Inspection on 11/08/09 for Community Places Ltd

This inspection was carried out on 11th August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Community Places Ltd 05/08/08

Community Places Ltd 09/05/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Community Places Ltd 43 John Street Great Houghton Barnsley South Yorkshire S72 0EA Lead Inspector Stephanie Kenning Key Unannounced Inspection 11th August 2009 09:15 Community Places Ltd DS0000064151.V377354.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. Community Places Ltd DS0000064151.V377354.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 Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Community Places Ltd Address 43 John Street Great Houghton Barnsley South Yorkshire S72 0EA 01226 755070 01226 753547 cplaces@amserve.com None Community Places Ltd 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) Sandra Asquith Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who can be accommodated is: 14 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: either whose primary care needs on admission to the home are within the following category: Learning disability - Code LD, maximum number of places: 14 Date of last inspection 5th August 2008 Brief Description of the Service: Community Places is a 14-bed home for younger adults between the ages of 18 and 65, it provides social and personal care for people with a learning disability. The home is in a residential area in the village of Great Houghton, where there is good access to public services. There is a bus route, a variety of shops, health centre, post office, pubs, and church near by. The home has disabled access and a there is passenger lift to the upper floor. There are 13 single accommodation bedrooms and one self contained flat; all have en-suite facilities. There is an additional bathroom with a Jacuzzi and an additional shower and toilets. There are a variety of lounges and seating areas, and some are designated as quiet places. The home provides a room with access to a computer and there is an activities room. The dining room is spacious and leads out onto a patio area, and there are spacious well-kept gardens with seating and a table. Car parking is available within the grounds of the home and the home has it’s own transport. Within the home there is a no smoking policy, however there is a summerhouse provided in the garden for people who do wish to smoke. The manager said fees are based on individual’s needs and assessments. The lowest weekly fee was £1784.51 and highest was £2519.02. If there are any additional charges these are agreed in the contract of care. Prospective service users and their families can get information about Community Places by contacting the manager. Community Places Ltd DS0000064151.V377354.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 home is zero star - poor service. This was an unannounced key inspection carried out by Stephanie Kenning, regulation Inspector. The site visit took place on 11th August 2009 between the hours of 09:15 and 18:00. The registered manager Sandra Asquith and the Responsible Individual Susan Dunford were present during the visit. Previously, a key inspection was carried out in August 2008. Prior to this visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which stated what the home was doing well, and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Surveys were not sent out to people as this inspection visit was brought forward because of concerns raised through safeguarding investigations and the suspension of several members of staff. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, and check some of the policies and procedures. Time was spent observing and interacting with people, and feedback from people present during the visit is also included in the report. The inspector checked all the key standards and some additional standards. We have reviewed our practice when making requirements, to ensure national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this reports’ recommendations, but only when it is considered that people who use service are not being put at considerable risk of harm. In future if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Community Places provides a modern, spacious environment with good facilities for the people living there. People liked their rooms and felt ownership of them. People also liked that the home was clean and fresh and well maintained, with outside spaces to use in fine weather. People also liked the range of activities and support they got to visit family and friends. Every comment about the meals provision was good, including that there were alternatives and healthy options. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 7 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 Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 8 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 using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had insufficient information on which to base their choice of home, and may not be assessed adequately by the service in regard to whether their needs can be met. EVIDENCE: We wanted to understand people’s experiences when they decide whether to choose this care home, and what it is like for people if they did decide to move there. We spoke to people living at the home, and to staff working at the home. We used information from the AQAA, and looked at the information the home give to people before admission and how they assess whether they can meet people’s needs. People said that they had had opportunities to visit the home before being admitted, but that they did not have any written or audio-visual or suitable information to read or look at. We looked at the Service User Guide and the Statement of Purpose available at the home, and found that they were not specific to this home, had no details of the service provided, and were not in easy read or different formats to meet people’s specific needs. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 9 The only assessments on file were those from the placing authorities describing what care needs would be required. There was nothing to show that the home had done their own assessment, or written evidence that they could meet those needs before the person decided to move there. There was evidence of a previous placement breakdown and of someone admitted out of the registered category, showing a lack of clarity about meeting needs and regulations. In addition four additional unregistered premises had been used for people placed at the service, though only one was being used at the time of the visit. The Responsible Individual and Registered Manager stated that they had not been aware the premises remained unregistered until recently, and they intended to submit an application form to us for the service being used. The manager showed us a daily living and needs assessment form, which was to be implemented from the next new admission. This was a comprehensive assessment, but still does not give an evaluation of whether the home can meet those needs. Admissions to this home have been stopped whilst a number of allegations are investigated Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 10 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 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 living at the home are generally able to make choices about their daily lives. EVIDENCE: We wanted to find out if people’s individual needs and choices were being met. We looked at the care records of three people at the home, and spoke to several people living at the home, and some of the staff. We observed the daily life at the home and watched the interactions of the people at the home with other people. We looked at records and information provided in the AQAA. Since the last visit the AQAA states that they have improved by providing more staff, a bungalow, a house, increases in occupational, educational and leisure activities. People living at the home and staff confirmed that these improvements had been made, and were particularly positive about the Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 11 improvements in leisure activities. Most people felt that the additional premises had provided opportunities for people to live more independently, though there were some concerns regarding the level of support provided and one person now back in the main unit was very pleased about being back. The care records of three people were looked at in detail. People did know about their plans and had some involvement in creating them, though they were not in an easy read format. They included behaviour management plans with target dates and action, which appeared appropriate and had been reviewed. They included a daily record of what had happened to that person, along with additional incident and accident records. The plans in place were not person centred, though it was stated that these were to be implemented in the near future. People generally did feel able to make decisions about many aspects of their lives, and staff were supportive when people changed their minds about their plans for the day. One person did not feel that they were able to refuse to do things. Staff appeared very respectful of people’s rights and choices, and stated that it was now easier under new management, because they had some leadership to guide them. Limitations on choices only appeared to be imposed as part of a development plan that had targets and dates planned out for the following few weeks. The person with this limitation understood and was positive about their progress. Each person living at the home was being reviewed by their placing authority during August to ensure that the service was meeting their needs and that only appropriate supported risks were being taken. We asked people if they felt that their needs were being met and most people felt that they were. Some people did have some concerns, one about lack of opportunity to discuss things with their key worker, and one with lack of progress towards their goals. These were individual circumstances and made more problematic because of the recent changes at the home, which were starting to settle down. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 12 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 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 living at the home have opportunities to take part in a variety of activities both within the home and in the community. People enjoyed the meals and had good choices. EVIDENCE: We wanted to understand people’s daily experiences and opportunities for personal development and leisure. We observed the routines and the activities taking place and spoke to people living in the home and the staff. We looked at the records of activities, routines and meals. The people living in the home did seem to have a good range of activities particularly around leisure. During the visit people went for country walks, to cafes, bowling and did activities within the home. Some staff were particularly employed to enable people to do the activities they chose, and were working Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 13 on enabling more educational and occupational activities. Support with relationships, including visits to family and friends, was provided, often including transport unless people were more independent. Generally, staff were aware of the need to support people to develop their skills, including social, emotional, communication, and independent living skills. Some people were seen helping in the kitchen or making themselves drinks. It was stated that the introduction of the person centred plans would help to expand people’s opportunities for personal development. Without them staff have been focusing on an individual aim, such as enabling someone to do a specific course, and then having to unravel all the smaller steps needed to achieve the aim successfully. This has taken time and the individual has become impatient thinking that nothing was happening. People found the food to be of good quality and they had choices on a four week rotating menu influenced by the preferences of people living there. Cooked options for all meals were available and people were seen having alternatives. There was fruit and fruit juices available, and home cooked vegetables every day. People’s plans referred to promoting healthy diets and healthy options were available. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 14 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 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 using this service generally had their health and personal care needs met and received medication safely. Person Centred Planning was progressing, but was not fully in place. EVIDENCE: We wanted to understand how people had their health and personal care needs met. We spoke to people in the home, observed practices in communal areas, and looked at records and medication systems. People were generally happy about how their health and personal care needs were met. There were entries on each record checked showing the involvement of a range of health professionals. There was also printed information available about individual’s specific diagnosis, to enable staff to understand them. In addition the home had some registered nurses employed to help to facilitate good health care. The AQAA states that they have improved the detail in health plans since the last visit. