Inspection on 16/09/09 for Allan Court

This inspection was carried out on 16th September 2009.

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

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

Other inspections for this house

Allan Court 29/10/08

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 24/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Allan Court Benwell Lane Benwell Newcastle Upon Tyne Tyne & Wear NE15 6RU Lead Inspector Elaine Charlton Key Unannounced Inspection 16th September 2009 09:30 DS0000072101.V377388.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Allan Court DS0000072101.V377388.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 Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allan Court Address Benwell Lane Benwell Newcastle Upon Tyne Tyne & Wear NE15 6RU 0191 274 1100 0191 274 1122 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) Southern Cross OPCO Ltd Vacancy Care Home 60 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (60) of places Allan Court DS0000072101.V377388.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 with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 60 2. Dementia Code DE, maximum number of places 26 The maximum number of service users who can be accommodated is: 60 29th October 2008 Date of last inspection Brief Description of the Service: Allan Court is a purpose built three-storey building situated in the heart of Benwell. The home is at the end of a sloping drive where car parking is provided to the front of the building. There is a landscaped area to the front of the home. Local facilities are a short walk away and the city of Newcastle is easily accessible through public transport. Allan Court accommodates sixty elderly people with a physical or mental frailty, some of who require nursing care. All rooms are single occupancy. The top floor of the home has been updated to provide care and support for people who have a mental frailty. The fees for the home vary and are available from the home on request. Information about the home is available in the service user guide that also contains the statement of purpose and previous inspection reports. This is kept in the reception area of the home. Allan Court DS0000072101.V377388.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 two star; this means that the people who use this service experience good quality outcomes. An unannounced visit was made on the 16 September 2009. A total of five and a half hours were spent in the service. The manager was present throughout the inspection. Before the visit we looked at Information we have received since the last visit on the 29 October 2008; The Annual Quality Assurance Assessment (AQAA) that gives CQC evidence to support what the service says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are; How the service has dealt with any complaints and concerns since our last visit; The providers view of how well they care for people, and the views of people who use the service, their relatives, staff and other professionals who visit the service. We have also reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. During the visit we Talked with people who use the service, staff and the manager; Looked at information about the people who use the service and how well their needs are met; Other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; We looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since our last visit. We told the manager what we found. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 6 What the service does well: Gets good information about the care and support needs of people who wish to move into the home so that everyone is sure they can be met. Carry out and record additional care plan evaluations as and when residents healthcare needs require. Work with a wide range of healthcare and other professionals to promote the health and well being of people who live in the home. Listen to the needs and wishes of people who live in the home and treat them with dignity, respect and in a sensitive way. Promote choice and independence and make sure that people have the chance to meet people with similar interests and get out and about in the local and wider community. Follow good recruitment and selection procedures and provide good induction, training and support for people who work in the home to help them do their job. Over 50 of care staff have achieved a National Vocational Qualification at a minim of level 2. This is in excess of the National Training Organisations minimum requirement. What has improved since the last inspection? All the requirements from the last inspection have been met. The manager has almost completed the formal process with CQC to become the registered manager. Bedrooms have been re-decorated and furnished for the comfort of residents. Care plans have become more person centred and sensitive to the needs of people who live in the home. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who wish to use the service have their diverse care and support needs properly assessed so that everyone is sure they can be met. EVIDENCE: The organisation has a standard format for pre-admission and admission assessments that are regularly used for everyone who may wish to move into the home. We were told that the manager and/or a nurse carry out the assessments so that they are sure all the information they need is collected. Where appropriate or necessary family are involved and are encouraged to provide information about their relative’s earlier years, interests and hobbies. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 10 We looked at the assessment for the person who had most recently moved into the home. This had been fully completed and included information not only about the persons healthcare needs but also their interests. A lady who had recently moved into the home met the inspector and asked to show her around. She told us that she liked to help staff out with washing dishes, setting tables and dusting. Her file included risk assessments to support these tasks. As she showed us around she said ‘this is our dining room’. The home also uses a range of professionally recognised assessment tools for nutrition, continence, mental frailty, and pressure area care. The home does not provide intermediate care. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have their care and support needs properly met and can choose who helps them with this. They are able to look after their medication if this is appropriate or get the help of staff when necessary. EVIDENCE: We looked at the records for three other people who live in the home. We chose one from each unit. All the records are kept in a standard way, were neat, tidy and up to date. We saw evidence of staff working with a wide range of healthcare professionals to make sure that residents got the care and support they needed. Additional reports had been provided to help staff deal with swallow and dietary problems, and any behaviours that may challenge daily routines. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 12 In each of the records we saw there was a copy of an individual Mental Capacity Assessment identifying whether the resident was able to make decisions and understand the consequences of those decisions. Where residents were having problems with their skin, damaged areas had been detailed on a body map and the input being given was recorded. Care plans were written in a person centred way, were detailed and sensitive and had been regularly evaluated. Additional evaluations had been carried out when a person was having extra input to support their healthcare needs. This is good practice. Risk assessments included healthcare, social activities and fire evacuation. Food and fluid intake charts are in place, where appropriate, and regularly completed. The form is a standard Southern Cross document but does not include a total column for fluid intake. There is also a standard form to record personal care input for each resident. Staff do not consistently complete these and this could give an inaccurate picture of the amount of care and support a person has received. Each resident’s record also included a copy of their latest review, who had been involved and what the outcome was. We identified notes on two assessments one a request that the resident wished to donate tissue to the hospital following their death, and a second that the person did not wish to be resuscitated. These had not been followed up, and there was no guidance in the files about what actions staff should take to support these wishes. Two staff are trained as moving and handling assessors, and a nurse has completed a continence course and does all the in-house assessments. We saw a number of profile beds and airflow mattresses in place to support the healthcare needs of individual residents. We carried out a random check of medications held in the home and the systems to support their proper administration. Medication is kept securely in the treatment room which is spacious, clean, tidy and alarmed. Controlled medication is kept in a secure cabinet within another cabinet. Oxygen cylinders were safely stored in the treatment room and disposal boxes for needles were easily accessible. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 13 We checked the medication and administration records for three residents. Each unit has its own medication trolley and medication administration record (MAR) file. MAR charts are separated by a laminated sheet containing a photograph of the resident, a note of their date of birth and GP and any allergies they have. The home uses the blister pack system for administering medication and can access additional prescriptions through a local pharmacy within an hour of faxing the prescription through. The majority of MAR sheets we saw were properly completed and staff were seen to use appropriate codes to explain why medication had not been dispensed. We identified two minor recording issues during the inspection: • • Some handwritten entries on the MAR sheets had not been signed by the person who had transcribed the instruction or by a second person to say that the information was correct; For one resident who has a very disturbed sleep pattern there was a recording error for Simvastatin, and it was not clear whether the resident had not taken the medication, refused to take the medication or it had been destroyed; The number of Paracetamol tablets for one resident had been recorded as 54, none had been dispensed, but there were only 44 in the box. • Refrigerated items were properly stored and had been dated when opened so that staff knew when they should be disposed of. All controlled drugs kept in the home were checked and found to be correct. The controlled drugs register was properly completed, up to date and had been signed by two staff when medication was dispensed. People living in the home were seen to be treated by staff in a sensitive and dignified way throughout the inspection. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to lead a healthy and fulfilling personal lifestyle. This takes account of their wishes and diverse interests and abilities. EVIDENCE: The home has a full time activities co-ordinator who helps people to use a range of services in the local community. Two residents also receive support from ‘befrienders’ who they go out with each week. Information is displayed on the notice board so that people know what is happening but events sometimes change to take account of resident’s wishes. The programme of social activities displayed on the notice board included beauty spas, bingo, newspapers, light exercise, sing-a-longs, arts and crafts, baking, coffee morning and board games. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 15 The home also has access to a mini bus every six weeks when they can enjoy getting out to the coast for fish and chips or other local areas. They also recently joined a 40s/50s afternoon at the Federation Brewery. A local church leads a fortnightly service in the home or residents can attend their own church if they wish. No one currently goes out to church. Residents are encouraged and helped to keep in touch with family and friends and people can visit when they wish. The manager puts a notice up giving visitors a month’s notice of relatives meetings but does not get a good response. She puts a copy of a newsletter in resident’s bedrooms to try and get information out to relatives and friends. A quality assurance questionnaire was recently sent to residents and there was a considerable amount of feedback amount mealtimes. Chef has spoken to all the residents and asked them what their favourite meals are and what they would like to see on the menu. He is now working to put together new menus using the organisations ‘Nutmeg’ system that works out the calorie and nutritional values of meals on the menu. Residents enjoy a roast dinner on Sundays and Wednesdays but on other days there are two lunch time choices. On the day of the inspection lunch was roast chicken and vegetables, followed by peaches and vanilla ice cream. Teatime choices were home made tomato soup or bangers and mash. At supper time residents can choose from sandwiches, crumpets, and scones. We were told there is always a mix of savoury and sweet items to meet every ones tastes. Staff have access to the food stores at all times so can get an alternative for a resident if they wish. The home has its own hairdressing salon and the hairdresser visits once a fortnight. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected through policies, procedures and staff training and know that they can make a complaint and will be taken seriously. EVIDENCE: The organisation has policies and procedures in place that promote the receipt, recording, investigation and reporting of concerns, complaints and allegations. There is a complaints register in place and the manager showed us evidence of the proper investigation and recording of the last complaint in January this year. The complaint was not upheld. The Care Quality Commission (CQC) has not received any complaints, concerns or allegations relating to the home. Staff have all completed training in safeguarding adults and are now also attending ‘awareness days’ on safeguarding that Newcastle City Council are running to update their knowledge. All staff are required to have a criminal records bureau check at an enhanced level before they are able to commence work. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 17 Care staff are employed in accordance with the General Social Care Council Code of Conduct that is issued as part of their induction. Nurses are required to provide evidence that their registration with the Nursing and Midwifery Council is up to date. The home carries out checks to verify that nurses’ personal identification numbers (PINs) are still current. Residents and their families have access to copies of the complaints procedure so that they know what to do if they have a concern. This is also displayed in the home. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a home that is warm and comfortable and where they can spend time privately or with others. The home is clean, tidy and generally odour free. EVIDENCE: The home is divided over three floors. All can be accessed through the main entrance but the lower ground floor also has its own entrance at the rear of the building. Welcome packs are placed in the bedrooms and en-suite rooms when new people move into the home. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 19 We walked around the premises with the manager who told us that there is a rolling programme of redecoration and refurbishment taking place. Six bedrooms at a time are being re-decorated and furniture replaced as necessary. All the bedrooms are for single occupation and have an en-suite toilet and wash hand basin. A new floor was being laid in the hairdressing room on the first floor. There are plans to move this to the ground floor and provide a sensory room on the first floor. Two new televisions have been ordered for the lounges on the first floor, these will be wall mounted making both rooms more spacious. There was a slight odour in the hallway outside one of the lounges on the first floor, and the carpet was slightly sticky. The carpet in the lounge has already been replaced. All other areas were pleasant and odour free. One lounge on the first floor is furnished as a bar, the gentlemen and some of the ladies enjoy using this room on a daily basis. They discuss football and play dominoes. Bathroom, shower and toilets are located on each floor, and can be easily accessed by residents with or without staff support. A shower room on the ground floor has a small cubicle shower in it that is fitted with a seat. A limited number of residents are able to use this and there was a faint damp odour here. We spoke to residents on the lower ground floor who said they were comfortable. One lady asked to show the inspector around their dining room. She told us that she liked to help staff out with washing up and dusting. The kitchen is on the ground floor and is due for refurbishment. The manager told us that she was waiting for dates from the Estates Department for this work to start. The laundry is located on the lower ground floor and was seen to be well organised and extremely clean and tidy. Washing machines can be programmed to carry out a range of washes to meet infection control requirements. Although the home is clean and tidy and the newly decorated bedrooms are fresh and welcoming, some of the communal areas are still decorated in a slightly dated way with heavily pattered, dark coloured chairs and curtains. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 20 The handyman keeps excellent records and works hard to complete maintenance checks and repairs. He also carries out checks required by the Fire Authority and fire drills. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are protected through recruitment and selection procedures that are regularly and properly followed. Staff receive good training and support to help them carry out their job. EVIDENCE: The organisation has comprehensive recruitment and selection procedures. We looked at the records for the most recently recruited member of staff and one other. Staff files are kept in a standard way and information is easy to find. The evidence from these files was that recruitment and selection procedures are regularly and properly followed. We saw good interview records and assessment notes, contracts of employment, application forms, job descriptions, evidence of CRB checks being carried out at an enhanced level and references being obtained. We talked to the manager about the need to consider carrying out reference verification checks. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 22 Staffing levels in the home are a nurse and two carers on the first floor, a nurse and 3 carers on the ground floor and a senior carer plus one care worker on the lower ground floor. They are supported by the manager, an administrator, domestic, laundry and kitchen staff. There is also a full time handyman and full time activities coordinator. The manager had made good notes on a staff counselling record and there was evidence of this being followed up and the improvement in the member of staffs practice was noted. A training matrix and staff supervision schedule are displayed in the manager’s office. Two staff are qualified to deliver moving and handling training to staff. Well over 50 of care staff have completed a National Vocational Qualification at level 2 or 3, and four more staff are currently working towards a qualification at level 2. Health and safety training is being rolled out to up date all staff. They have also completed or are working to complete infection control training. Two qualified nurses had applied to update their skills and knowledge on catheterisation but the course has been cancelled until February 2010 as they were the only people who applied. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in an open and inclusive way, in the best interests of the people who live there. Health and safety checks are regularly carried out to help keep both the people who live and work in the home safe. EVIDENCE: The manager sent us the home’s Annual Quality Assurance Assessment (AQAA) when we asked for it. It was well completed and told us where evidence could be found about what the home did well, what areas they would like to improve and what had changed in the previous 12 months. Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 24 The manager is currently in the process of completing her registration with CQC. She is a qualified registered nurse and has worked as the homes deputy manager for a number of years. She is also working towards obtaining the Registered Managers Award. The home is run in an open and inclusive way and relationships between staff and residents were seen to be warm, sensitive and professional. Staff know the residents well and are able to help them make choices about what they want to do. Newcastle City Council Commissioning department has recently visited the home and we were told that the home met 12 out of the 14 standards required by the Commissioners. The organisation has a comprehensive computer system for recording money held on behalf of residents and any credits or debits made. The administrator is required to carry out regular checks on these records. We saw accident and fire log records for the home. These were all up to date and properly completed. The handyman carries out regular fire drills and makes good recordings about staff responses and actions during the drill. Servicing and maintenance records for systems and equipment in the home were seen. These were all up to date with the exception of: • • The certificate for the home’s electrical installation. A company is currently working to replace lights and circuit boards and will provide a new five year certificate when their work is completed; The gas boiler certificate is out of date. The manager is waiting for a date from the Estates Department for the boiler to be replaced. If this not going to be done in the near future the existing boiler must be serviced. Staff supervision takes place on a regular basis and is on target to achieve six meetings a year. The manager holds meetings for qualified staff and general staff. Attendance at these meetings is noted and minutes are available. Night staff attend the general day staff meetings. Allan Court DS0000072101.V377388.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12 Requirement The home must follow up information from a resident’s assessment. This will mean that their wishes about tissue/organ donation and resuscitation are properly explored, documented and planned for. 2 OP38 13 CQC must be provided with a copy of the electrical installation for the home. This will help to promote the health, safety and wellbeing of people who live and work in the home. 3 OP38 13 CQC must be provided with evidence that the homes gas boiler has been replaced or serviced. This will help to promote the health, safety and wellbeing of people who live and work in the home. 16/10/09 16/10/09 Timescale for action 16/10/09 Allan Court DS0000072101.V377388.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 Refer to Standard OP8 Good Practice Recommendations The organisation should consider amending the food and fluid intake chart to provide a space for fluid intake to be totalled. This will make it easier for staff to check whether people have taken the required amount of fluid over each day. Staff should consistently use the personal hygiene charts to record all help and support they give each resident. This will mean that everyone knows that each resident has had the support with the areas of their personal care they are not able to do for themselves. Handwritten entries on MAR charts should be double signed. This will help to keep people who live in the home safe and well. Staff should take extra care when administering and recording medication they have given to people who have disturbed sleep patterns. This will help to keep people who live in the home safe and well and ensure that they get all the medication they are prescribed. Staff should make sure that they properly record the reason that they have not been able to administer medication to a resident. This will help to keep people who live in the home safe and well and provide a clear pattern of their compliance with medication routines. The manager should consider carrying out and recording reference verification checks for people wanting to work in the home. This will promote good recruitment and selection procedure and help to keep people who live in the home safe. 2 OP8 3 OP9 4 OP9 5 OP9 6 OP29 Allan Court DS0000072101.V377388.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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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