Inspection on 27/05/09 for Byron House

This inspection was carried out on 27th May 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

Key inspection report CARE HOME ADULTS 18-65 Byron House 104 Drummond Road Skegness Lincs PE25 3EH Lead Inspector Wendy Taylor Key Unannounced Inspection 27th May 2009 09:30 Byron House DS0000073165.V375594.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. Byron House DS0000073165.V375594.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 Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byron House Address 104 Drummond Road Skegness Lincs PE25 3EH 01754 768909 01754 768909 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Christine McMahon Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is 23 New Service Date of last inspection Brief Description of the Service: Byron House was purchased by Prime Life Limited in December 2008 as a going concern. It is a three-storey building combining two houses with three extensions, and it is situated in a residential area of the seaside resort of Skegness. The home is approximately half a mile from the town centre, although several local shops are available within a few hundred yards of the home. Accommodation is provided on ground, first and second floor levels. There are limited car parking spaces at the side of the house, and there are some limited on-street parking facilities. The gardens are small, but there are well maintained seating areas for people to enjoy the outdoors. Transport is provided by the home, and there is good access to public transport. The home cares for people with mental health needs, who require personal care. The registered manager said that current fees range between £360:00 and £475:00 per week. Information about these fees and the day to day operation of the home, including the latest inspection report, are available from the main office within the home. Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. This key unannounced inspection took place on one day in May 2009 and lasted for approximately 8 hours. Nineteen people were living at the home on the day of the visit. The care received by four people was followed in detail using a method called case tracking. This method involves things like talking to the people, looking at their care plans and medical records, talking to the staff who support them, and watching how staff put care plans into practice. We also looked at their daily notes, some general house records, and staff records. The manager was spoken to during the visit, and information already held by us, such as a self assessment, was also used as part of the process. Comments made by people who live at the home, staff and the manager are reflected in the main part of this report. What the service does well: What has improved since the last inspection? It is not possible to say how the service has improved since the last inspection, as this is the first key inspection since the new provider has registered with us. However it is acknowledged that the new providers of the service have refurbished many parts of the home, and they have provided a new ‘people carrier’ vehicle. Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 6 What they could do better: At this inspection we made four requirements, which are things that the home must do to meet the required standards. Firstly we said that everyone living at the home must have a care plan that shows what they need, and what their wishes and preferences are. This is so that staff have clear guidance about how to support people in the right way. We also said that assessments need to be completed for any identified risks, so that people are protected properly. We saw that some signatures were missing from medication administration records, so we said that the records must be completed appropriately at the time of administration. This is to help make sure that people get their medication in a safe way. We also said that the home must tell us when any thing happens in the home that affects the people who live there, such as someone being ill or having an accident. This is so that they can show us how they are managing people’s health, welfare and safety. As well as making requirements, we made six recommendations. These are things that we think are good practice, and may help to improve the service. We said that there should be more details in the records of care plan reviews. This would help to show who was involved with the review, how it was carried out, and what happened as a result of the review. We also said that people should have their own activity records, instead of them being all kept together. This is so that people’s personal records are kept in a private way. At the moment staff write down what people have chosen to eat, but this is not always what they actually have. We said that it would be better for staff to record what people actually eat so that they can help people to have a good diet, and they can monitor people’s health in a better way. We said that the home should display the complaints policy where people who live there and visitors can see it. This is so that everyone can see how to make a complaint, and know how it will be dealt with. At the moment the up to date policies and procedures are kept in the manager’s office, which is kept locked. We said that it would be better to keep all of the relevant policies and procedures in a place where people who live there, and staff, can refer to them whenever they need to. Lastly we said that it would be a good idea for the manager to carry out regular audits of things like the medication records and care plans. This will help to make sure that documents like these are completed properly, and that they are of a good standard. Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 7 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. Byron House DS0000073165.V375594.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 Byron House DS0000073165.V375594.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 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 assured that their needs can be met within the home due to a clear introduction and assessment process EVIDENCE: We saw that there is a statement of purpose and service user guide in place at the home. Since registering with us the home has amended its name, and we have changed our contact details. Information received from the provider shows us that these documents will be updated with the correct details. We looked at the files of four people who live in the home. The files contain assessments of the person’s need, and their personal details. There are no details about things like how people make decisions, or if there are any restrictions placed upon their lifestyles, but the manager told us that new assessment formats allow for this information to be recorded. We saw the new formats for assessments and staff told us that they are currently transferring and updating information for each person who currently lives in the home. Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 10 People told us that they had lots of information about the home before they moved in, and they had a chance to visit to see if they liked the home. They also told us that staff had spoken to them about how they wanted to be looked after, and staff and other people living at the home had helped them to settle in. Byron House DS0000073165.V375594.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, 9 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. People’s needs are met in the way that they want them to be, and they have choice and control over their daily lives. However shortfalls in care planning processes puts people at risk EVIDENCE: Most people who live at the home have a formally written care plan; however people who have come to live at the home recently do not. There is lots of information in their files from the placing authority about their needs and what support they should have, and they told us that staff look after them very well and make sure that they get everything they need. Staff were also able to tell us about those people’s needs in detail, and we saw that they supported them to make choices and decisions about what they wanted to do. Care plans that are in place contain information about things like making choices, encouraging independence, vulnerability, emotional support, privacy and dignity, and Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 12 personal safety. People told us that staff talk to them about their care plans and they can say if they want anything changed. Records show that care plans are reviewed; however they do not contain very much detail about how the review process was carried out. The manager told us that they are currently transferring everyone’s care plan into a new format, which allows people to sign to say they have been involved with the planning and review of the plan. We saw that the copies of the new format are available and ready for use. There are also risk assessments in place for issues such as using the kitchen, smoking, and personal safety. People told us that staff talk to them about things that might cause a risk and help them to deal with the situation. However, one person’s file showed that they were at risk of falling, and although there was a clear plan for moving the person, there was not a formal risk assessment in place regarding falls. Throughout the visit we saw that people who live at the home are encouraged to make their own decisions and choices about how they live their daily lives (see also Standards 11-17). For example, people told us that they decide for themselves when they get up or go to bed, where and with whom they spend their time, and how they spend their money (see also Standards 22-23). Byron House DS0000073165.V375594.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: 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 benefit from the person centred arrangements for meals and mealtimes, and they enjoy a range of activities that suit their wishes EVIDENCE: People told us that they have plenty to do at the home such as games and quizzes, and one person told us about their birthday outing to the pub. A few people told us that they have some outings. Information we have from the service provider shows that they have provided a new vehicle for the home. People said that there is a ‘good night’ on a Monday with different foods and films provided. The activity records show that people join in with things like puzzles, quiz mornings, shopping, bingo, and themed food nights. These records are currently held as one document. Because the home is located near to a busy town centre people told us that there are plenty of places for them to Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 14 shop and go to cafés and pubs. There was information on notice boards in the home about local theatres, and community activities. We saw that people received their own mail and could deal with it in their own way. We also saw that staff responded to people’s request for support with mail if they needed it. People told us that they are able to vote in elections, and we saw that some people have postal voting arrangements in place. Some of the people who live at the home had visitors whilst we were there and we saw that they were welcomed into the home. People told us that staff support them to have visitors and there are places for them to meet in private. There are balanced guide menus available in a five week plan. Each day the menu is placed on dinning tables to remind people what is offered, and to show what alternatives are available. We saw that people choose what they want to eat at the beginning of the day and this is recorded, however we saw that people were able to change their minds at any time and all of the requests for alternative meals were met. Records do not show what people have actually eaten. Drinks and snacks are freely available in the dinning room. For example there is a large fridge containing things like fruit, yoghurts and biscuits, and a range of sandwiches are available in the evening. There is also a soup kettle available in the afternoons so that people can help themselves. People are able to cook their own evening meal if they choose to, and a separate kitchen area has been provided for this purpose. A system is in place to make sure that food is available for them to cook and staff are allocated to provide support. They can also use this kitchen to make drinks and snacks throughout the day, and risk assessments are in place for those who choose this option. Staff told us, and records show us that staff have received training about food hygiene. People told us that they can eat their meals where they choose to, and that the food is ‘lovely’. They were also able to describe the arrangements in place to help them cook their own food if they wished. Byron House DS0000073165.V375594.