Inspection on 22/04/09 for Pear Tree Lane

This is the latest available inspection report for this service, carried out on 22nd April 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.

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 10/07/2009.

Key inspection report CARE HOME ADULTS 18-65 Pear Tree Lane 198A Cannock Road Wednesfield Wolverhampton West Midlands WV10 8PT Lead Inspector Sue Woods Key Unannounced Inspection 22nd April 2009 09:20 DS0000072765.V375041.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. DS0000072765.V375041.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 DS0000072765.V375041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pear Tree Lane Address 198A Cannock Road Wednesfield Wolverhampton West Midlands WV10 8PT 01902 305 862 01902 305 862 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) Midland Heart Limited Joanne Louise Shaw Care Home 13 Category(ies) of Learning disability (13) registration, with number of places DS0000072765.V375041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 13 2. The maximum number of service users to be accommodated is 13. Date of last inspection Brief Description of the Service: Pear Tree Lane is a purpose built property developed in 1991 by the Wolverhampton Primary Care Trust. The home is registered with the Care Quality Commission (CQC) to provide accommodation and personal care to a maximum of thirteen adults with learning and physical disabilities. The service fees are paid direct from the PCT to the provider with service users making a small contribution towards the care element. Midland Heart is responsible for the delivery of the care service and maintaining the buildings. Their headquarters are in Birmingham. The home is situated in Wednesfield, on the outskirts of Wolverhampton and close to a small number of shops, public houses, bus routes and motorway links. The home consists of three bungalows with parking facilities to the front and large well maintained gardens to the rear. Each bungalow has its own kitchen, laundry, dining room, lounge and adapted bathing facilities. People who live at Pear Tree lane are provided with single rooms, which have all been personalised. The aims of the home are included in the Statement of Purpose and include providing good quality accommodation and the support necessary for each service user to maximise and fulfil their potential and their positive experiences of life. DS0000072765.V375041.R01.S.doc Version 5.2 Page 5 People who use the service and their representatives are able to gain information about this home from the Statement of Purpose, Service User Guide and inspection reports produced by the Care Quality Commission (previously the Commission for Social Care Inspection). Inspection reports can be obtained direct from the provider or are available on CQC’s website at www.cqc.org.uk DS0000072765.V375041.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. The unannounced key inspection of Pear Tree lane took place on 22nd April 2009. The inspection started at 09.20 am and lasted eight hours and ten minutes. The inspection reviewed all twenty two of the key standards for care homes for younger adults and information to produce this report was gathered from the findings on the day and also by review of information received by CQC prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection we met people who live at the home however due to their complex needs was unable to directly obtain their views in relation to the quality of the service they receive. Interactions were observed and these are reflected within the report. We looked at three care files and extracts were seen from others. We also looked at a number of other records referred to within this report. We also obtained the views of staff about the home via surveys that were completed on site on the day of the inspection. We looked at three staff files, including recruitment, supervision and training records. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the home was registered on 22nd October 2008. This included notifications received from the home. These are reports about things that have happened in the home that they have to let us know about by law, and an Annual Quality Assurance Assessment. (AQAA). This is a document that provides information about the home and how they think that it meets the needs of people living there. DS0000072765.V375041.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: It is considered that people living at Pear Tree Lane receive a good service although six recommendations for good practice were made as a result of this inspection to make the service even better. Records are not always easy to find or access and it is acknowledged that the new care plans soon to be introduced may well resolve this issues as it will bring information together making it easier to access and records themselves easier to maintain. DS0000072765.V375041.R01.S.doc Version 5.2 Page 8 The environment, although safe, is in need of refurbishment to ensure that people living at Pear Tree Lane have a homely and nicely decorated place to live. Policies and procedures and some documents are not easy to read or specifically relevant to support the needs of the people living at the home. Although factually accurate they will provide better guidance if they related more to the service provided at Pear Tree Lane. Protocols to support the use of medicines given as and when required will ensure consistency and reduce the likelihood of them being given inappropriately. 