Inspection on 02/06/09 for 4 Beech Close

This inspection was carried out on 2nd June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

Key inspection report CARE HOME ADULTS 18-65 4 Beech Close 4 Beech Close Dunstable LU6 3SD Lead Inspector Nicky Hone Key Unannounced Inspection 2nd June 2009 14:00 4 Beech Close DS0000073230.V376277.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. 4 Beech Close DS0000073230.V376277.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 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4 Beech Close Address 4 Beech Close Dunstable LU6 3SD 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) 01582434336 01582434337 TACT UK Ltd Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 4 Beech Close DS0000073230.V376277.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 category: Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 This is the first inspection since this home was registered on 19/01/09. 2. Date of last inspection Brief Description of the Service: 4 Beech Close is a home for up to 4 adults with learning disabilities. The home was registered in January 2009 and at the time of this inspection there were 2 people living here. The home is managed by TACT UK Ltd who provide the care and support. MacIntyre Housing Association owns the property and is responsible for its maintenance and upkeep. 4 Beech Close is a bungalow, situated a few minutes walk from the A5 and about 1 mile from Dunstable town centre. There are some local shops, and a good bus service close by. It shares a site with 3 other registered care homes and a resource centre. The bungalow has 4 single bedrooms, each with its own sitting room across the hallway. There are 4 bath/shower rooms, a kitchen, laundry room, dining room and 2 large lounges, as well as an office and a ‘quiet room’. There are good sized gardens to both the front and rear of the property, and parking is available in the close. The home has its own transport. 4 Beech Close DS0000073230.V376277.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 adequate. For this inspection we (the Care Quality Commission) looked at all the information that we have received, or asked for, since 4 Beech Close was registered. This included: - The AQAA (Annual Quality Assurance Assessment) that the Divisional Director of TACT completed and sent to us in April 2009. The AQAA is a selfassessment that focuses on how well outcomes are being met for people living at the home. It gives the provider the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live and stay here. The AQAA also gives us some numerical information about the service; - Surveys which we sent to the home to give to the people who live here. The home did not receive these; - Surveys for staff which we emailed to the home following the inspection: we received 5 replies; - Telephone conversations with relatives; - What the service has told us about things that have happened in the home. These are called notifications and are a legal requirement; - Any safeguarding issues that have arisen; and - Information we asked the home to send us following our visit. This inspection of 4 Beech Close also included a visit to the home on 02/06/09. No-one who lives or works at the home knew we were going to visit on this day. We spent time talking to the acting manager, and other staff. We looked round the home and spent time in the bungalow, observing what happens. We looked at some of the paperwork the home has to keep including care plans, risk assessments, medication charts, and records such as staff personnel files, staff rotas, menus and fire alarm test records. The first acting manager, Darren Rawlings, went on sick leave in April 2009 and another acting manager, Louise Tedeschi, had been seconded to the home. It was Louise who was present for this inspection, and it is Louise who we refer to as ‘acting manager’ throughout this report. 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: We have made 3 requirements following this inspection. The most important thing the organisation must do is make sure the home is managed by someone who will give good strong leadership so that quality of life for the people who live here continues to get better. 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 7 Staff must receive training in all relevant topics so that they can do their jobs as well as possible, and records must be available to show this. The wires hanging from the wall light fittings must be made safe. We have recommended that there is only one version of the service user guide; that files are tidied up; and that healthcare appointments are clearly recorded. In their responses to our questionnaire, some staff indicated they are not completely happy with the way they are treated. The organisation will have to find a way to deal with staff’s apparent discontent so that it does not impact on the service provided. In the AQAA the divisional director showed that she is aware of areas in which the home can continue to improve. 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. 4 Beech Close DS0000073230.V376277.