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are happy with the support they receive for personal and health care needs. However shortfalls in care planning and record keeping put them at risk. EVIDENCE: People told us that they get to see professionals like GP’s, dentists and opticians whenever they need to, and they said that staff will go with them to appointments if needed. One person described a time when they had needed hospital treatment, and described the support they received from staff at the home as ‘excellent’. Everyone told us that staff know how to help them, and they make sure that everything is done in private for them. We saw that staff followed care plans about how to move and handle people, and records show that they have been trained to do this (see also Standards 610). As noted earlier in this report (see Standards 6-10) not everyone has a Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 16 formal care plan, and for those who do not there is a lot of information about the support they should have, including personal and healthcare support. No-one is administering their own medication at the moment, and the manager told us that she will be speaking to people about this option in the near future. We saw that staff followed medication procedures in a satisfactory way, and they spoke to people privately about their medication needs. Administration records contain a photograph of the person, and there are clear instructions for administering medication that is only needed when necessary. Staff told us that they are trained to give out medication, and the training includes being supervised by more experienced staff. Some signatures for administration were missing from records. Byron House DS0000073165.V375594.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. Clear systems and knowledgeable staff make people feel safe living in the home. EVIDENCE: Information we have from the home shows us that there are policies in place for issues such as keeping people safe, making complaints, and what to do if someone is missing. This information also shows us that there have been no referrals to the Local Authority Safeguarding Adults Team since the home was registered by the current providers. We saw that there are leaflets available to tell people how to report any issues they have with their safety and well being. Records in the home show us that one complaint has been received, and this was dealt with in the right way. On the day of the visit the complaints policy was not freely available to people who live at the home, or visitors (also see Standards 37-43). Staff told us that they have had training about how to keep people safe, and records confirmed this. Records also show that criminal record bureau checks are carried out before anyone is allowed to work at the home. Staff were able to describe what they would do in a number of potential situations to make sure that people were protected and situations were reported. They were also able to show us that they knew about policies and procedures, and how to help people make complaints. Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 18 Some people are helped by the home to keep their money safe. The money is kept locked away, and staff keep records to show how much they hold, and how it is spent. We looked at four people’s records and the receipts and total cash amount held matched the records. We saw one person being supported to collect their money. They told us that they can get it when they want, and there have never been any problems with the system. Other people said they look after their own money. People told us that they feel safe living at the home because staff look after them very well. They said that they can tell staff if they have a problem, and they and the manager will help them to sort things out. Byron House DS0000073165.V375594.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, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely and well maintained environment that suits their needs. EVIDENCE: The home is located in a central position for good access to local facilities such as shops, leisure centres, pubs and restaurants, and there are also good public transport links within easy reach. The home has recently been refurbished by the current owners, to a high standard. The refurbishment includes things like new furniture in communal and personal rooms, new floor coverings, decoration, and new garden furniture. There is a new kitchen area to help people develop their independence, and there are several sitting rooms for people to choose from. People told us that they are very pleased with the refurbishment of the home, and they were able to help choose things like colours and fabrics. They told us that they are comfortable in their own rooms, Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 20 and they could have all their own things around them. We saw that everyone can have a key to their own rooms, and there are security key pads on external doors for safety. We saw that people know how to use the key pads and can come and go freely. One person told us that they feel safe knowing strangers cannot just walk into the home. We looked at records for maintenance within the home and all of the jobs listed were dealt with in a timely way. Information we have shows that the provider has increased maintenance budgets, and a programme for rolling refurbishment and maintenance is in place. On the day of the visit the home was very clean and tidy, and people said that is how it always is. Substances that could cause harm to people were locked away in a store room when not being used and records show that staff have received training about health and safety issues. We also know that there is a policy about how to deal with substances that could cause harm to people. We saw staff using hand washing procedures, gloves, and aprons and in the right way, and there was a good stock of gloves and aprons available to staff. The manager told us that she is currently arranging for staff to receive training in how to control infection. Byron House DS0000073165.V375594.