Inspection on 27/04/09 for Coney Green

This inspection was carried out on 27th April 2009.

CQC found this care home to be providing an Adequate service.

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

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Coney Green 18/20 Coney Green Drive Northfield Birmingham West Midlands B31 4DT Lead Inspector Kerry Coulter Key Unannounced Inspection 27th April 2009 08:30 DS0000073057.V375169.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. DS0000073057.V375169.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 DS0000073057.V375169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coney Green Address 18/20 Coney Green Drive Northfield Birmingham West Midlands B31 4DT 0121 693 0182 0121 693 0187 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) Kelso Care Consortium Limited Miss Sophie Kay Donnelly Care Home 9 Category(ies) of Learning disability (9) registration, with number of places DS0000073057.V375169.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 9 The maximum number of service users to be accommodated is 9 2. Date of last inspection Not applicable as new registration. Brief Description of the Service: The home is located in a quiet residential area, which is part of the Austin Village Preservation Trust. It is close to local amenities including shops, post office, banks and pubs. Transport links are also close by for Birmingham city centre and for Bromsgrove and Worcester. The home has a rear driveway with a garage that can provide off road parking for two vehicles. However, there is only street parking at the front of the building. Coney Green Drive is a three storey building that had previously been used as a care home for older people and a children’s’ residential home. The premises have undergone a process of renovation to bring it up to the National Minimum Standards. The home provides care to people who have a learning disability. The statement of purpose for the home records that care is provided both on a respite (short stay) and long term basis. The accommodation consists of nine bedrooms offering en-suite bath and shower facilities. Three bedrooms are quite small in size but they are intended for use by people having respite care. The home has a large communal lounge, smaller lounge, dining room, communal bathroom, laundry and kitchen. The first and second floors of the home are accessed via stairs and so are not accessible to people who have mobility difficulties. The front of the home is DS0000073057.V375169.R01.S.doc Version 5.2 Page 5 also not fully accessible to people who have mobility difficulties. However the home has applied for planning permission for a handrail to be fitted next to the entrance. Information in the service user guide records that the standard fee to live at the home is £867, this does not include hairdressing, transport, chiropody, outings, telephone and toiletries. DS0000073057.V375169.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out over one day, the home did not know we were going to visit. This was the homes key inspection for the inspection year 2009 to 2010 and their first inspection since registration. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and an Annual Quality Assurance Assessment completed by the manager. This provides information about the home and how they think it meets the needs of the people living there. Surveys were sent to and received from two people who live at the home and their comments are reflected within this report. Only two people have moved into the home so far, but only one was living at the home when we visited. We case tracked the care people received. This involved establishing individuals experience of living in the care home by meeting and talking with them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked at parts of the home and a sample of care, staff and health and safety records were looked at. Discussions with staff took place and the manager was available during our visit. What the service does well: Before a person moves into the home an assessment of their needs is completed to make sure their needs can be met. Staff were observed to give support with warmth, friendliness and patience and treat people respectfully. Staff support the people who live there to go out and do the things they want to do. Staff support people to keep in contact with their family and friends so that their emotional and social well being is promoted. DS0000073057.V375169.R01.S.doc Version 5.2 Page 7 People living there do different activities inside and outside the home so they have a meaningful quality of life that meets their personal preferences. Regular meetings are held with people at the home so that their views are sought and they can be involved in how the home is run. The medication is well managed so that people get their prescribed medication helping them to stay healthy. The home has a satisfactory complaints procedure and people know how to make a complaint if they are dissatisfied with the service received. The home is homely and does not present as an institution, how it is decorated reflects a warm and relaxing atmosphere. All areas of the home were clean so it is a pleasant place for people to live in. There are enough numbers of staff on duty to support and care for the people who live at the home. Staff have the training they need so they know how to help the people living there. What has improved since the last inspection? What they could do better: The Service User Guide would benefit from additional information so that people thinking of moving to the home have all the information they need to make a decision about moving there. Care plans should be developed further so that staff support people to meet all their needs and achieve their