Inspection on 07/04/09 for Stratford Court

This is the latest available inspection report for this service, carried out on 7th April 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stratford Court 28/11/05

Stratford Court 17/05/05

Stratford Court 27/10/04

Stratford Court 11/05/04

Stratford Court 10/02/04

Stratford Court 12/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Stratford Court 35 Highfield Road Hall Green Birmingham West Midlands B28 0EU Lead Inspector Jill Brown Key Unannounced Inspection 7th April 2009 08:30 DS0000016788.V375365.R01.S.do c 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 homes for older people 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. Stratford Court DS0000016788.V375365.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 Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stratford Court Address 35 Highfield Road Hall Green Birmingham West Midlands B28 0EU 0121 778 3366 0121 778 6288 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) Ashdale Care Homes Limited Mrs Carole Wilkins Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Stratford Court DS0000016788.V375365.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: 2. Old age, not falling within any other category (OP) 30 The maximum number of service users who can be accommodated is: 30 4th July 2006 Date of last inspection Brief Description of the Service: Stratford Court provides residential care for up to 30 older people on both a long and short-term basis. It is a purpose built care home conveniently placed for local amenities and public transport. The Home offers accommodation over 2 floors and an eight-person lift provides access between floors. Bedrooms range from single rooms with en suite facilities to studio type accommodation. These studio rooms are for single occupancy and also have en suite facilities. They are intended for use by residents who are more independent but who will still benefit from the security of 24-hour supervision, care and support services. There is one double room with en suite for use by couples or friends. There are also fully assisted bathing and showering facilities available. The main complex has three separate lounge areas, a large dining room, and a hairdressing salon. Disabled toilet facilities are available close to the lounges and dining room. The Home is equipped with a loop system and talking books for service users with sensory difficulties. Television and telephone points are sited in all bedrooms and a payphone is also available for residents use. There is a well-tended garden with seating for residents to enjoy, and some car parking facilities are available for visitors. The current fees range from £359 to £550 per week for those funded by the local authority top up fees range £50 to £150 pounds per week. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We visited the home without notice on a day in April 2009 and undertook a key inspection where we looked at the majority of the National Minimum Standards. The home gave us information in an Annual Quality Assurance Assessment (AQAA) before the key inspection. The AQAA shows how the home rates their performance in the areas set out in this report and how they intend to improve. During the inspection 2 peoples care was case tracked, this involves looking at all the records about this person and how the home manages their care and we looked at parts of 2 other peoples care. We spoke to 4 people who live at the home, 2 staff and the care manager and the other Director of the service whilst we were at the home. We received 6 completed comment cards from people living in the home 8 from their relatives or representatives, 4 from health professionals and 10 from staff. We looked at the homes medication records. We looked around parts of the building and viewed the health and safety checks that had been undertaken. We have received one complaint about the home before we inspected. Information about all of the above is contained in this report. What the service does well: People coming into this service are assisted to gain checks on their eyesight, foot and dental care if this hasnt been done for some time it is arranged quickly after admission. The home has a good working relationship with health professionals who said:People are supported to live the life they choose. The residential home requests and has regular small teaching sessions as and when required. In my professional opinion the whole service that is offered by Stratford Court is excellent. Peoples medication is given correctly and good records are kept about this. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 6 People thought that the carers were very good they and their representatives said: The home endeavours to maintain a resident self-respect and ensure that the residents are well presented (regular baths for hygiene, hair washed and clothing very well cared for). Activities at this home well catered for and every effort is made for the residents to join in. The staff are caring and very respectful towards the residents and relatives too. We are welcomed and if we asked about my mothers condition they give that information. People have an opportunity to join in group activities and people are encourage to develop activities they can enjoy on their own such as knitting and painting. People were happy with the food when we talked to them they said that the food was good, better than in a previous home. Residents have an input into menus on a seasonal basis and the menus suggested that meals were nutritionally balanced. There were no undue restrictions on people and they could spend the time in their rooms or with other people. The homes layout and environment is good so people have the benefit of a warm, airy and comfortable place to live. The home has enough trained staff to assist people with their personal care needs and as there is a low turn over of staff people can get to know them. The home is well run with good attention the health and safety requirements. What has improved since the last inspection? There is now decking in the garden area and this makes access to it more wheelchair friendly. They have invested in hardwood garden furniture. The home has developed a process to ensure that peoples health and wellbeing is checked following admission and this safeguards their health. The home has an activities co-ordinator that works various shifts and is encourage people to take up individual interests. The home says that people can take advantage of their bi weekly personal shopping service. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 7 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. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 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): 1,2,3,4 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. Information is given to people about the home and this helps them decide whether the home will suit them. Detailed information is not collected about people before they are admitted and this may mean that the home has not determined whether they can meet the persons health and care needs. EVIDENCE: Information is available in a statement of purpose and service user guide and this assists people in making a decision if this home is suitable for them. This information had been reviewed and updated since the last inspection. From the comment cards received people thought they got enough information Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 10 before they were admitted to the home. One person acknowledged that they had to move in very quickly so there hadnt been time to get information. The statement of purpose states that the home accepts people who have mild to moderate dementia. The home cannot admit people where dementia is their primary need as this would be outside their conditions of registration. The home has a contract, which sets out the service that people can expect for the fees and this helps to ensure that people are aware of the terms and conditions of their stay. The home does not always record when a copy of the contract is given to the person or their representative and this may be useful. We looked at the information collected about three people before they were admitted into the home. We found that the amount of information collected varied. Peoples health conditions, any allergies, their communication, continence and nutritional needs were recorded but the reasons for their admission were not and this can mean that needs are not met. A number of assessments had gaps in information expected by the standards and this can lead to people being admitted when the home cannot meet their needs. From talking to staff we found that people come into the home for a few hours to see if they want to consider the home. We did not find any records of this visit in peoples files. On admission people are checked to see if they are well. Some information like peoples weights, blood pressure and last appointments with opticians and dentists are recorded. This means that arrangements can be made for consultations where people have not had these health checks for some time; records showed that the home organised these checks. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 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): 7,8,9 and 10 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. Although care planning and recording needs improvement people receive good care due to a stable and trained staff team. Medication administration was good and this helps to ensure people that people keep as well as possible. People are treated kindly and with respect and this makes them feel safe. EVIDENCE: People have plans of care these tend to be written in the first 4 weeks of peoples stay in the home. We were told that the staff are verbally told at each shift the care that people need and that key workers were not allocated until the initial four weeks were completed. A care plan for a person admitted three weeks previously had not been fully completed. Areas such as life style, physical wellbeing and at a glance daily routine were left blank. At a glance Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 12 daily routine as a minimum should be completed to ensure that staff have a reminder of the care they are to give and risks they are to minimise before a fuller care plan is written. A number of people have been admitted with memory problems. The home completes a memory test, which for three people had resulted in a statement of consider further action one person had an episode of challenging behaviour and no plans had been completed. A comment card from a GP stated people with severe dementia should not be housed here as it is too near to a busy main road. People have contact with health professionals as and when needed. A GP commented people are supported to live the life they choose. A district nurse commented the residential home requests and has regular small teaching sessions as and when required. In my professional opinion the whole service that is offered by Stratford Court is excellent. People looked well cared for with their personal hygiene and laundry needs met. We tracked a person that had a health issue that needed intervention and found that the home referred for medical assistance when needed and acted as required. Some daily and evening records were not detailed enough to track events. Medication administration was good. Medication was stored securely and in appropriate conditions. People in the home received their medication as prescribed and the Medication Administration Records matched the supply left in the home. In one case the GP had not prescribed sufficient medication and this had not been identified but the manager immediately rectified this. Medication left over from the previous cycle in this instance had not been carried forward. Staff have been trained by community nurses to administer insulin injections and undertake blood sugars but no written protocols were in place to say in what circumstances further action is needed. We observed that staff talked to people in a sensitive and respectful way, encouraging people to assist themselves when ever possible. A community nurse commented that they had witnessed people being given care in a way that maintains their privacy and dignity. A relative commented: The home endeavours to maintain a residents self-respect and ensure that the residents are well presented (regular baths for hygiene, hair washed and clothing very well cared for). Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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): 12,13,14,15 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 in this home are encouraged to maintain and join activities and this helps to maintain their skills and well-being. People are encouraged to maintain their lifestyle and have visitors when they wish and this enhances their life. People have food that is nutritious and wholesome and this helps to keep them well. EVIDENCE: People living in the home have an activities plan this includes information about their lifestyle prior to coming into the home and what activities they liked. The home has an activities co-ordinator who looks at events in the community as well as activities that can be achieved in groups in the home or Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 14 that she can encourage people to do in their leisure time. For some people that means as well as board games, quizzes and physical games such as skittles they have taken up past interests such as knitting or art. One person said that when they first came to the home they found out that the person used to paint and they have organised him to start again. The activities co-ordinator does a mixture of times of shifts. They stated that there have been some outside activities