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 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 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. Information about the home is available so that people know what to expect from the service, and people know their care will be based on a thorough assessment of their needs. EVIDENCE: We looked at the information that 4 Beech Close has available so that people know what service the home offers. We saw the Statement of Purpose, and 2 different versions of a Service User Guide on one person’s file. The Service User Guide stated that Darren Rawlings is the ‘Registered Manager’: Mr Rawlings has not completed his registration, so is not yet registered. None of the documents had been updated to reflect the change from CSCI to CQC. The Service User Guide included information about weekly fees. The acting manager told us that each person has a contract with the home which explains what the person can expect from the home, and what is expected of them. One person’s relative was still to sign and return the 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 10 contract. On both the files we found a lot of assessment information which had been completed before people were offered a place at the home. Each person had been supported through a transition period which met their individual needs. Annual reviews will be carried out by a care manager from the social services team to assess how well the home is meeting the person’s needs. 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 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. Support plans are based on each persons assessed needs and give good guidance to staff on the way each person prefers their needs to be met. People are supported to make decisions about their lives, and risk assessments enable people to be as independent as possible. EVIDENCE: For this inspection we looked at the information the home has about both of the people who live here. Each person has a support plan. These are written in the first person (that is, 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 12 using I), and give staff good, clear guidelines about the support each person needs and wants, and how they like their support to be given. Each support plan also includes goals that the person wants to work towards. Staff we spoke with said “This is a new service and we’re getting to know people – they are changing all the time. One person has calmed down and can even wait for a short time now”. Some information in the plans was repeated several times and sometimes inconsistent (see Conduct and Management section of this report). Risk assessments and risk management guidelines have been written for all the risks each person might be involved in: for example, walks out in the community; in the kitchen; visits to health professionals; meals out; personal care; and so on. The risk management guidelines give staff good information on how to support the person so that the risks are minimised, but the person is still able to do whatever the activity involves. Each person has a communication passport which describes in detail the way that person communicates. We could see that people are involved as much as possible in making decisions about their home and how they want to lead their lives. Staff write daily notes which give a good picture of how each person has spent their day. Each person has a keyworker, who meets with them regularly to make plans for the coming weeks, sort out any problems, for example with money, and generally making sure the person is as satisfied as possible. 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are offered a wide range of opportunities to lead full, satisfying and interesting lives. EVIDENCE: Each person has a weekly activity plan in their support folder, which they put together with their keyworker. This is not ‘set in stone’ but gives a guide as to what the person likes to do. Both people who live here are autistic, so a ‘schedule’ is used each day so that people know what they will be doing and when. The acting manager said that both people are “always out”. This was confirmed by the daily records which show that both people are supported to 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 14 do a range of different activities. One person goes to an organised day service for 2 days a week. One relative we spoke with said that her relative has improved greatly since moving to 4 Beech Close because “they keep him occupied all the time”. Families of the people who live at 4 Beech Close are encouraged to be involved in their relatives lives as much as they want to be, and are welcomed at the home when they visit. Staff support people to keep in contact with their families and an advocacy service is available for anyone who needs additional support. The acting manager told us that people choose what they want to eat using a book of photographs of different meals. Staff then plan the menus, using the meals people have chosen, as well as what staff know people like and dislike. There are always alternatives available if people don’t like the meal that has been prepared. At the time of the inspection, because both people are still relatively new to the home, the staff are completing risk assessments on peoples’ safety in the kitchen. Both of the people who live here help with some of the household chores, such as hoovering, taking out the rubbish, and making their bed. 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported with their personal care in the way they prefer, and their health needs are met. Medicines are administered safely. EVIDENCE: Support plans we saw show that staff have spent time working out the ways in which each person prefers to be supported, and the detail of the guidelines makes sure that the person gets consistent staff support. Both people who live at 4 Beech Close have a Health Action Plan (HAP) in place. They are written in a very person-centred way, with details about the way in which each person wants to be supported to maintain their health. One person’s HAP showed that he had a health check from a nurse, covering blood pressure, urine test and so on. Both files showed that each person has 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 16 had a hearing test and a sight test. There was a note on one file that “appointment is needed for the dentist”: the acting manager said this was being