goals. Risk assessments need to be further developed to keep people as safe as possible. The way in which people’s money is used needs to be reviewed to make sure they are not paying for things which the home should pay for. The home needs to make sure that all staff who work there have had the right checks to help make sure people are not put at risk of having unsuitable staff working with them. Staff should receive supervision more frequently to ensure that they are well supported to meet the needs of the people living in the home. DS0000073057.V375169.R01.S.doc Version 5.2 Page 8 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. DS0000073057.V375169.R01.S.doc Version 5.2 Page 9 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 DS0000073057.V375169.R01.S.doc Version 5.2 Page 10 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, 4 and 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People generally have all the information they need about the home so they can make an informed choice as to whether or not they want to live there. Individual needs and aspirations are assessed before they move into the home to ensure the home can meet people’s needs. EVIDENCE: The Service User Guide and Statement of Purpose were available in the home. People have their own copy of the guide in their bedroom that is in an easy read format that includes pictures. The guide tells people about the home including the fact that the home may accommodate people who are having respite (short term) care in addition to people who are living there long term. We suggested that the language explaining this may not be easy for someone with a learning disability to understand and needed simplifying. It is important that people thinking of moving into the home permanently are aware that people they do not know may move in and out of the home on a regular basis. It is good that people moving to the home receive an ‘induction’. This includes the opportunity to visit prior to moving in. The ‘induction’ record also shows that people had in addition to receiving a copy of the service user guide been DS0000073057.V375169.R01.S.doc Version 5.2 Page 11 given information about the fire procedures and house rules. People told us that they had received enough information about the home. Since the home has opened two people have moved in. When we visited only one person was living at the home as the other person had been there on respite care. We looked at the admission process followed for both people. For one person records showed that a full pre admission assessment had been completed prior to the person moving in. This included their communication, physical health, mental health, behaviour, medication, activities, daily living skills, social, religious and cultural needs. The other person had moved in as an emergency and the home ensured they had a copy of their care plan completed by the social worker when they moved in. An assessment of their needs was also completed by the home as soon as they moved in to make sure the home could fully meet their needs. We checked that the person currently living at the home had been provided with a copy of the terms and conditions of their stay there. We saw that this was in place and included fee information so that people know how much it costs to live there. DS0000073057.V375169.R01.S.doc Version 5.2 Page 12 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 and 9 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. Care plans and risk assessments do not always give staff the information they need to support people to meet all their needs and achieve their goals in a safe way. People who live in the home are supported to make decisions about their lives to enhance their independence. EVIDENCE: We looked at the care plan for the person living at the home when we visited. The person had been living at the home for approximately three months but the home was still using a care plan completed by the social worker prior to the person moving in. Whilst the plan was informative an up to date care plan should have been in place that was specific to the home. We discussed this with the manager who was able to demonstrate that a draft care plan was near completion. This needs to be completed as soon as possible to make sure DS0000073057.V375169.R01.S.doc Version 5.2 Page 13 that staff have all the information they need to help them support the person and make sure they get the care they need. Since the person has been at the home a review of their care has taken place, minutes of the review show they were involved in this. It is good that a summary of the minutes of the review have been made available to the person in an easy read format that includes pictures. This makes them easier for the person to understand. Surveys we received from the two people who have lived at the home recorded they were involved in making decisions. During our visit to the home we observed staff encouraging the person who lived there to make decisions and choices about what they wanted to do that day. Regular meetings are held with people who live at the home. Minutes of the meetings show that people have been given the opportunity to make decisions about things such as activities, holidays, menus and key workers. We looked at one persons care file regarding the assessment of any risks to their health and safety. Records sampled and discussions with staff showed that the person was at risk of harm due to some of the behaviours they may display. A risk assessment was available for one of the risks but this had been completed some time before the person moved into the home and was not up to date and did not reflect current practice. A risk assessment had not been completed for one of the identified risks. This means that people