with people going to a local nursery, to the pub, for rides out and so on. The home also has an entertainer who attends to play music and sing. Some people attend day services that they used to attend before being admitted. Relatives said : Activities at this home well catered for and every effort is made for the residents to join in. There are activities that my (relative) could join in but they usually prefers to sit in the lounge of her room watching the television and the staff respect their wishes. People are able to receive visitors when they wish. Relatives said of their experience of the home: The staff are caring and very respectful towards the residents and relatives too. We are welcomed and if we asked about my mothers condition they give that information. The carers always cheerful as a visitor Im always greeted with a smile and made to feel welcome and I believe the girls manage very well to make each resident feel that their well-being and happiness is of fundamental importance. Relaxed ambience. People living in the home can spend time in their rooms if they wish and rooms have a television in if they wish to concentrate on a particular programme. A number of people have breakfast on a tray in their room whilst some come downstairs. The home stated that Menus are changed seasonally and that people living in the home are asked to comment on meals they would like. The manager then pulls together a menu that is nutritionally balanced. People can have alternatives to the set menu. We looked at the menus and found that the lunchtime meal was varied and nutritious, at tea as well as sandwiches there was a hot meal option and there were home made soups available. People can leave a note of special requests for meals and we saw a number of these. The home needs to consider how people with short-term memory loss choose food and make special requests. People living in the home said about the meals supplied: The meals at Stratford Court are a vast improvement on the meals of the previous home. On Sunday we had a lovely chicken casserole with beautiful Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 15 chunky vegetables. For tea we have sandwiches, home made soup or cake but we can have cheese or beans on toast. The foods good They bring breakfast on a tray in my room. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 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 living in this home are safeguarded by staff that are appropriately recruited and who would raise concerns. People can raise complaints but more needs to be done to ensure people have a voice in the home to shape the way the service provided. EVIDENCE: The home stated in their annual quality assurance assessment (AQAA) that they had no complaints in the last 12 months. We received a complaint about lack of contract being supplied on request, lack of medical attention and arrangements where a person needs exceeded what the home could give. We looked at this under the relevant standards and made recommendations. The home does not have regular meetings for people living in the home and their representatives. The home needs to develop methods of showing how peoples requests and views impact on the service that they receive. People living in the home spoken to were happy with the help they received one said: If Im not sure just ask them. There have been no issues of a safeguarding nature referred to the commission in the last year. The home has appropriate policies and procedures in place should there be a need to refer anybody. The home has put into place Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 17 checks for when people are newly admitted or readmitted to ensure that any concerns can be identified quickly. Staff spoken to would refer any concerns they had to the manager but needed to be prompted about some aspects of the procedure. Staff recruited to the home only start work after checks are undertaken about their suitability to work with vulnerable people. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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): 19,20,24,26 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 living in this home have the benefit of a suitable, warm, clean and wellmaintained place to live and this makes their day-to-day life comfortable. EVIDENCE: The home was purpose built and met all the National Minimum Standards in terms of space and facilities. The home was clean fresh and well maintained on the day of the inspection. People said about the home: My room is very comfortable, big enough for one. Peoples relatives said: The properties spotlessly clean. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 19 Bedrooms and lounge and dining areas are well furnished. Private room for seeing residents. The accommodation is at the very high standard and cleanliness/hygiene of the home is excellent. The home has three lounges, which gives a good amount of space for people to spend their leisure time. There is an electric organ that is used during church services, and up until recently a person used to come in play for people living in the home. We looked at the garden and found that there were pleasant grounds for people to enjoy in the good weather. The garden is wheelchair friendly, has decking and access to the lower level. Peoples bedrooms were well furnished and decorated, people were able to bring in small items to personalise the rooms to make it feel more like home. The owners are undertaking a refurbishment programmes some rooms have flat screen TVs and the owners intend these to be available in all bedrooms. Peoples bedding and curtains were colour coordinated and well laundered showing an attention to detail and this can make bedrooms a pleasant space for people to spend their time. The laundry was appropriately sited and equipped with a sluice cycle washing machine. There were appropriate systems for the disposal of clinical waste and protective equipment after being used by the staff. The kitchen was found to be clean and well equipped. The Food safety Department had given the home a 4 H rating for food hygiene and this means they maintain good hygiene practices. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are 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): 27,28,29 &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 have the benefit of trained staff that know them and this helps to ensure that people receive care in the way they need and wish. People can be assured that staff are recruited appropriately and this helps to maintain peoples safety. EVIDENCE: There were enough members of staff to ensure that people received help when they needed this on the day of the inspection. The rotas did not include the hours that the care manager and her husband who are also directors of the company were on the premises so it was difficult to assess whether this was true at all times. There is a maximum of 5 care staff on including the deputy and a minimum of 2 care staff. There are 2 care staff on duty on a night and on some days between 5pm and when the night staff are on duty. In addition the home has staff in the kitchen and housekeeping and administrative staff. The staff have mostly worked at the home for some time and this gives people living in the home of having care provided by people that have got to know them. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 21 All care staff in the home except the most recent employee have achieved a National Vocational Qualification level 2 in care which means that they have the knowledge about the care needs of older people. One person had been recruited recently and from the staff file we could see that the person had checks with the Criminal Records Bureau, the Protection of Vulnerable Adults list, and references. Staff are recruited safely and this protects people living in the home. There was evidence of the person receiving and continuing to receive induction training and the manager needs to ensure that this meets all the requirements of the Skills for Care Common Induction Standards are met. Staff commented In terms of induction, for all areas I was given time to shadow an experience care worker to understand what was required. Everything was covered at the time of induction including who to ask if you were at all sure of anything. We asked staff about training and looked at 3 staff files. We found that staff had appropriate training in mandatory courses such as moving and handling, fire safety and first aid and so on but we could not evidence that these were always subject to refresher training within time scales. Staff do have specific training to meet the needs of people living in the home such as diabetes, dementia awareness and deprivation of liberty awareness under the Mental Capacity Act. Staff have completed safeguarding training. Staff were receiving supervision sessions and these looked to be frequent enough to meet 6 times a year standard. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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): 31,33,35,38 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 can be assured that the home is well run and that the health and safety of people was well managed. Further development of quality assurance is needed to ensure that people can be involved in the improvement of the home. EVIDENCE: The manager was a qualified nurse and had undertaken the Registered Managers Award (RMA). She had several years experience of managing a care home and caring for elderly people. She is a director of the company that owns the care home. The deputy manager has also undertaken the RMA. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 23 The home has a business development plan that ensures the continued good fabric of the building and its commitment to ensuring that staff receive National Vocational Qualifications. The manager completed the Annual Quality Assurance Assessment well and this could be used as a basis for a full quality assurance system. We were told that the home did not have resident meetings. The home need to demonstrate how they give people a regular opportunity to speak about the care that receive and how their comments and suggestions have changed the service. The home needs to consider how they gain the views and measure the well being of people that have dementia. There are regular drug audits and this ensures that medication administration remains good. People can have small amounts of money held for them by home. This is kept in a separate bank account and there is an electronic record of the money that people have and what it is spent on. There are receipts for the money spent. We looked at three accounts and found that these were accounted correctly. People spent their money mainly on hairdressing, chiropody and toiletries. We found that the home had ensured that the servicing and inspection to maintain gas, lifting equipment and fire safety had been undertaken and this means that the environment is safe for the people that live there. The electrical inspection needs some checking to ensure that it meets the health and safety and insurers requirements. We looked at the accident records in the home there were not many accidents however a formal audit of accidents and small injuries should be undertaken to feed into the homes quality audit. Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (a)(d) Requirement The home must collect enough information as defined by the standard, and record this, to determine whether they can meet the persons needs. This is to ensure that people are not admitted inappropriately. People must have a plan of care to show how their needs are to be met and risks minimised within 72 hours of admission. This is to ensure that the person receives safe consistent care. People that have shown behaviours due to dementia or other mental health conditions must have a plan to show how these are to be managed. These plans need to be reviewed after each incident. Timescale for action 15/06/09 2 OP7 15(1) 15/06/09 3 OP7 13(4), 12(1)(a) 15/06/09 4 OP9 13(2) This is to ensure that people living in the home are consistently cared for and all people in the home remain safe. Where the home is undertaking 15/06/09 invasive medical treatments such DS0000016788.V375365.R01.S.doc Version 5.2 Page 26 Stratford Court as insulin injections a written protocol should be in place advising at what point further medical advice and intervention is to be sought. This is to ensure that there are clear lines of responsibility and the persons health is maintained. 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 OP2 OP27 Good Practice Recommendations It should be recorded when information and the contract are given to people or their representatives. Information and contracts should always be available on request. Staffing rotas should include when all staff giving a service to people are in rostered on shift, are on call or are working in the building and this includes the directors of the company. The manager should ensure that induction processes meet the skills for care Common Induction Standards and evidence is maintained to demonstrate staff competence. A matrix of the teams mandatory training and refresher training should be maintained. People should have the opportunities to talk about the service they receive on a regular basis and be involved in the development of the service. The management need to assure themselves that the electrical wiring certificate meets the needs of the insurers and ensures the safety of the people living in the home. 3 4 5 6 OP30 OP30 OP34 OP38 Stratford Court DS0000016788.V375365.R01.S.doc Version 5.2 Page 27 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Fax: 03000 616171 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. 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