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 15 We looked at three people’s care records in detail, and were told that they were soon to be completing person centred plans for everyone, though they were not all available at the time of the visit. There were service user plans for the three people studied, not all areas were completed fully, and they did not have person centred goals. There were good progress plans for the management of individuals with dates and action, showing that they were working towards some areas, and daily records and reviews were completed well. There was also evidence of some involvement in these plans by the individuals concerned, and people did know about their plans when asked. Medication records were checked and showed that the home do not get two people to sign hand written entries, as recommended at the previous visit. There were several examples of this, and many entries did not have any signatures. Other medication administration practices appeared to be safe and accurate. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 16 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 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 living at the home were not fully protected by the procedures in place, and there are ongoing investigations that have raised concerns. EVIDENCE: We wanted to understand how people were protected from abuse or neglect and how the service responds to complaints. We looked at records, policies and procedures and talked to people using the service. The service had three safeguarding alerts and one complaint since the previous visit. The complaint was investigated by the provider and was not upheld. The safeguarding investigations have not yet been completed. Since the previous visit four staff members have been dismissed with their cases referred to the Protection of Vulnerable Adults Register. The home does not have a complaints log to record complaints made. There was evidence that notification of some incidents, a death, and safeguarding alerts were not sent to us by the management of the home. People living at the home felt that they were usually listened to by staff and the manager, and that they mainly felt respected by the staff. People were aware of changes such as closure of unregistered premises and staff changes, and most felt that they were positive changes and helped them feel safer. They said that they would feel able to complain or raise concerns with either Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 17 the manager or another member of staff. There had been independent advocates available for people at the service, though a new advocacy provider was being sought. Information on how to complain was provided in a formal written form that may not be accessible to people at the home. There was evidence during a recent investigation that sometimes people were not clear about boundaries, which resulted in some poor practices. Staff stated that they felt much clearer about boundaries now under new management. Each individual has been reviewed by their placing authority to check that they are receiving appropriate care and support. The service has not implemented systems for checking practice yet. Seven staff recruitment and training records were examined and showed that people did have a CRB check and POVA check prior to commencing employment, along with references and a suitable employment procedure. Staff confirmed that they had received training in safeguarding people and knew about the whistle-blowing policy. Community Places Ltd DS0000064151.V377354.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 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 home that is safe, comfortable and meets their needs. The unregistered premises have not been assessed. EVIDENCE: We wanted to understand what it was like to live in the premises and whether they were appropriate for the lifestyles of the individuals living there. We were shown around the premises including the rooms of two people living there who invited us in. We observed for good repair, maintenance and cleanliness. We looked at the facilities available and spoke to the people living and working there. We looked at records of maintenance and safety checks to ensure that equipment was kept in good working order. People liked their rooms and the communal rooms and gardens. All comments were positive and people felt that the home was generally kept clean and Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 19 fresh. It was observed that the home was clean and well maintained. There was an activities room with games and a pool table, and a computer for people to use in the main sitting room. There were areas outside with seating and plants, including seasonal hanging baskets. One person was using an area of the grounds to grow their own plants with the support of staff. Records show that routine checks and maintenance were carried out to ensure that equipment was working well and safely. The manager was aware of precautions regarding preventing the spread of infections. The additional unregistered premises were not seen as we were under the impression that from the following day they would no longer be used. However, one of these services was noted to continue operating, so they have continued to breach The Care Standards Act. Community Places Ltd DS0000064151.V377354.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 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. Although safe recruitment procedures were used, not all staff had received the training and support they needed to safely do their job. EVIDENCE: We wanted to understand how staff were recruited and trained to ensure that they could carry out their jobs well. We talked to people living at the home, and to staff, including the manager. We checked the recruitment files and the training records to see if procedures had been followed. People were generally satisfied that the care and support they received was meeting their needs, but there was concern about recent changes, particularly regarding staff that no longer worked there. Most people praised the staff for their respect and allowing them to live their own lives. One person spoken to did not feel that moving to Community Places was a positive move for them, and another that it was not as good as it used to be. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 21 Staff members felt that there was a good skill mix of staff in sufficient numbers to carry out their roles. They felt that their roles were clearer under new management and were pleased to have some leadership. Seven staff recruitment and training records were examined and showed that people did have a CRB check and POVA check prior to commencing employment, along with references and a suitable employment procedure. Staff had evidence of induction training records, some supervision records, and a range of further training. These records showed that not all staff had received all training or updates, including handling aggression and techniques to control difficult behaviours. Over 50 of staff had been trained in NVQ level 2 or above with many more people recruited on to the training. During the visit a training session and assessments were being held. Staff confirmed that they had received training in safeguarding people and knew about the whistle-blowing policy Community Places Ltd DS0000064151.V377354.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 using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has been poorly managed, with a lack of adherence to correct procedures which could have had negative outcomes for people at the home. EVIDENCE: We wanted to understand how the home was managed and ensuring the quality of service for people living there. We talked to people in the home, staff, and the manager and responsible individual. We looked at some records and used information from the AQAA. Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 23 The Registered Manager of the home is Sandra Asquith, who has completed the Registered Managers Award and has several years experience working in care. The Responsible Individual is Susan Dunford who has returned to this position since June this year and has been working full-time at the home to address the problems identified. People at the home felt able to talk to them and staff felt that the home had improved during the past few weeks. Despite the recent improvements there was evidence of some serious breaches of regulations. The use of unregistered premises is a serious offence and could have caused harm to the people living there. The fact that three of them have been closed by the management, with an application to register the fourth sent to us since the visit, shows a willingness to work with us. In addition there was evidence that notifications had not always been sent to us as required, for example, when a death occurred, when untoward incidents happened at the home, and when safeguarding referrals were made. During the visit the management showed completed documentation that they thought had been sent to us, but found in a previous managers’ office. They confirmed that they were familiar with the correct procedures and produced a copy of information from the CQC website. Some recent notifications had been received. The registration certificate displayed at the premises was misleading to visitors as it only showed page one and not the details of the registration. Up to date insurance certificates were seen but were not displayed as required. A number of records were seen that contained basic information, such as accident records, with no follow up information or analysis. Many records, procedures and systems were being revised, or rewritten by the new management. People’s finances, where held by the service, appeared to be accurately recorded. There was no clear audit of these records available. Maintenance and safety checks were carried out as required and recorded, and staff received training in safe working practices. Information presented in the AQAA was brief and did not give a realistic picture of the service. It was explained that this was completed in a hurry, as the Registered Manager was not aware that the AQAA had been received by the service. People were generally pleased about the management changes and did usually feel listened to. Staff confirmed that they were also pleased with the changes and felt that things were starting to be much more organised, with clearer roles and responsibilities. Community Places Ltd DS0000064151.V377354.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 1 2 2 3 1 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 1 3 1 X 2 3 1 Version 5.2 Page 25 Community Places Ltd DS0000064151.V377354.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 YA2 Regulation 14 Requirement The needs of people must be assessed prior to being admitted to the home. This is to ensure that their needs can be met. All relevant incidents must be referred appropriately, including to CQC, under the Care Homes Regulations 2001. This is to ensure that people are safe. Staff must receive training appropriate to work they are to perform. This is to ensure that people are safe. Timescale for action 30/09/09 2. YA37 37 01/09/09 3. YA35 18 31/10/09 Community Places Ltd DS0000064151.V377354.R01.S.doc Version 5.2 Page 26 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 YA1 Good Practice Recommendations A Statement of Purpose should be produced covering all the required information specific to this care home. All changes to the statement of purpose should be notified to the commission within 28 days. A Service User Guide should be produced providing specific information about the home in formats that are accessible to people living and working at the home. Each person and potential resident should be given a copy. The service should record the home’s capacity to meet the assessed needs of people admitted to the home. People at the home should have person centred plans, which they can understand and be involved with. Hand written entries on Medicine Administration Records should include the signature of the person making the entry, and the signature of a second person confirming the accuracy of details to promote the safety and wellbeing of service users. Record concerns and complaints raised by people using the service in order to monitor the action taken and the outcome, and to learn from these issues raised. Consider the training and development needs of the staff team in light of recent issues at the home, and the future plans for the service, and agree a plan of action. Fully implement staff supervision and identify areas of concern, development needs, and clarify roles. The Registration certificate should be displayed to show both pages, and up to date insurance certificates should also be displayed. Effective Quality Monitoring systems should be implemented including for care practices, service users money, medication, records, policies and procedures, and an annual development plan for the home put in place. Feedback form people using the service should be actively sought within these processes. There should be regular audits of money held on behalf of people at the home. DS0000064151.V377354.R01.S.doc Version 5.2 Page 27 2. YA1 3. 4. 5. YA3 YA6 YA20 6. 7. 8. 9. 10. YA22 YA35 YA36 YA37 YA39 11. YA39 Community Places Ltd Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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). 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