recently been redecorated and people using the service told us that they had been consulted. The home was generally clean and tidy and free from offensive odours in the communal areas. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 20 Staff told us that they were pleased that two major renovations that they had wanted for sometime were both due to start in the New Year. This was a kitchen refurbishment and new windows. The resident who took us around stated that the kitchen was not always accessible at night but food and drinks were left out on a trolley. He and other resident were perfectly comfortable with this and did not feel that they were prevented from having anything they wanted. There was a variety of seating within the lounge, and the dining room was just big enough for all the residents to sit together if they wanted. A large dining table was made up of four smaller tables so people did not have to be together if they choose otherwise. The bathrooms were basic and one resident told us he would prefer there to be more showering facilities. One new shower had been installed since the last inspection. The staff sleeping area was being refurbished and the staff toilet and shower was not in a good state. Laundry facilities were available and residents told us that although they had a set laundry slot they could usually do any washing when they wanted. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 There was competent and experienced staff to meet the needs of people using the service. Staffing rotas took into account the needs and routines of the people using the service, but the service had a heavy reliance on agency staff. 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. EVIDENCE: The staff team was very small but was committed to the care and the support of the people using the service. There were two staff supporting the residents at the start of the inspection with an extra member of staff on duty to provide one to one support for an individual resident. The service had to use agency staff on a regularly basis and although we were told they used ‘permanent’ agency staff, (meaning they used the same person again and again) and that agency staff were considered part of the team and joined in training opportunities it was apparent that the service needed to recruit more staff to the team. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 22 The service supported staff to attend training and all of the staff employed either had an NVQ qualification or were working towards it. New staff had completed an induction period and were mentored and supported to complete induction training. During this visit we picked three staff files at random to view in detail, and we also spoke members of the team about their work experiences in the home. Generally staff were very happy with the day to day running of the home, and felt that they were a strong team that was compatible with the residents. Two of the staff that we spoke to had worked in the home for a number of years. The recruitment process for each employee was very clearly documented, and files contained all the necessary documentation, which included; fully completed application forms, at least two references, including one from their most recent employer prior to coming to this service, Criminal Record Bureau (CRB) and POVA first checks, Home Office documentation where required, various forms of identification, including passports, birth certificates and driving licenses. There was also photographic ID present in the files. Residents had been part of the recruitment process. Staff had, and were, receiving regular supervision and although there had been a gap in this because of changing roles it was being made up and was once again on track. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,4042. The manager had the required qualifications and experience to run the home. She had a clear understanding of the key principles and focus of the service. There was a strong ethos of being open and transparent in all areas of running of the home. The AQAA contained clear, relevant information and told us about changes the service had made and where they still needed to make improvements. 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. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 24 EVIDENCE: The manager at this home, Emma Edwards had been confirmed in post for less than one week when we carried out this inspection. She had however been working at the home for a number of years and had been acting into the post since the previous manager was promoted within the company. We had yet to be formally informed of this change so that the relevant changes could be made to the certificate of registration. She had completed the AQAA for us. The previous manager was now her line manager and consequently Emma told us she felt well supported by her area manager. She was very passionate about the residents that she cared for and promoted their independence as a priority. Discussions with both staff and residents indicated that she was well respected. One resident told us. I have lived in several other places, and some I would like to forget; here is managed well and the manager cares, she will do anything she can for me. Ms Edwards told us that she intended to start the process to become the registered manager within the next three months. She demonstrated a commitment to the necessary study to improve her qualifications. All three staff that we spoke to indicated they were very happy in their jobs and felt well supported by the manager. One said. Shes always available to us and we can talk to her about anything. Throughout this inspection the manager demonstrated a clear understanding of the needs of the residents in the home, and the importance of encouraging their independence. There were clear policies in place in this home and the Annual Quality Assurance Assessment (AQAA) we received prior to this inspection clearly identified when reviews had taken place. The manager, known as the project coordinator, carried out monthly MMR (monthly monitoring reports) which indicated the need for change and any plans for the service. Staff met together two-weekly and a residents meeting was held two weekly. These meetings were documented and used to share concerns for the service and individuals as well as to make plans for the future, Records that we looked at in this home were well organised and reflected individuals progress and problems. As already stated there was a need to archive or separate some of the information to make the files more manageable. We looked at Health and Safety records relating to fire evacuations, smoke detector testing, water temperature testing, and general environmental Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 25 checks. All of which were carried out on a daily, weekly, or monthly basis, and recorded on file. A resident was encouraged to be part of this testing process. We spoke to the manager about her understanding of reporting incidents under regulation 37, and referring to the safeguarding teams. She was able to demonstrate a clear understanding of the processes. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 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 3 2 3 3 X 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 3 3 3 X 3 x Version 5.3 Page 27 Kelvin Grove DS0000015007.V378709.R01.S.doc NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement Staff must clearly record the amount of unused medication that had been dispensed in a bottle or box was then carried forward to the next. The planned refurbishment of the home must be given priority in the new year. Timescale for action 01/02/10 2 YA24 23 01/03/10 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. Refer to Standard YA6 YA7 Good Practice Recommendations Consideration should be given to the amount of duplicated information held in the current care files. Consideration should be given to providing documented evidence that people using the service had been involved in decisions about themselves and their care and support. Consideration should be given to people preferences for bath or showers and appropriate suitable facilities provided. YA27 Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission Eastern 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. Kelvin Grove DS0000015007.V378709.R01.S.doc Version 5.3 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!