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. DS0000072765.V375041.R01.S.doc Version 5.2 Page 9 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 DS0000072765.V375041.R01.S.doc Version 5.2 Page 10 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): Standard 2 People using the service experience good quality outcomes in this area. People who move in to Pear Tree Lane are supported by appropriate assessments of their care and support needs to ensure as far as is possible their successful admission to the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: One person has recently been supported to move into Pear Tree Lane. The manager and the staff team said that the move has been successful despite the way in which the admission took place. The home accepted the person to live at the home sooner than would be the usual procedure in order to ensure that the person had somewhere to live and since that time has started gathering essential information about the persons needs to ensure that he settles in well. The home has a Statement of Purpose and a Service User Guide that provides information about the home and the service that it offers and the manager is looking to develop both of these documents to make them more user friendly. DS0000072765.V375041.R01.S.doc Version 5.2 Page 11 The latest person to move into the home had a Service User Guide in his file detailing his fees and other information about the cost of living at the home. The manager reported that this information was shared also with his next of kin. DS0000072765.V375041.R01.S.doc Version 5.2 Page 12 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): Standards 6, 7 and 9 People using the service experience good quality outcomes in this area. Personalised care plans ensure people’s needs are met and that they receive care and support in a way that they prefer. People are supported to enjoy full and active lives and risks are assessed to ensure people can do so as safely as possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We met everyone who lives at Pear Tree Lane and were supported to speak with a small number of people. Through smiles, physical gestures and movements people told us that they were happy at Pear Tree Lane and liked the staff who supported them. Everyone we met looked relaxed and DS0000072765.V375041.R01.S.doc Version 5.2 Page 13 comfortable and were fully involved in making any decisions about their day as far as they were able. Staff are supported to meet peoples care and support needs by care plans that are very detailed, identifying peoples likes and dislikes and preferred routines to support all aspects of daily living. The home has plans to develop these care plans further to make them more user friendly and where this has happened they identify very person centred care that reflects each persons individuality. This means that staff can meet peoples identified support needs how they prefer and this ultimately gives people a better quality of life. During the time we spent in each of the three bungalows that make up Pear Tree Lane staff were seen to offer people choices and involve them in all decisions that needed to be made about the day ahead. One person had stayed at home to see a health care worker however she had been unable to attend. Staff asked the person if he would like to go to his usual day service or would he like to stay at home. This means that as far as is possible people retain control of their lives. The home supports people to be as independent as they are able and use risk assessments to identify possible risks in activities planned. Likewise risk assessments enable staff to carry out personal care tasks as safely as possible and where risks are identified actions are taken to reduce these risks. Assessments are regularly reviewed to ensure that people continue to be supported safely. DS0000072765.V375041.R01.S.doc Version 5.2 Page 14 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: Standards 12, 13, 15, 16 and 17 People using the service experience good quality outcomes in this area. People benefit from supported family contact and involvement meaning that they are able to stay close to the people that matter to them. Detailed support plans enable staff to meet individual needs and assist people as they prefer. People enjoy a range of structured and relaxing activities however better recording would demonstrate that people live the lives they chose. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The majority of people living at Pear Tree Lane attend day services that provide a range of structured activities. Staff communicate well with day services staff ensuring continuity of care. DS0000072765.V375041.R01.S.doc Version 5.2 Page 15 In the evenings and at weekend the pace of life is much slower. The manager stated that this reflects that people are getting older and thus are not so active. When people returned from their day services on the day of the inspection they were able to relax in the lounge, spent time on their bed or just relax in their rooms. Meal times are staggered, as some people prefer to eat earlier than others. Records to show what activities people take part in were not up to date. Information was recorded in a number of areas making it difficult for the home to show that activities take place as and when planned. For example it stated in one persons plan that she likes to attend the local church once a fortnight. Records showed that she had only been once in a month. No reasons were documented for her not going. The manager acknowledged that better record keeping in relation to activities would improve the service by demonstrating the full range of what people do. She is also looking to reintroduce a form that evaluates activities. These changes will mean the home will be better able to demonstrate it meets the standards in this outcome group and show that people receive a good quality of life. Each bungalow has its own menu and the manager said that they reflect people’s likes and preferences. Menus seen looked to be varied and nutritious. Peoples support needs in relation to how they like to be assisted at meal times were recorded enabling staff to support people safely and as they prefer. DS0000072765.V375041.R01.S.doc Version 5.2 Page 16 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): Standards 18,19 and 20 People using the service experience good quality outcomes in this area. The personal and health care needs of the people who live at Pear Tree Lane are appropriately documented and well met enabling them to have a good quality of life. People are safeguarded by the home’s system for handling, storing and administering prescribed regular medication although people may be vulnerable if staff do not know when to administer medicines prescribed as and when required. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care records showed that people attend regular health care appointments and on the day of the inspection one person was expecting a visit form the district nurse and the chiropodist was at the home visiting two people. Staff support DS0000072765.V375041.R01.S.doc Version 5.2 Page 17 visits and keep good records to show outcomes meaning that new information is passed on to everyone providing the persons care and support. As a result people living at Pear Tree Lane are all well and are having all of their current health needs attended to and met. Care plans are very detailed as they describe how personal care should be given to reflect individual needs and preferences. Attention to detail means that staff maintain peoples privacy and dignity in all tasks that they support people with. Arrangements in place for the recording and storage of medication were satisfactory. Medication recorded in peoples care plans was seen to reflect the medication administration sheets also seen. The manager was knowledgeable about the reasons why people take prescribed medication and information is available to inform staff of any possible side effects meaning that people are safeguarded while taking their medication. The manager had not developed protocols to support medicines given ‘as and when required’ and therefore people may be vulnerable to receiving he medication when not appropriate possibly affecting their health and wellbeing. The manager said that she would produce this guidance straight away. DS0000072765.V375041.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): Standard 22 and 23 People using the service experience good quality outcomes in this area. The manager and the staff team know how people living at Pear Tree Lane communicate their feelings meaning that people can express their satisfaction or unhappiness at any aspect of the service they receive and be confident that these feelings will be recognised and responded to. People are also protected by procedures in place for managing concerns and complaints raised on their behalf. People living at the home can be assured that the home operates with their best interests at heart by being knowledgeable of local safeguarding procedures to protect people from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a complaints procedure that is shared with the next of kin and families of people living at the home. There has been one complaint received and investigated by the home using this procedure and records showed that the manager had thoroughly and sensitively investigated it. The home is aware of the procedure to follow if abuse is suspected within the home. The assistant manager trains staff in their roles in relation to recognising and reporting abuse and so people can be reassured that they are protected within the home as far as is possible. DS0000072765.V375041.R01.S.doc Version 5.2 Page 19 Records are kept in relation to money spent by people living at Pear Tree Lane and there are safeguards in place to ensure money is accounted for. All records are regularly checked and money is counted at the start of each shift to identify if any mistakes have been made. The home would welcome more external audits of people’s money for their own protection and the manager stated that she believed that this was going to happen in the future adding further safeguards. DS0000072765.V375041.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): Standards 24 and 30 People using the service experience adequate quality outcomes in this area. People who live at Pear Tree Lane are provided with a safe place to live however redecoration and refurbishment will make the bungalows more homely. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We visited each of the bungalows as part of out inspections. Bedrooms seen had been personalised and reflected individual preferences. All areas were seen to be clean however planned redecoration of the buildings has not taken place and as a result the environment is starting to look ‘run down’. Carpets in some areas are badly stained and walls are scratched with wallpaper hanging off in places. This does not provide a homely environment for people who spend a lot DS0000072765.V375041.R01.S.doc Version 5.2 Page 21 of time at home. The manager reported that there is no money in the current budget to make improvements to the décor although she did say that repairs and other maintenance is carried out promptly ensure the home is safe. The home was inspected by Wolverhampton PCT Infection Control Unit in December 2008. Recommendations were made about systems that would better promote and facilitate infection control. The manager confirmed by letter following the inspection that all of the areas identified had been addressed. These changes have improved infection control within the home making it safer for people who live there. DS0000072765.V375041.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): Standards 32, 34 and 35 People using the service experience good quality outcomes in this area. The people who live at Pear Tree Lane receive good care and support from a well supported and committed staff team enabling their needs to be effectively met within the home. Appropriate pre employment checks on staff who work at Pear Tree Lane ensure that the home only appoints people who are suitable to work with vulnerable people. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We spoke with senior staff on duty individually and as a group and they demonstrated a great understanding of the needs of the people they support and of the strengths of the service they provide. They are also aware of areas where improvement is required and work effectively with the manager to make changes to improve the quality of the lives of people living at the home. For DS0000072765.V375041.R01.S.doc Version 5.2 Page 23 example they all felt that good support and teamwork enable people to receive a good service. All felt that the environment needed to be improved. The observations of staff interactions made by us at the time of the inspection were very positive. Staff supported people sensitively and discreetly respecting their privacy and responding to requests promptly. Staff said that they had enough time to carry out their roles effectively and respond to individual needs. A high number of staff have achieved a qualification in care and in supporting people with learning disabilities. This means that staff are competent to support people living at Pear Tree Lane and are able to deliver quality care and support. In the home’s self-assessment the manager stated ‘We have ensured that a large group of staff have completed the Learning Disability Qualification (LDQ) that should give them a deeper understanding of individual’s needs and choices’. Individual training records were