followed up, but there was nothing on the file to show that this was happening. The “All about me” document in the HAP had been completed so that information is available about each person if they have to go into hospital. We looked at the way the home deals with medication. Neither of the people who live here would be able to deal with their own medication. The Medication Administration Record (MAR) charts showed that all medication is signed in correctly, and that staff have signed every time to show that a medication has been administered. All changes to the MAR charts had been dated and signed as they should be, and there were good, clear guidelines on the files for giving ‘when needed’ medicines. The acting manager told us that all staff have done training in administering medication, and have their practice observed by the acting manager and/or another member of staff every 3 months. Only 3 staff have been trained in specialised administration of diazepam which is prescribed for one person. The acting manager said that if there are no trained staff on duty, staff ring the other 3 care homes on the site. If there are no trained staff anywhere, staff ring 999. 4 Beech Close DS0000073230.V376277.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know that their concerns will be listened to and acted on, and that staff have the knowledge to keep them safe from harm. EVIDENCE: 4 Beech Close has a complaints procedure. Each person has a copy on their file, and the acting manager said that a copy is given to peoples’ relatives/representatives. A record of complaints would be kept, but there have not been any since the home opened. One relative we spoke with was very clear about who to contact if things were not going right. We looked at the arrangements the home has in place for dealing with finances, as the people who live here are not able to manage their own money. The acting manager explained that one person’s benefits are still being sorted out, so the person has no money at the moment. The home lends him any money he needs. The other person’s finances are dealt with by his relative. A small amount of cash is kept for each person in the safe. The home uses a 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 18 sealed pouch system, so the money is checked each time the pouch is opened and then re-sealed. We looked at the records of what each person has spent: these were accurate. The acting manager said that safeguarding vulnerable adults (SOVA) is a topic which is covered during staff induction. Some staff have been on further safeguarding training, but not all. She feels confident that the induction is in enough depth for staff to recognise any safeguarding issues and how to report them. We discussed whether a current issue should be referred to the SOVA team: the acting manager will discuss this with the person’s care manager. 4 Beech Close DS0000073230.V376277.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 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. 4 Beech Close offers the people who live here a comfortable and pleasantly decorated home which suits their preferred lifestyle. EVIDENCE: The home was refurbished before being re-opened in January 2009. There are now places for four people, who will each have a bedroom with a small sitting room opposite it. There are 2 further lounges and a dining room, as well as 4 bath/shower rooms, kitchen, laundry and office. At the time of the inspection most of the home was still well decorated and it 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 20 was comfortably furnished. Both people who live here have autism so they have found some things in the environment difficult to tolerate. They have taken some things they did not like off the walls, such as the wall lights in the dining room and lounge, lights over wash-basins, shower curtains, notice boards and so on. Staff are trying to re-introduce items slowly so that the bungalow is homely, but still furnished and decorated in a way that the people who live here like. There are large enclosed gardens to the front and back of the bungalow. The front is pleasantly landscaped. The back is mainly lawn as the people who live here have shown they prefer not to have things such as a football goal, chairs and so on in the garden. 4 Beech Close DS0000073230.V376277.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live here benefit from staff who are recruited well, and who have good supervision and support, as well as some training, so that they can do their jobs properly. EVIDENCE: The acting manager said “The staff team is really good here – they’re very good with the 2 guys and they all muck in and get the work done”. She said there are 14 staff including the deputy manager and acting manager. It was a new team and they all started in December, although some of the team were already working for TACT. There are always 3 staff on duty during the day, and 2 staff awake at night. The acting manager and staff we spoke with said that this is enough staff for the 2 people living here. 