Inspection on 12/05/09 for 94 Tennyson Road

This inspection was carried out on 12th May 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

94 Tennyson Road 01/07/08

94 Tennyson Road 15/01/08

94 Tennyson Road 28/08/07

94 Tennyson Road 13/10/06

94 Tennyson Road 03/02/06

94 Tennyson Road 19/10/05

94 Tennyson Road 11/03/05

94 Tennyson Road 22/12/04

94 Tennyson Road 29/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Key inspection report CARE HOME ADULTS 18-65 94 Tennyson Road Luton LU1 3RR Lead Inspector Andrea James Unannounced Inspection 12th May 2009 10:00 94 Tennyson Road DS0000014976.V375323.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. 94 Tennyson Road DS0000014976.V375323.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 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 94 Tennyson Road Address Luton LU1 3RR 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) 01582 725735 ann.dalton@advanceuk.org Advance Support Ltd Ms Ann Dalton Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Conditions of Registration 1. The registered person may provide the following category/ies 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: Mental Disorder, excluding learning disability or dementia - Code MD 2. The maximum number of service users who can be accommodated is: 4 Date of last inspection 1st July 2008 Brief Description of the Service: 94 Tennyson Road is a semi- detached house situated in a quiet residential road in south Luton. The home is owned by Advance Housing and Support Limited and provides accommodation for four service people with mental health needs. The home has four single bedrooms and a bathroom and toilet on the first floor. The ground floor contains a lounge, dining room, toilet laundry room and a kitchen. The people use the garden at the rear of the house in the summer months. There is a parking area at the front of the house. The home is within walking distance of the town centre and two local parks and the bus stop. Mrs. Ann Dalton is the current registered manager. The fee ranged from £580.17£600.00 per week. 94 Tennyson Road DS0000014976.V375323.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 a one star. This means that people using the service experience adequate quality outcomes. This was an unannounced inspection carried out on the 13th of May 2009. The registered manager was president at the beginning of this site visit and at the end. The inspection process lasted for five hours. The purpose of this inspection was to check compliance of requirements made at the last inspection in July 2008 and to undertake a full key inspection of the service. The inspection process followed the case tracking methodology where a sample of people using the service was case tracked. In this instance the home only had two people and as a result they were both case tracked. We were able to speak to both people, interview their key workers and look at their files. The inspection report also consists of information received from the AQAA (Annual Quality Assurance Assessment) and relatives of the service. What the service does well: The service provided support to individuals in order for them to feel safe in their living environment and the wider community. People had opportunities for personal development and were supported by various advocates and interpreters groups. People who use the service were supported by a team of medical professionals that helps to provide effective health care to people to help prevent mental relapses. They told us in their AQAA that they encourage people to get involved in their recruitment selection processes and sought their views through meetings and annual questionnaires, about the running of the home. The service ensured that staff knew and were able to develop a relationship with the people they support in a positive way. People spoken to on the day of the site visit said they staff enabled them to do as much for themselves as they can. One person said, the staff are very supportive to me. The service said they were able to meet the needs of people and paid special attention to individual needs with particular attention to gender, age, cultural background and personal interests. All staff received equal opportunities training, including disability equality training provided by disabled trainers and race equality and anti-racism training. People spoken to on the day of the site 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 6 visit said they were happy with the service they received. One person said. the staff helps me the best way they can. One person who used the service was able to self- medicate, prepare his own meals and visit community resources. He was also aware of his own limitations and was able to discuss this with us. The staff team were also competent and skilled in their ability to deliver the service to people as they required. Staff spoken to said, they were happy in the way they were enabled to work with the people who use the service. The home welcomed social work students who were able to take their placements within the home. The manager said they were vital in supporting the staff team as the staff were lone workers. What has improved since the last inspection? What they could do better: The home should ensure that one persons nutritional needs are met and foods kept in the home are stored in accordance with food hygiene regulations. The home should also ensure that a Health Action plan is made available for people who use the service in order that their medical needs can be identified. All areas of the home to include the bathrooms should be free from trip hazards. The gardens should be maintained and made more user friendly. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 7 The medication procedures should be reviewed to ensure homely remedies are not pooled. The policy for administering and storing controlled drugs should also be reviewed to ensure the procedures are clear. Some areas of the home should be re-carpeted to ensure the environment can maintain its pleasant and homely feel. Effective fire risk assessment should be implemented to ensure the safety of people can be maintained at all times. 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. 94 Tennyson Road DS0000014976.V375323.