cannot be sure that risks are being managed in a safe way. The manager accepted that risk assessments should have been updated but was able to show us that action was being taken to address this and that draft risk assessments were in the process of being completed. DS0000073057.V375169.R01.S.doc Version 5.2 Page 14 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 and 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. Arrangements are in place so that people living at the home experience a meaningful lifestyle that includes doing activities they enjoy. People are offered a healthy and varied diet that they enjoy. EVIDENCE: People who live at the home have their own individual timetable of activities which they put together with their key worker. We spoke with staff and looked at records and these showed that activities on offer include shopping, cooking, music, bowling, meals out, walks, pubs and visits to local places of interests. Where people have expressed a wish to visit religious services records show this has been supported by the home. At the time of our visit one person was observed enjoying playing a board game with staff. Surveys we received from DS0000073057.V375169.R01.S.doc Version 5.2 Page 15 people at the home indicated they were happy with the activities on offer. One person told us ‘they help me sort my activities’. Records indicated that people maintain contact with their families which is facilitated by staff and ensures contact is maintained. During our visit to the home the person who lives there was assisted by staff to go and visit a relative. Menus were observed to meet healthy eating guidelines, offer variety and meet people’s special dietary needs. There was a good stock of food and a supply of fresh fruit and vegetables, so that healthy diet guidelines are followed. Staff said that people at the home are supported by staff to do the food shopping and this was later confirmed by the person living at the home. People were observed being able to access the kitchen. The person living at the home during our visit told us ‘I like living here, food is good, I get a choice, get fruit, get to make my own drinks’. DS0000073057.V375169.R01.S.doc Version 5.2 Page 16 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 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home receive personal support in the way they prefer and require and their health needs are met. Medication practice ensures people receive the medication they need in a safe way. EVIDENCE: People’s personal care needs are assessed prior to them being admitted to the home so that staff know what support they need. During our visit we saw that the person living at the home was well groomed in appearance. It was evident that they are able to dress, use cosmetics and have hairstyles that are individual and of their own personal choice. The home employs a mix of staff that reflects the gender of the people living in the home so people can chose who they want to support them with their personal care. Interactions between staff and people who live at the home observed on the day were entirely positive and respectful. DS0000073057.V375169.R01.S.doc Version 5.2 Page 17 Two people have lived at the home since it opened. Records sampled show that information on their health needs is obtained as part of the initial assessment. Their care records showed that they had both been supported to register with a GP and had health check ups with a nurse, dentist and optician shortly after moving into the home. Records showed that where appropriate health professionals are involved in the care of individuals. For example where people have been unwell they have been supported to visit the GP. During our visit the manager told us that people’s keyworkers were in the process of assisting them to complete health action plans. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to use. At the time of this visit medication administration was well managed. The home retains copies of prescriptions so that staff can check the correct medication has been received from the chemist. We saw that medication is kept in a locked cupboard. Shortly after people are admitted to the home staff carry out an assessment to see if they are safe to administer their own medication. When we visited the home there was no one living there who was assessed as safe so staff were responsible for administering medication. Records sampled showed that staff who administer medication receive training to help ensure they are competent to do this. The medication records were sampled and had been satisfactorily completed, showing the person had received the medication they had been prescribed. Where people are prescribed medication on an ‘as required’ basis protocols are in place so that staff know when to give this medication. One person had recently received as required medication frequently. Discussion with the manager and sampling of records showed that the manager had completed a report on this and had discussed the need for a medication review with the persons GP to make sure they were getting the medication they needed. DS0000073057.V375169.R01.S.doc Version 5.2 Page 18 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 and 23 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 in the home are generally confident that their complaints will be listened to and acted upon. The systems in place to safeguard people from abuse may not always ensure that people are protected. EVIDENCE: We have not received any complaints about this home since it opened. The home’s complaint log shows the home has not received any complaints directly. The complaint procedure is on display in the home and an easy read version with pictures is also available for people who live there. Surveys we