Inspection on 29/08/08 for 230a Mountnessing Road

This inspection was carried out on 29th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

230a Mountnessing Road 03/09/07

230a Mountnessing Road 17/10/06

230a Mountnessing Road 03/11/05

230a Mountnessing Road 02/06/05

230a Mountnessing Road 02/11/04

230a Mountnessing Road 25/05/04

230a Mountnessing Road 08/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 22/11/2008.

CARE HOME ADULTS 18-65 230a Mountnessing Road 230a Mountnessing Road Billericay Essex CM12 0EH Lead Inspector Pauline Marshall Unannounced Inspection 29th August 2008 10:05 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 230a Mountnessing Road Address 230a Mountnessing Road Billericay Essex CM12 0EH 01277 632914 01277 632914 yolanda.inciong@estuary.co.uk 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) Estuary Housing Association Limited Yolanda Inciong Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Nursing and personal care to be provided to 8 service users with a learning disability. Nursing and personal care to be provided excluding any service user liable to be detained under the Mental Health Act 1983. 3rd September 2007 Date of last inspection Brief Description of the Service: 230 Mountnessing Road provides nursing care and accommodation to eight adults with learning disabilities. The home comprises of two semi-detached bungalows with an internal interconnecting door. Each bungalow has its own lounge, dining room, kitchen, shower room with WC, bathroom with WC, sluice and laundry room, as well as four single bedrooms with washbasins. There is a large garden with raised flowerbeds and a pond with seating areas. The home has car-parking facilities to the front and is situated within reasonable access to all local amenities and transport links. The weekly fee is £1,758.84 and people living in the home pay a contribution towards this of between £65.20 and £102.95 each week dependent on their age. Various additional charges are made for hairdressing and activities in the community, and chiropody, sensory sessions and aromatherapy at home. 230a Mountnessing Road DS0000015548.V370863.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 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection that lasted for five hours and five minutes. People living in the home had limited verbal communication but were able to show their views using various other methods. The process included discussions with the manager and the staff; an examination of a random sample of files (including those of staff and people living in the home) and some of the records that the home is required to keep. The inspection covered all of the key standards and included a tour of the property. The manager completed her annual quality assurance assessment (AQAA) and information from this has been reflected throughout this report. The AQAA is a form required by law for the manager or provider to carry out a self-assessment of how well the outcomes of people using their services are being met. Surveys were sent to the manager to distribute to eight people who live at the home, eight of their relatives, four health and social care professionals and ten care staff. At the time of writing this report thirteen surveys were returned which all appeared to have been completed by staff working in the home. The returned surveys contained mainly positive comments about 230 Mountnessing Road but several staff did say in their surveys that the home would do better by employing more permanent staff; comments from the surveys are reflected throughout this report. What the service does well: The manager gives people good up to date information on the service that she provides and can also supply the information in pictures. Care plans are written in a person centred way; people have their own talking book. There is plenty to do at 230 Mountnessing Road both in the home and outside locally in the nearby town. People living in the home are encouraged to make decisions about what activities they want to do, what they want to eat and drink and when to go to bed and get up. People have a holiday every year and they have the chance to choose different places to go to each time. The home has its own mini-bus. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 6 Staff said in their surveys “the home does well in activities and holds regular service user meetings”. People have access to good health care and they have regular check ups to make sure that they stay healthy. The food is good and people are able to choose what they would like to eat from large coloured pictures of different meals. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People will receive accurate information about the home. The thorough assessment process ensures that people know that their needs will be met. EVIDENCE: The manager reviewed the Statement of Purpose in April 2008 and the Service User Guide in May 2008; both documents provide people with sufficient information to enable them to decide if the home is appropriate for them. Each person living at the home has a copy of the Statement of Purpose and Service User Guide in their rooms. Each of the three care files examined contained thorough assessment documentation that included information provided by other relevant people. There have been no admissions to the home in the past year; the manager said that there is a detailed admission policy and procedure and it would be used for any future admissions; All three care files examined contained a pictorial copy of the individuals contract with the home; either the person living in the home or their 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 10 representative did not sign these. The manager said that due to the recent increase in fees each person would receive an updated contract and that she would ensure these were correctly signed. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care planning ensures that people are cared for in the way they would like to be and they are treated with dignity and respect. EVIDENCE: Three care files were examined and they all contained detailed person centred plans; each file had risk assessments together with their corresponding management plans. The manager said in her annual quality assurance assessment (AQAA) “residents have a person centred programme and a talking book in their rooms, staff sit with them and discuss these documents at regular times”. Staff spoken with confirmed that they regularly spend one to one time with people living in the home and talking books were seen in people’s rooms. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 12 The daily notes were detailed and informative and all areas of the care plan were regularly monitored; there was evidence of monthly and six monthly reviews having taken place. People living in the home are involved in planned meetings to assist them in making decisions about every day issues; the manager said that although meetings are scheduled monthly they have not always taken place. The last meeting took place on 8/5/08 and one other meeting was recorded within the last year that was held on 27/3/08. The manager said that people living at 230 Mountnessing attended regular forums in addition to the meetings that are held in the home. There was evidence that these forums take place at people’s day centre. The manager said in her annual quality assurance assessment (AQAA) “people are empowered to make their own decisions which is shown in their PCP (personal care profile) and talking book - people choose when they want to eat, when to go to bed, they choose the drink they like and whether to stay in bed late at week ends”. Care plans and the notes of meetings for people living in the home confirmed this. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of internal and external activities enhances people’s well-being and they have nutritious and well presented meals and snacks, at a time and place to suit them. EVIDENCE: People living in 230 Mountnessing Road regularly access leisure activities within the local community that includes visits to Marsh Farm, theatres, meals out and the Wickford Exchange day centre. The home has a sensory room that the manager says is used daily by the people living there, staff spoken with confirmed that the sensory room is used regularly. The manager says in her annual quality assurance assessment (AQAA) “we encourage people to do simple domestic jobs like putting cutlery back in the drawer and putting their own dirty laundry in the basket”. Care plans and staff spoken with confirmed that people are encouraged to participate in household tasks. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 14 There is a whiteboard in the office that shows the planned activities for the week ahead; the manager said that changes are made to suit the needs of individuals living in the home. On the day of the inspection people living in the home were receiving aromatherapy by an external therapist. Each of the three care files examined contained activity sheets and activities included walks, puzzles, games, sensory sessions, mini-bus rides, lunch out, activity ball, music and visits to relatives; all of the sheets were fully completed and evaluated on a monthly basis. People living in the home have regular annual holidays and destinations are discussed at the house meetings. Some of the people living in the home have regular contact with their family and friends and are visited by them regularly. The families of other people living in the home visit mainly on special occasions such as Christmas and birthdays. People living at 230 Mountnessing Road are able to access all of the home and the gardens. Each person has his or her own bedroom with shared bathing facilities. Staff was observed interacting with people living in the home in a respectful way, they explained their actions allowing time for people to respond to them before carrying out any activities. People appeared happy and relaxed in staff company. The menus are pictorial and are displayed on the wall in both dining rooms. The manager says in her annual quality assurance assessment (AQAA) “food pictures are provided to facilitate dialogue with people living in the home”. Each of the care files examined contained fully completed nutritional records that identified when people’s dietary intake was insufficient and charts were put in place where people’s food or fluids were to be monitored. The records and menus showed that people were offered a variety of foods and that people living in the home enjoyed a take away meal on a regular basis. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s physical, emotional, health and personal care needs will be met in the way that they prefer. The medication practice could potentially put people at risk. EVIDENCE: The care files examined provided full details of how personal care was to be provided and staff spoken with confirmed that people living in the home received their care as detailed in the care plans. It was evident from the records and speaking to staff that meals, bathing and routines in the home are flexible and are adapted to meet the needs of the individual. Bedroom and bathroom doors were kept shut whilst staff were providing people with personal care. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 16 Staff spoken with and surveyed said that the home provides adequate equipment including hoists, individual slings, an assisted bath and shower and beds that can be raised and lowered. Each of the care files examined contained evidence of health care appointments; the records identified which professional was seen and the outcome of the visit and included any follow up actions that were necessary. Each of the three care files examined contained a health screening checklist but these were not fully completed. There were weight, bowel and epilepsy charts in place and they were fully completed. The three care files examined all contained evidence of medication reviews having taken place. The manager said that the medication policy and procedure is due for review and that only qualified staff administer the medication at 230 Mountnessing Road although all staff is trained in the use of medication. Medication is stored in locked cupboards in the office. A random check on the medication system was carried out. The manager uses a mediform monitored dosage system for recording the administration of all medication including as and when (PRN) and homely remedies; the mediform document covers an eight-week period. The manager said that qualified staff undertakes regular weekly audits to ensure that medication is correct. An examination of one medication administration sheet (mediform) showed that a qualified staff member mid way through the eight-week period had carried out an audit. The examination showed that the amount of tablets entered on the medication administration sheet (mediform) was incorrect, the full amount prescribed at the start of the twenty-eight day period was written up and this made the following audit incorrect. This indicated that a tablet count could not have taken place. On undertaking a tablet count the manager identified that there should have been forty-two tablets left in the bottle; it contained forty-seven tablets; it was not possible to determine from the records why there were extra tablets in the bottle. The manager says in her annual quality assurance assessment (AQAA) “medication is locked in medication cabinet and people are protected by the home’s policy & procedure and all medication is administered by qualified staff”. The manager said that she would investigate the matter with her qualified staff. All other medication and the corresponding records that were checked were found to be correct. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s complaints will to be listened to and acted upon. The lack of written procedures providing staff with guidance on the safeguarding of adults could potentially put people using the service at risk. EVIDENCE: The manager had a copy of Estuary Housing Association’s complaints leaflet pinned on the notice board in the hallway; the leaflet contained out of date information with regard to the CSCI contact details. The Service User Guide includes a list of key contacts (including CSCI), details of how to complain and the photographs and telephone numbers of the home manager and Estuary’s chief executive. The manager said that she had never received any complaints but that she kept a record of the compliments she received and there was provision for any complaints to be recorded in this book. The manager said that the complaints policy was last reviewed in June 2004 but she was unable to provide a copy of it for this inspection. One safeguarding issue has been outstanding since 20/06/07; the manager said that she does not hold any information about the issue except the regulation 37 notice that was sent to CSCI; she could not locate the original incident forms. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 18 The manager said that she has an abuse policy that was last reviewed in January 2007. The policy was not in the policy folder and the manager was unable to locate this on her computer. The manager said that staff may have removed this for their NVQ work and not replaced it. All staff had received adult safeguarding (POVA) training. The manager said that she has a whistle blowing policy and that staff are aware of the actions to take if they suspected abuse. The manager says in her annual quality assurance assessment (AQAA) “the whistle blowing policy is read and discussed with staff, and they are aware of the appropriate action”. Staff spoken with were aware of the actions to take if they suspected abuse. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment. EVIDENCE: The home consists of two large semi-detached bungalows that are connected together; the hallway is spacious allowing plenty of room for wheelchairs to manoeuvre. Each bungalow contains four bedrooms, bathing facilities (assisted) a dining room, lounge and kitchen; there are shared laundry facilities in the middle of the properties. One of the kitchens is due for refurbishment and the manager said that the other kitchen is currently used for preparing all main meals. The home is nicely decorated and well furnished, individual bedrooms are fitted with key locks and contain many personal items, and they are decorated to 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 20 each person’s individual taste. The home has a large sensory room that contains specialist sensory equipment and a luminous carpet. The manager said in her annual quality assurance assessment (AQAA) “the home has been redecorated and carpeted and is bright and airy and bedrooms are personalised and have new soft furnishings like curtains, lampshades and matching bed linen”. Relatives confirmed this in their surveys and matching soft furnishings were observed on the day of the inspection. All outward opening doors are marked with warning signs to open them carefully. Care staff are responsible for maintaining the home’s cleanliness and the manager said that a cleaning rota is in place and that guidelines are pinned on the kitchen notice board. Staff spoken with and surveyed said that the home was always clean and tidy and that it was a nice place to work in. The garden area has raised flowerbeds, a fishpond and plenty of seating areas. There is a ramp that allows people wheelchair access to the gardens. The manager said that people living in the home are able to participate in planting flowers and shrubs. The home was safe, clean pleasant and hygienic. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Well-trained and supervised staff supports people living in the home. Shortfalls in the home’s recruitment checks can potentially place people at risk. EVIDENCE: The manager draws up a four weekly roster and copies the information onto a weekly sheet that she uses when changes need to be made due to any sickness or the cancellation of any shifts. The rosters examined were mainly written in pencil; the manager explained that she was able to make changes more easily and that she intended to go over them with ink once they were finalised. Some of the older rosters examined were still written in pencil and did not contain the full names of the staff that had worked. The last inspection identified that the manager has had staff vacancies for a long time and that two members of staff were on suspension and that the investigation is on-going. The manager said that although two people had been interviewed for the posts they had not taken them up, however a further 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 22 two people had been interviewed and they are waiting for clearances before they can start work. The roster showed that there is one qualified and three support workers throughout the day and one qualified and one support worker throughout the night. The manager said that she uses agency staff to maintain her staffing levels and she said in her annual quality assurance assessment (AQAA) “regular agency staff is deployed to ensure consistency of approach for all aspects of care”. Staff surveyed said, “the home could do better by employing more permanent staff, although there is enough staff to meet needs but they are mostly agency staff”. Four permanent staff files and one agency staff file were examined and there were some shortfalls in each which included two files that contained one reference