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, 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. People are protected by recruitment procedures, and a well trained staff team. EVIDENCE: Staff records were looked at, and we saw that they contained things like application forms, criminal record bureau checks, identification and written references. Staff confirmed that they had thorough checks and an interview before starting work at the home. They also told us that they had a good introduction to the home and the people who live there. Records show that induction training is based on nationally recognised standards, and a personalised introduction to the home. Records show that staff are trained in subjects such as fire safety, protecting people, health and safety, medication, and moving and handling. The majority of staff hold a nationally recognised care qualification at various levels, and other staff are working towards the qualification. There is also a training plan in place which includes mental health awareness, and there are training videos Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 22 available to staff for things like epilepsy awareness, infection control, food hygiene, and new laws to help people with decision making. Staff said that they have a good programme of training to help them do their job well, and people who live at the home told us that staff know how to look after them. Staff said that there is good team work in the home, and they feel supported in their work. They told us that they receive supervision from senior staff, and records confirmed this. People told us that there is usually plenty of staff to help them with their daily needs, and staff confirmed that there are enough of them on duty. We saw that people’s requests for support were readily met. As well as care staff there is a cook and two housekeepers on duty. Byron House DS0000073165.V375594.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, 39, 40, 42 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 home is generally well managed and people have a say in how the home is run. EVIDENCE: The registered manager has worked at the home under previous ownership for many years. She has a professional nurse qualification, and is currently working towards a management qualification. People who live at the home, and staff, say that they can talk to her about any issues and she will help them to sort things out. They also said that she makes sure that they are kept up to date with issues in the home, and they have regular meetings in which they can say what they think of the service. We saw records of house meetings, Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 24 which show that people talk about things like menus, leisure activities, building work, and maintenance issues. We received a self assessment document from the provider and manager as part of the inspection process. It told us that there are a good range of policies and procedures within the home for issues such as first aid, codes of conduct, record keeping, and moving and handling. The manager and staff told us that they have their own booklet with some of the more common policies in. We saw that the main policy file was located in the manager’s office, which staff and people who live in the home do not have access to. The self assessment document shows that there is a system to monitor the quality of the service provided to people who live at the home. We know that the manager has carried out a survey about the refurbishment of the building, and managers from the provider’s company carry out regular visits to look at the quality of things like the environment, and staff training. The self assessment also tells us that the provider carries out annual environmental audits and staff recruitment file audits. There were no records of in-house audits for things like care planning or medication records. Records show that regular checks of fire safety equipment are carried out, and there is a fire risk assessment in place. People were able to tell us what they would do in the event of a fire. We also saw information sheets about substances that could cause harm to people. Accident records were detailed however we have not received statutory notifications about any of the incidents. Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 3 X 2 X Version 5.2 Page 26 Byron House DS0000073165.V375594.R01.S.doc No Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Requirement Care plans must be in place for all of the people who use the service, which show their needs, wishes and preferences. This is so that staff have clear and consistent guidance about how people prefer their care to be delivered. All identified risks to a person’s health, safety and welfare must be assessed and a plan put in place to reduce those risks. This is so that people are protected from any unnecessary risks. Medication records must be completed appropriately, at the time of administration. This is to make sure that people receive their medication is a safe way. The Care Quality Commission must be notified promptly of any incident described in Regulation 37 of the Care Homes Regulations, 2001. This is to show us how they are managing people’s health, safety and welfare. DS0000073165.V375594.R01.S.doc Timescale for action 21/06/09 2 YA9 13 27/06/09 3 YA20 13 27/06/09 4 YA42 37 27/06/09 Byron House 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 YA6 Good Practice Recommendations It is recommended that care plan review records contain more detail about how the review was carried out, who was involved, and what the outcomes were. This is so that the home can demonstrate that they have consulted with the person, and there is clear information to help monitor people’s changing needs more effectively. It is recommended that records about activities that people have been offered and participated in are kept individually in personal files. This is so that their personal records are kept in accordance with Data Protection Act 1998, and any other statutory requirements. It is recommended that records are kept of what foods people eat each day. This is so that people’s dietary and nutritional needs can be monitored more effectively. It is recommended that the complaints procedure is displayed prominently within the home. This is so that people who live there, staff and visitors, can see how to make a complaint, and know how it will be dealt with. It is recommended that regular audits of things like medication records and care plans are carried out. This is so that the completion and quality of those records can be monitored more effectively. It is recommended that all relevant policies and procedures are kept in an accessible place within the home. This is so that people who use the service and staff can refer to them whenever they need to. 2 YA13 3 4 YA17 YA22 5 YA39 6 YA40 Byron House DS0000073165.V375594.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA 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. 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