received from people living at the home indicate they are aware of the complaints procedure and know who to speak to if they are unhappy. Staff training records showed that staff had received training in the prevention of abuse so they know how to protect the people living there. The home also has a copy of the Birmingham Multi Agency safeguarding guidelines that staff can refer to as well as the organisation’s own policy and procedures. Staff we spoke with during our visit knew what to do to keep people safe should an allegation of abuse be made. Records and discussions with the manager show that the home had been a little concerned when one person who lives there had donated a large sum of money to an external organisation. The home acted in the persons best DS0000073057.V375169.R01.S.doc Version 5.2 Page 19 interests by discussing with their social worker if they had the capacity to consent to the donation. A decision was made that this was not a safeguarding incident. We looked at the financial records for one person who lives at the home. Receipts were available for all expenditure but we were a little concerned to see that on some occasions the person had paid for the meals of staff accompanying them to meals out. The manager said that this was because the home did not have a budget for this. Staff meals is not something that people living at the home should be expected to pay for. Discussion with the manager indicates that the home does not actually have a policy that details who should pay for what regarding meals out and activities. The manager said that a policy would be developed and monies paid out for staff meals would be reimbursed. DS0000073057.V375169.R01.S.doc Version 5.2 Page 20 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, 26 and 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, safe and clean environment that meets their individual needs. EVIDENCE: This is a newly registered home and accordingly all parts of the home seen were clean, of a comfortable temperature and well maintained. As the home has only had a couple of people living there for a short time then it does not yet have a ‘lived’ in feel to it. The accommodation consists of nine bedrooms offering en-suite bath and shower facilities. Three bedrooms at the home are smaller than the others and it is intended these will be used for people having respite care. All bedrooms had suitable locks that guarantee people’s privacy but could be overridden in an emergency by staff. We looked at the bedroom of the person living at the DS0000073057.V375169.R01.S.doc Version 5.2 Page 21 home and saw that it had been personalised to their own preferences. The person told us that they liked their bedroom. The ground floor has sufficient communal space for the size of the home and number of people to be accommodated. This consists of a large lounge, separate dining room and a smaller lounge. A laundry room is provided and the layout of the building indicates that any soiled linen would be transported without having to go through the communal and kitchen areas. The home has a communal bathroom. When we visited the home prior to its registration we recommended that a grab rail needed to be fitted above the bath to help people get in and out safely. At this visit we saw that this had been done. We also previously saw that there was no rail at the front of the building where people would have to negotiate steps to get to the front door. The annual quality assurance assessment completed by the manager records that planning permission for a hand rail has now been applied for. Surveys we received from people told us that the home is always fresh and clean. The home has recently been visited by the environmental health officer and given a rating of ‘very good’ for its food hygiene arrangements. DS0000073057.V375169.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 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 who live in the home benefit from a staff team that can support them to meet their individual needs and achieve their goals. Recruitment arrangements do not always help to make sure that staff have had the right checks to help ensure people are supported by suitable staff. EVIDENCE: Direct observations of staff interactions with people who live at the home provide evidence that they have a good relationship with people in their care and a good general understanding of their needs. Five of the seven staff have a National Vocational Qualification in care and this means that the people who live there are supported by a well qualified staff team. The person living at the home during our visit told us ‘staff are good’. Surveys received from people indicate staff treat them well, one person told us ‘staff look after me’. Current staffing levels in the home are generally one staff on duty as there is currently only one person living at the home. The home does not use agency DS0000073057.V375169.R01.S.doc Version 5.2 Page 23 staff and instead uses staff working extra hours to cover any gaps. This means that people living there are supported by staff that they know. Current staffing levels seem appropriate to the needs of the person living there. Unfortunately the annual quality assurance assessment completed by the manager did not tell us much about the homes recruitment practices. We looked at the recruitment procedures followed for three new members of staff. Each member of staff had completed an application form and the home had sought references before people started working there. Whilst all staff now had a criminal records bureau disclosure rotas showed that for two staff they had worked unsupervised in the home before the full disclosure was received. This puts people who live at the home at risk of having unsuitable staff working