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 94 Tennyson Road DS0000014976.V375323.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): People who use the service experience a good quality outcome. We made this judgement using a range of evidence to include a visit to the service. The people who used the service were provided with sufficient information and they received comprehensive assessments of their needs. Potential users were also able to have the information they required prior to admission. EVIDENCE: The service told us through their AQAA that they ensured all prospective people had ample time to consider the home via reports and brochures and by being able to visit the service. They told us that they always have up-to-date Statement of Purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions that provided each person with a Service Users’ guide to the home. The Statement of Purpose also sets out the physical environmental standards. They told us that, New Service Users, were admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective person using an appropriate communication method and with an independent advocate as appropriate. Family carers’ interests and needs were taken into account subject to the agreement. Staff, individually and collectively, had the skills and experience to deliver the services and care 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 10 which the home offered to provide. We were able to confirm this by speaking to people, the care team and looking at recorded evidence. Staff spoken to were also able to confirm that potential users of the service were able to have tea stays, overnight stays and weekend stays in order to test drive the home prior to admission. One person was undergoing that procedure in the hope that he will move in permanently into the home. We saw contractual agreements on peoples care plans that were signed and dated by the person using the service, the homes representative and other professionals. 94 Tennyson Road DS0000014976.V375323.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): People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The care planning procedures in place ensured peoples individual needs and choices were being met and opportunities were offered to individuals to be able to participate in the day to day running of the home. EVIDENCE: Individual peoples care plans sets out how current and anticipated specialist requirements would be met for example through positive planned interventions; rehabilitation and therapeutic programmes; structured environments; development of language and communication; adaptations and equipment. The care plans were detailed and had specific, measurable, achievable, realistic and time bound objectives. The plans were drawn up with the involvement of the people who use the service together with family, friends and/or advocate 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 12 as appropriate and relevant agencies/specialists. The plans were signed and dated my all those involved. There was evidence that the support plans identified choices, freedom or restrictions posed on the person with appropriate risk assessments. These included for example restrictions placed on people who were drug or alcohol dependent. There were also evidence to suggest all aspects of the care plan were risk assessed. These risk assessments were inspected which showed the level of risk posed for each area identified. The people who use the service were also able to confirm the information recorded in their care plans. We saw where one person had written his own review notes for his pending care review. This showed that people were empowered to make choices about their lives and to be involved in their expected outcomes in regards to progress. We saw people leaving and entering the home at different intervals throughout the day. People spoken to said they were able to access the community, attend day centres and visit friends. One person needed more motivation than the other but staff appeared patient but ensured that the support required to motivate the person was given. 94 Tennyson Road DS0000014976.V375323.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: People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The opportunities available to people was positive but further development was needed to ensure the nutritional needs of people are structured in order to offer a healthy balanced diet. EVIDENCE: The service told us that they were currently supporting one person to buy his own property using a shared ownership scheme. One person spoken to was very positive about how he had developed and was able to tell us that he was able to manage his own money, self medicate, prepare his own meals and clean his bedroom. He also said that he was able to access the community at least three times per week and attended various day centres such as MIND and ACE enterprise. He complemented the staff about the way they had supported him. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 14 People were also encouraged to visit family and friends on a regular basis. Staff said one person visited his friend most evenings. This person was able to confirm this information. We saw evidence that people were encouraged to go out into the community and were supported where people found difficulties. An activities programme was implemented as a part of their care planning procedures. People were also supported to undertake house hold chores such as cleaning their bedrooms and doing their laundry. We were concerned that one person who lacked motivation to eat healthy meals were not supported by the staff team effectively. We saw menu charts that were not completed for months. There was no evidence that this person had a full meal in the home. We were told that on the 3 days he attends MIND where he was offered a meal but staff said sometimes this could be just a salad. The service did not keep a weight chart for this person and as a result it was not possible to say how they were monitoring his nutritional needs. The care staff said that they prepared one meal per week with people but there was no evidence of this happening. Staff said sometimes people dont want to eat and will just have chocolate. It was discussed with the staff team the importance of not neglecting their duties as carers in supporting people in their care. We inspected the kitchen facilities and found that sufficient food was kept in the home but the staff team were not vigilant in ensuring food was stored appropriately. We saw several cereal boxes, pasta, rice and other dried good all left open without proper storage. They also failed to ensure dates when some foods were open were recorded. Since the inspection the manager said she had addresses the issue and have implemented procedures in place that will ensure a meal is prepared for or with the person on a daily basis. 