unavailable at the time of the inspection but the manager was confident that training is up to date. Staff said that they felt well trained. Fifteen staff, who had come to the home to attend a staff meting, completed surveys for us at the time of the inspection. Comments of what the home does well included: ‘Deliver excellent care to our customers’ ‘Customers are offered a range of activities outings and holidays’ ‘Deliver a quality service. The attention to the customers is excellent’ Training and support were also seen as the home’s strengths. When staff were asked what has improved within the home they said that communication, staff training and support had improved. Staff were also positive about the changes within the staff team to enable each bungalow to have its own dedicated staff team and this will ensure consistency in delivering support and also allow the staff team to really get to know the people they are supporting. All of which will further improve the quality of the service provided. Better communication from head office, more external activities and more staffing were listed by staff as areas where the home could do better. Our findings reflected that more staff would enable more one to one support, and thus improve community based activities however the manager reported that staffing levels have improved recently with the home being almost fully staffed. Senior staff reflected this. The home has implemented a robust induction programme and this will ensure that new staff to the home will receive detailed and comprehensive information DS0000072765.V375041.R01.S.doc Version 5.2 Page 24 required in order to effectively support the people who live at Pear Tree Lane. The manager agreed that in the future she would record when new staff work along side experienced staff in order to further learn their job. This practice is already part of the process, just not yet recorded. The staff files of the last three care staff to join the team were reviewed and found to contain the essential information required for the home to demonstrate that people are recruited safely to ensure the protection of vulnerable people. All checks are carried out before people work with the people living at the home. Records were well maintained and readily available for inspection. DS0000072765.V375041.R01.S.doc Version 5.2 Page 25 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): Standards 37, 39, 40 and 42 People using the service experience good quality outcomes in this area. People living at Pear Tree Lane benefit from being supported by an effective and open management team. Effective health and safety checks mean that the people living at Pear Tree Lane live in a safe environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager of Pear Tree Lane is well respected by her staff team and has good knowledge of the care and support needs of people living at the home. She was observed supporting someone to meet their personal care needs and DS0000072765.V375041.R01.S.doc Version 5.2 Page 26 was discreet, supportive and friendly. The manager attends training to update her knowledge in relation to personal and professional development. She recently attended ‘Deprivation of Liberties’ training and as a result she has been able to implement her knowledge within the home and in particular within the care plans to ensure the protection of people living at the home. Midland Heart, the organisation that operates the home, have a good senior management structure and the home manager stated that she is well supported to do her job competently. Senior managers carry out quality audits and regular visits to ensure the quality of care provided is of a good standard. The manager is conscious that a significant amount of her time taken up by financial matters. In her self-assessment she states ‘Much management time is used in the financial management and the overall survival of the service’. There is no evidence to suggest that this is having a detrimental effect on the service provided although the manager does work long hours. The manager also reported financial constraints on the budget this year and as a result the planned redecoration of the bungalows has not happened despite it being much needed. Health and safety checks are carried out regularly to ensure the home is a safe place to live and all equipment used within the home, including aids to support the moving and handling of people are well maintained and regularly checked to ensure they are safe to use. Policies and procedures and a number of standard documents used within the home do not fully reflect the service provided at Pear Tree Lane and work is taking place to redevelop forms to ensure that they are more user friendly. DS0000072765.V375041.R01.S.doc Version 5.2 Page 27 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 X 3 X DS0000072765.V375041.R01.S.doc Version 5.2 Page 28 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 YA24 YA8 Good Practice Recommendations The manager should ensure that the home is well maintained with a regular programme of redecoration to ensure the home is a nice place for people to live. It is recommended that the home have a regular programme of activities in place to meet people’s individual needs and wishes and for records to be kept to evaluate their success. It is recommended that the home produce protocols to support the use of medicines taken as and when required. This will ensure consistency and reduce the risk of people receiving the medication inappropriately. It is recommended that the manager maintain regular access to the staff training records to demonstrate that all staff have received all required training opportunities. It is recommended that the home start to review policies and procedures to ensure they reflect the service offered at the home. It is recommended that the home review record keeping DS0000072765.V375041.R01.S.doc Version 5.2 Page 29 3 YA20 4 5 6 YA35 YA40 YA41 processes to ensure that all information is readily available at all times. This will prevent duplication of information recording and allow easy access to information for monitoring purposes. DS0000072765.V375041.R01.S.doc Version 5.2 Page 30 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT 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. DS0000072765.V375041.R01.S.doc Version 5.2 Page 31 - 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!