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 22 We looked at the records the home keeps about two of the staff. All the information the home must get before staff start to work at the home, including references and a Criminal Record Bureau (CRB) check, is in place. Bank staff also work at the home: a pro-forma is in place for each of them confirming that all the required documents are in place at TACT’s head office. The training records we saw did not give us enough information for us to be sure all staff have completed all the training they need. The acting manager explained that she had found no accurate records of staff training when she arrived so she had started again by asking all staff to bring their training certificates to her. She was building the record from scratch, making sure the information was accurate, but was still waiting for some of the information. However, as the home is so new, she felt that staff would have done all the necessary training in their induction period. Staff we spoke with told us that there is enough training, and the company is good at keeping the training up to date. The acting manager said that all staff have attended training in ‘breakaway’ techniques, and some staff have done safeguarding training. Only 3 staff are trained in specialised administration of diazepam. All staff have regular supervision, every 4-6 weeks. Notes are taken and the staff member and supervisor sign to agree the notes are accurate. Staff meetings are held monthly or more often if needed. In their responses to our questionnaire, staff indicated that they are not altogether happy with some aspects of the way the organisation treats them. One staff member said “The management of the home could do better by seeing to the needs of the staff for the smooth running of the home, so that there will be consistency and avoid staff turnover”; another “Ensure everybody gets a fair share of the shifts on offer”; and a third “Work on staff satisfaction”. The organisation must find a way to deal with this so that it does not impact on the service provided. 4 Beech Close DS0000073230.V376277.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 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. 4 Beech Close needs good, strong, stable management to make sure it becomes an excellent service for the people who live here. EVIDENCE: The acting manager who assisted us with the inspection, Louise Tedeschi, has only been at 4 Beech Close for a few weeks. The previous acting manager started when the home opened but went off sick in early April 2009. Louise is 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 24 on secondment from another of TACT’s homes where she is a deputy manager. She explained that she is putting things in place, but is hesitant to make too many changes as she does not know how long she will be at the home. The home is developing ways of making sure the home runs in the way the people who live here want it to. People have regular meetings with their keyworkers and they also have PCP (Person Centred Planning) meetings. Keyworkers write a monthly summary of the daily records so a picture builds up of how each person has enjoyed their activities, meals and so on. Staff keep in close contact with people’s relatives so that their views are taken into account. A representative of TACT carries out a visit to the home at least monthly and writes a report, which includes actions if any shortfalls have been found. We looked at some of the records the home has to keep. People’s support plan files were very full, with lots of information. We found several documents relating to the same thing, which was confusing. We also noted that some of the documents which should have contained the same information but in a different format, actually contained slightly different information. This is difficult for staff and could lead to people receiving inconsistent care and support. We discussed this with the acting manager who said she had introduced new care plans but had wanted to leave the previous information on file so that the acting manager who is off sick could make decisions about what should remain. Some of the information in people’s files, for example detailed information about autism, was for staff and not appropriate to be on someone’s file. We looked at the records of the tests of the fire alarm and emergency lighting systems. The fire alarms had been tested every week, and the emergency lights monthly, which meets the requirements. A fire evacuation was carried out in May 2009. We noted that there were electrical wires hanging from the wall fittings where the lights in the dining room and lounge had been damaged and the glass removed. We asked the acting manager to get these seen to as a matter of urgency. 4 Beech Close DS0000073230.V376277.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 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 2 2 X 2 2 X Version 5.2 Page 26 4 Beech Close DS0000073230.V376277.R01.S.doc Are there any outstanding requirements from the last inspection? Not applicable 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 YA35 Regulation 18 Requirement All staff must receive sufficient training in all relevant topics so that they can do their job in the best way possible. This must include specialist training when needed. Training records must give clear evidence of this. 2 YA37 8 and 9 A person who meets the requirements of the regulations must be appointed to manage the home. So that the people who live here, and the staff, receive good, strong leadership. Health and safety must be given high priority. The electrical wires hanging from the damaged wall lights must be made safe. 30/09/09 Timescale for action 30/09/09 3 YA42 13 02/06/09 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 27 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 YA1 YA6 Good Practice Recommendations Information about the home would be clearer if there were only one version of the Service User Guide. The information in people’s current files should be easily accessible to staff, clear and up to date. All other information should be archived. There should be a clear audit trail on the files to show what is happening about healthcare appointments. 3 YA19 4 Beech Close DS0000073230.V376277.R01.S.doc Version 5.2 Page 28 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@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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