94 Tennyson Road DS0000014976.V375323.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): People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Peoples healthcare needs were being met but further development was needed to ensure some medication procedures are reviewed in order to protect people from risk of errors. EVIDENCE: The home had polices and procedures in place to ensure peoples medical needs could be met. We saw evidence that people were supported to attend hospitals, General Practioners, and other medical professionals within the community. Where it was necessary nurses also visited the service in order to meet peoples needs. Staff spoken to said they would accompany people to doctors appointments etc if they needed the support. The care plans seem suggested people received regular assessments from consultants about their mental health. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 16 The service however failed to implement Health Action Plans in order to ensure all areas of medical needs could be identified. The manager said they would be implementing this policy in the near future. The home had medication policies and procedures but a review of the policy was needed as the policy stated that they would provide controlled drugs for people but failed to have any facilities in place for doing so. Staff were not trained in administering controlled drugs. Staff spoken to had very little knowledge about this procedure. The manager said they had an agreement with the district nurses to administer controlled drugs to people and as a result did not facilitate it within the home. We discussed that the policy needed to reflect the procedures of the home. We inspected the medication stocks kept in the home and one person was selfmedicating while the other was administered medication by the staff team. All records such as Medication Administration Records (MARS) were satisfactorily kept. However we saw where the home was pooling paracetamols as homely remedies for both clients and there was no evidence that it was being prescribed. The arrangements for people upon their death were recorded in peoples care plan documentation. 94 Tennyson Road DS0000014976.V375323.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): People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The procedures in place ensured peoples concerns would be listened to and they would be safeguarded from abuse. EVIDENCE: The home had satisfactory polices and procedures in place to ensure peoples complaints would be dealt with effectively. Since the last inspection the home had not received any complaints or concerns. They had made their complaints procedures known to people who use the service by displaying their policy in the communal areas of the home and the Service User Guide. One person spoken to said he would know what to do in the vent that he had a concern or a complaint. The home had a safeguarding policy and people spoken to were aware of what it meant to them. The home had not made any safeguarding referrals in recent months, but were aware of the procedure to follow. Staff spoken to said they received safeguarding training. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 18 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): People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home was warm and welcoming and appeared to promote peoples independence, however some areas of the home were unsafe and needed attention. EVIDENCE: On the day of the site visit we were able to tour the premises. Two bedrooms had recently been painted and were due to be re-carpeted. The carpets in the communal areas of the home were worn and because of the dark colour made the home look dark. Some improvements had been made to the environment namely new television and new kitchen had been installed. We were also told that all hot water taps had been fitted with thermostat control valves. We were told that new front doors had been ordered and were due to arrive in the near future. This would offer people who use the service a better standard of security. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 19 They told us that they have a planned maintenance and renewal programme for the fabric and decoration of the premises. We were told that people were encouraged to bring their own furnishings to their bedrooms in order to personalise them. We saw evidence of people having personal items in their rooms such as exercise bikes, etc. people spoken to said they liked their rooms. People were also encouraged to clean their rooms on a regular basis. We were able to see health and safety records for areas on the home such as hot water checks. We were concerned that a puddle of water was settled in the bathroom, this we were told occurred after one person had a shower. It was identified as a trip hazard in the last inspection and the home had not resolved the issue to date. The garden in the home was also in need of attention as the grass had grown and the furnitures appeared unkempt. The staff team showing us around said that the people who use the service sometimes help but they were not very motivated at the moment. The manager later informed us that a gardener was due to visit the service to undertake the gardening duties. The premises were clean, hygienic and free from offensive odours. They also told us that they had measures in place for controlling the spread of infection. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 20 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): People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The people who use the service benefited from a competent, experienced and trained staff team that provided a good standard of service delivery. EVIDENCE: The home had a consistent staff team of 5 care staff that worked between two services. Care staff worked during the day and at nights on a lone working basis. The service told us that nearly 100 of their staff team had received their NVQ level 3 in care. We saw evidence to suggest that all but one person had achieved their NVQ level 3 in care. The manager said they also had plans in place to ensure the staff were ware of the Mental Capacity Act and Deprivation of liberty legislations. Since the last inspection the home had lost their team leader and so the manager is having to so more the way of day to responsibilities. We were told that interviews were planned for the week after the site visit in order to recruit to this post. The staff team were complimented by student social workers who worked closely with the people who use the service to achieve their daily goals and 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 21 objectives. On the day of the site visit one student social worker was on shift who appeared competent in supporting people with their daily tasks. She commented that people were encouraged to do things for themselves but sometimes they lacked motivation. People spoken to said, they liked the staff team. The interaction observed between staff and the people who used the service was one of a relaxed and happy atmosphere. Staff spoken to said they were supported to undertake their job roles. They were able to confirm that they received regular supervision and staff meetings. The records of supervision were evidenced when viewing staff files. The staff files were all satisfactorily maintained with satisfactory clearances and references to ensure people were protected. All staff members had individual development plans which should what training they had undertaken. We also saw evidence to suggest future training needs had been identified. The records seen suggested training for mental Health, medication, food and hygiene and safeguarding were booked for the months to come. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 22 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): People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service benefited from a home that provided good leadership and promoted their health and welfare but further development was needed to ensure people are safeguarded from risk of trips and falls. EVIDENCE: The manager worked in two services which were opposite to each other. Staff were aware that the manager would come to the home at allocated times but she could be contacted by phone in an emergency. The manager worked 17.5 hours at the home in a supernumerary position. The home appeared to be run in the best interest of people who use the service. The manager was qualified and competent in undertaking her job role and was still planning to further her qualifications to enhance the skills needed in the organisation 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 23 All staff and people who use the service spoken to said the manager was approachable. One person said I would go and see her if I was not happy about something. The service had a quality assurance procedure which was published in the Statement of Purpose last year. We were told that the information needed to be collated for his year had not yet been sought. There were plans in place to have the support from social work student who would support people in completing their surveys. We could therefore not evidence how peoples views were being monitored at this visit. The home had a health and safety policy and procedures seen suggested peoples welfare were protected with the exception of the potential trip hazard that could put people at risk of falling when using the bathroom or toilet facilities. This was still outstanding from the last inspection. We saw evidence of fire records, engineer reports and fire drills where weekly and monthly tests were undertaken. There was a need however to ensure up to date fire risk assessments are undertaken as the last fire assessment undertaken was in 2005. This was identified as a requirement in the last inspection and remains unmet. 94 Tennyson Road DS0000014976.V375323.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 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 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 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 X 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 2 X X 2 3 Version 5.2 Page 25 94 Tennyson Road DS0000014976.V375323.R01.S.doc 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 YA17 Regulation 12 (1) (a) Requirement Timescale for action 30/06/09 2. YA24 23 (2) (b) (d) Arrangements must be made to ensure structured menu planning and nutritional information is in place to promote the health and wellbeing of people who use the service. All areas of the home must be 30/07/09 decorated and furnished to create a homely environment for people living at the home. Previous timescale 30/04/08, 30/089/08: Partially met. Appropriate actions must be taken to prevent the settling of water in the bathroom floor. Previous timescale 30/08/08. A clear quality assurance system must be in place that monitors and seeks the views of the users in order to meet the aims and objectives of the service. Previous timescale 30/11/07 and 30/03/08. Partially met 30/06/09 3. YA27 23 (2) ( C) 4. YA39 24(1) (a) (b) 12/05/09 5. YA42 13 (4) ( c) Fire risk assessments must be up 30/06/09 to date to ensure avoidable risks DS0000014976.V375323.R01.S.doc Version 5.2 Page 26 94 Tennyson Road are identified. Previous timescale 30/09/08 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. 2. Refer to Standard YA17 YA20 Good Practice Recommendations Arrangements must be made to ensure food and hygiene regulations for the storage of foods in the home. You should ensure the medication policy and procedures are reviewed to reflect what the actual practices are for administering controlled drugs. You should ensure that the dietary needs of all people using the service reflect healthy eating. 3. YA17 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 27 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 94 Tennyson Road DS0000014976.V375323.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!