with them. We spoke with the manager who accepted that an error had been made and assured us that this would not happen again. New staff receive an induction so that they have the basic skills needed to do their job. Training records show that staff receive the training they need, this included safeguarding people from abuse, food hygiene, health and safety, first aid, fire, autism, learning disabilities, epilepsy, manual handling and infection control. Whilst we were visiting the home staff were having training about the new deprivation of liberty legislation. Staff we spoke with during our visit told us they receive the training they need. Minutes of staff meetings show they are held on a monthly basis to help ensure that staff are kept updated with ‘best practice’ and the changing needs of the people living there. We sampled the supervision records for three staff. One staff had received regular supervision but for two staff this had not happened at least every other month. The frequency of supervision needs to be improved so that staff receive good support to do their job and their training and development needs are identified to ensure they have the skills to meet the needs of the people living there. DS0000073057.V375169.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements need to improve so that people will benefit from a service that is run in their best interests. EVIDENCE: The manager and deputy manager were on duty during our visit to the home. The manager is a qualified nurse who also has a management qualification. She has sixteen years experience working in care. During the visit the manager was professional in her approach and demonstrated good knowledge of the needs of people who live at the home. The manager completed and returned the annual quality assurance assessment when we asked for it. We found that this had only been completed DS0000073057.V375169.R01.S.doc Version 5.2 Page 25 to a basic standard and for some outcome areas had very little information on how the home was performing, for example in staff recruitment and quality assurance. We found that some outcome areas for people had not been well managed, particularly in relation to the recruitment of new staff. Poor recruitment practice puts people at risk of having unsuitable people working with them. Ultimately it is the responsibility of the manager to ensure recruitment practice is robust. However, as already stated in this report the manager has assured us that recruitment practice will be improved. All staff spoken with during the visit said they found the manager approachable. They told us ‘can discuss things, she is open and professional’ and ‘manager is supportive, very down to earth’. The home has a variety of methods in place to assess the quality of the care they are providing. The Provider visits the home monthly and seeks the views of the people living and working there and a report of their visit is made. Internal audits are also completed and cover areas such as peoples care files, staff files, medication, health and safety, meals, accidents and money. Discussion with the manager indicate that the home also has an annual audit tool that it intends to use once more people have moved into the home. This will include sending out questionnaires to people who live at the home, staff, care professionals and relatives. Systems are in place to make sure the safety of people at the home is promoted. Fire records showed that staff test the fire equipment regularly to make sure it is working. An engineer has serviced the fire equipment to make sure it is well maintained and in good working order. Fire drills had been held monthly so that staff and the people living there would know what to do if there was a fire. Certificates sampled showed that gas and electrical installations in the home had been checked by a qualified engineer to make sure they were safe. Staff check the water temperatures regularly to make sure they are not too cold or hot which could put people at risk of being scalded. DS0000073057.V375169.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 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 3 X 2 3 3 X X 3 X DS0000073057.V375169.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Not applicable. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement An up to date care plan must be available for each person who lives at the home. To help ensure people receive the care and support they need. An up to date assessment of risks to people who live at the home must be available. To help ensure that risks to people are reduced and they are safe from harm. Ensure that all staff who work at the home have had the right recruitment checks to make sure people are not put at risk of having unsuitable staff working with them. Timescale for action 30/06/09 2 YA9 13(4) 30/06/09 3 YA34 19 30/06/09 DS0000073057.V375169.R01.S.doc Version 5.2 Page 28 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 Improve the information in the service user guide so that people thinking of moving into the home permanently are fully aware that people they do not know may move in and out the home on a regular basis. A policy should be developed that clearly records what people are responsible for paying for regarding meals out and activities to help ensure they are not charged for things they shouldn’t be. This will help ensure people’s money is looked after. Staff should receive supervision at least every other month to ensure that they are well supported to meet the needs of the people living in the home. 2 YA23 3 YA36 DS0000073057.V375169.R01.S.doc Version 5.2 Page 29 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT 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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