only and three files with limited evidence of induction. The manager said that staff had been employed since 1982 and 1990 and that they had transferred to Estuary on 1/4/2000 with limited information. The staff file of the most recent employee contained one reference and a letter from Estuary confirming that the all clearances had been received. The agency staff file contained a staff profile dated 7/3/07 and it highlighted that training updates were due by late 2007; there was no evidence on this file to confirm that the updated training had been carried out. There was evidence that the agency staff had been provided with one supervision session on 16/2/08. The permanent staff files examined contained evidence of staff training including, moving and handling, food hygiene, first aid, health & safety, risk assessment, adult safeguarding (POVA), medication, infection control, epilepsy, dementia, palliative care, challenging behaviour and understanding valuing people. The deputy manager is undertaking the registered managers award and one support worker has completed their NVQ level 3 and two other support workers are working towards the qualification. The manager said in her annual quality assurance assessment (AQAA) “staff that are taking NVQ’s are given time allowances to attend study days, completing their assignment and assessments”. The manager has a schedule for carrying out staff supervision and the four staff files examined contained evidence of regular supervision having taken place and staff spoken with and surveyed confirmed that they receive regular supervision. There was evidence of regular support staff meetings and qualified staff meetings, both are scheduled monthly and topics discussed included activity plans, outings, finance, hydrotherapy, staff daily tasks, start times of shifts and issues about people living in the home. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of up to date policies and procedures and the need to obtain other peoples views on the running of the home does not provide people with the best outcomes. EVIDENCE: The registered manager of 230 Mountnessing Road is a qualified nurse who has worked at the home for some years and has completed the registered managers award. The manager regularly attends training courses to update her practice. The manager identified in her annual quality assurance assessment (AQAA) that there was a shortfall of policies and procedures and that where they were available, their review dates varied between 2003 and 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 24 2006. The complaints policy was last reviewed in 2004 and contained out of date information and the abuse policy could not be located either in the policy file or on the computer system. There was no evidence that the manager had sent surveys to people living in the home, their relatives or health and social care professionals to obtain their opinions on how the home is run. The manager said that she now understands the need to obtain the views of others as part of her own quality assurance systems. The manager said in her annual quality assurance assessment (AQAA) “effective quality assurance and monitoring systems are in place to ensure the achievement of the aims, objectives and Statement of Purpose” and “policies, procedures and record keeping safeguard the rights and best interests of people living in the home”. There was evidence that regular visits from the provider have taken place recently and the manager said that improvements have been made in this area. The manager also said that regular checks are carried out on the systems in use to make sure they remain effective. All of the home’s safety certificates were in place and up to date and there was evidence that regular fire drills have taken place. Staff spoken with and surveyed said that they felt the home operates safe working practices and this was observed on the day of the inspection. 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 25 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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 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 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 2 X 2 X X 3 X 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 (2) Requirement To protect people from potential medication errors the manager must ensure that all medication audits are carried out correctly and recorded on the mediform system. To ensure that people using the service and their relatives receive sufficient details to make a complaint, the complaints procedure must be up to date and available and include the contact details of the Commission. To protect people using the service the manager must make sure that the policy and procedure for dealing with abuse is available to staff. To ensure that there are adequate suitably competent staff to meet the needs of the people using the service the roster must be clear, contain full staff names and be written in ink. This is a repeat requirement. To ensure that people using the service receive the best DS0000015548.V370863.R01.S.doc Timescale for action 31/10/08 2. YA22 22 (7) (a) 31/10/08 3. YA26 13 (6) 31/10/08 4. YA32 YA33 18 (1) 31/10/08 5. YA37 10 (1) 31/10/08 230a Mountnessing Road Version 5.2 Page 27 6. YA39 24 (3) outcomes the manager must make sure that there are up to date policies and procedures kept in the home. The quality assurance system must include the views of all people having an interest in the home to ensure that people are satisfied with the quality of care provided. 31/10/08 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. Refer to Standard YA5 Good Practice Recommendations To ensure that people using the service and their representatives are clear on the level of fees it is recommended that the contracts be updated when fees increase and that they are signed and dated by the person using the service or their representative. To protect people using the service it is recommended that the manager obtain copies of all of the staff documents held at head office and keep them in her staff files. To ensure that competent agency staff cares for people living in the home it is recommended that the manager obtain regular updated information on agency staffs training. 2. 3. YA34 YA35 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 230a Mountnessing Road DS0000015548.V370863.R01.S.doc Version 5.2 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. 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